概要
介绍
这是有关近红外荧光（NIRF）夹式胃切除术的第一份报告。 NIRF剪辑ZEOCLIP FS在激发时会发出NIRF信号。我们假设ZEOCLIP FS的术前放置在胃部病变附近将允许在手术过程中荧光腹腔镜定位夹子，从而定位病变。我们在两种情况下报告了这种技术。
案例介绍
病例1：一名81岁的女性被诊断出患有早期胃癌，并且有蒂的4 cm大增生息肉带蒂十二指肠脱垂，并计划进行腹腔镜辅助的远端胃切除术，这是因为有可能解剖胃十二指肠壁息肉。在手术前一天，将ZEOCLIP FS夹子在内窥镜下放置在癌部位和息肉上。使用全色荧光腹腔镜在术中确认荧光夹的位置。
病例2
一名81岁男性计划在荧光钳引导下进行腹腔镜辅助胃癌全胃切除术。在最初的术中观察期间无法确认夹子的位置。但是，在第二次观察尝试中使用镊子将胃壁抬高时，确认了荧光夹的位置。
讨论区
在病例1中，很容易确定夹子的位置，从而有助于在不切除息肉的情况下完全切除早期胃癌。在病例2中，通过抬高胃部并调节胃壁与荧光腹腔镜之间的角度来定位荧光夹。
结论
这两个案例的积极结果值得对使用此方法进行可行性研究。
关键词：胃癌；荧光夹；术中内窥镜检查
缩写：NIRF，近红外荧光灯
1.引言
这些案例报告的报告符合SCARE标准。近红外荧光（NIRF）辐射会穿透软组织[...]，并且当荧光源和激发源均具有NIR波长并且可以通过NIRF相机观察时，可以将其检测为穿过空心器官壁的半透明光。自2016年以来，我们一直在合作开发用于肿瘤部位标记的NIRF夹子。 NIRF夹ZEOCLIP FS的峰值激发和荧光波长分别为760和790 nm，已制造并于2019年批准用于临床（注册号13B1X001111000020）。 ZEOCLIP FS具有荧光树脂填充的尖端，在激发时会发出NIRF信号。在腹腔镜胃切除术中，重要的是术中确认病灶在切除前的重要性。用于术中病变确认和确定切除切缘的方法是决定手术的肿瘤学安全性以及能否实现保留胃切除功能的因素之一。因此，腹腔镜胃切除术之前的肿瘤部位标记变得越来越重要。
我们假设ZEOCLIP FS的术前腔内放置在病变附近，以及随后在手术过程中使用荧光腹腔镜进行的术中观察将有助于病变的定位。我们首先开始在大肠癌病例中使用该夹子，在确认一定水平的有效性后，开始在涉及胃的病例中使用它。据报道，近红外光穿透软组织的厚度可达10毫米。因此，我们不确定是否可以使用荧光腹腔镜观察位于胃中的夹子，因为胃壁的厚度约为8毫米，比结肠壁的厚度还要厚。这是NIRF夹钳式胃切除术的首次报道。我们在两个合格的案例中使用了该程序。
2.Presentation of cases
Case 1: An 81-year-old female presented to our hospital for gastric cancer screening. She was diagnosed with early gastric cancer (M, post, cType0-IIc, cT1b, cN0, M0) and a 4 cm large, pedunculated, hyperplastic gastric polyp that had prolapsed into the duodenum. She was scheduled for laparoscopy-assisted distal gastrectomy, which had the potential risk of dissecting the polyp with the duodenal wall. The patient's consent was obtained for intraoperative use of the newly designed fluorescent clip and for reporting the study results. On the day preceding surgery, during upper endoscopy, ZEOCLIP FS were placed at two sites because removal of both the tumor and the polyp was planned. Two clips were deployed on the proximal side of the tumor, with one clip each placed on the lesser and greater curvatures, at the same level as the tumor. Three clips were deployed on the polyp and one clip was deployed on its peduncle (Fig. 1a and b). During surgery performed the following day, the locations of the fluorescent clips were confirmed using a full-color fluorescence laparoscope, Vision Sense® (Medtronic, Minneapolis, MN, USA) (Fig. 1c and d). Vision Sense is a new near-infrared fluorescence laparoscope that allows bright field full color observation, and has the property that it can adjust the intensity of excitation light and quantify the intensity of fluorescence during observation. Using the clips as a guide, we were able to successfully identify the appropriate proximal and distal resection margins, and were able to remove the tumor and polyp as a single specimen. Pathological evaluation confirmed the preoperative findings (tumor: pT1b, pN0, pM0; polyp: Hyperplastic polyp). There were no adverse events associated with use of the clips. The patient's postoperative course was uneventful and she was discharged on the seventh postoperative day.
Fig. 1
Fig. 1
Preoperative endoscopic and intraoperative laparoscopic view of the clips in Case 1. a) b) Endoscopic view: Clips were intraluminally placed around the gastric lesion, two on the proximal side of the tumor, one clip each on the small and large bowel side, and four at the polyp site, respectively. C) d) Laparoscopic view: Locations of the fluorescent clips were intraoperatively confirmed using a full-color fluorescence laparoscope, VisionSense (Medtronic, MN, USA). (For interpretation of the 参考 to color in this figure legend, the reader is referred to the Web version of this article.)
Case 2: An 81-year-old male presented to our hospital with anemia. He was diagnosed with gastric cancer (U, post, cType2, cT3, cN0, M0) (Fig. 2a) and was scheduled for laparoscopy-assisted total gastrectomy. Preoperatively, under upper endoscopy, two ZEOCLIP FS clips were placed intraluminally around the cancerous lesion on the distal side of the tumor (Fig. 2b). Intraoperatively, during the initial observation, we could not confirm the locations of the fluorescent clips (Fig. 2c). Subsequently, however, by raising the stomach wall and applying the excitation light perpendicular to the gastric wall during a second attempt at intraoperative observation, we were able to confirm the locations of the fluorescent clips (Fig. 2d). In this case, although ZEOCLIP FS clips were placed in the field of view for the possibility of distal gastrectomy, when we confirmed the location of the clips using Vision Sense during surgery, it was determined that the tumor was indicated for total gastrectomy. Pathological evaluation of the resected specimen confirmed the preoperative findings (pT3, pN0, pM0). As with the previous case, there were no adverse events associated with use of the clips. The patient's postoperative course was uneventful and he was discharged on the seventh postoperative day.
Fig. 2
Fig. 2
Preoperative endoscopic and intraoperative laparoscopic view of the clips in Case 2. a) Endoscopic view of the gastric cancer (U, post, cType2, cT3, cN0, M0). B) Two clips were placed intraluminally around the tumor on the distal side of the tumor, as seen endoscopically. C) The locations of the fluorescent clips could not be confirmed during initial laparoscopic observation. D) Subsequently, when the stomach wall was raised and the excitation light was applied perpendicular to the gastric wall during a second intraoperative observation, the locations of the fluorescent clips were confirmed.
3.Discussion
In case 1, using the clips as a guide, it was easy to confirm the tumor location in the stomach, which facilitated intraoperative determination of the proximal resection margin. The position of the prolapsed polyp could also be clearly identified, facilitating determination of the distal resection margin in the duodenum.
In case 2, contrivance was needed for observation of the fluorescence. Based on our experience with fluorescence-guided surgery for colorectal cancer using ZEOCLIP FS, we adjusted the viewing angle of the fluorescence laparoscope relative to that of the gastric wall to confirm the locations of the fluorescent clips using a full-color fluorescence laparoscope during surgery. In the first attempt at intraoperative clip observation using the fluorescence laparoscope, the locations of the fluorescent clips were not identifiable because we did not pay attention to the angle of the fluorescence laparoscope relative to the gastric wall. However, by raising the stomach using forceps, we were able to confirm the locations of the fluorescent clips. Raising the stomach might have changed the angle between the stomach wall and the fluorescence laparoscope. Ideally, the transmission distance through the stomach wall of the excitation light emitted by the fluorescence laparoscope should be as short as possible. Assuming the stomach wall is 8 mm thick, when the fluorescence laparoscope is placed perpendicular to the stomach, the excitation light should be able to identify the clip through the 8 mm wall. Placing the fluorescence laparoscope at an angle to the stomach wall increases the transmission distance. For example, if the laparoscope is placed at an angle of 53° to the stomach wall, the transmission distance is 10 mm. If the transmission distance through the stomach wall exceeds 10 mm, the fluorophore tip of the clip is not excited, and hence, the location of the clip might not be recognized. This suggests that the angle of the laparoscope relative to the stomach wall should be 53° or more to allow appropriate application of the excitation light to the clip (Fig. 3). Raising the stomach wall using forceps might not only change the viewing angle between the fluorescence laparoscope and stomach wall, but also reduce the thickness of the stomach wall by an extension force, thus shortening the transmission distance. The focal intensity of light is also affected by the transmission distance, which alters the color of the fluorescence, as seen in the difference in fluorescence between the images for case 1 and case 2. In our previous cases of preoperative marking of the tumor site in the large intestine using the clips, four fluorescent clips were placed intraluminally at angles of 90° around the lesion. However, this method is technically difficult in the stomach. We believe that for lesions of the stomach, it is important to place the clips on the greater curvature and/or the anterior stomach wall to enable confirmation of the location of the fluorescent clips. Details about the number of clips to be placed to confirm the exact type of surgery needed for complete resection of the tumor should be assessed in future studies. More cases of fluorescent clip-guided gastrectomy need to be performed to confirm the utility.
Fig. 3
Fig. 3
Schematic diagram showing the relationship between the angle between the laparoscope and gastric wall and transmission distance of the near-infrared light. It is estimated that the laparoscope should be at an angle of 53 or more to the stomach wall for application of the excitation light to the clip.
Currently, intraoperative endoscopy is usually used for intraoperative localization of gastric tumors, although the procedure has several drawbacks, such as prolonged operation time and need of a skilled endoscopist [, , ]. Intraoperative fluorescent clip-guided tumor marking is a simple and inexpensive alternative (the approximate cost per clip is $100, with no additional insertion charge), to intraoperative endoscopy. If the effectiveness of fluorescent clip-guided gastrectomy is confirmed, tumor marking with the ZEOCLIP FS has the potential to replace intraoperative endoscopy as a method of intraoperative localization of gastric tumors.
4.Conclusion
This is the first report of fluorescent clip-guided gastrectomy. In our patients, preoperative endoscopic placement of the fluorescent clips was easy and was performed without any adverse events. Insertion of the clips did not prolong the duration of endoscopy. Intraoperatively, it was possible to observe the position of the clips by adjusting the angle between the stomach wall and the fluorescence laparoscope. The near-infrared clip method might be useful for intraoperative confirmation of the tumor site during gastrectomy.
Author contribution
SN have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data.
MY have been involved in drafting the manuscript or revising it critically for important intellectual content.
HT have get in on a discussion about this study.
TK have get in on a discussion about this study.
RM have get in on a discussion about this study.
NS have get in on a discussion about this study.
HO have get in on a discussion about this study.
SH have get in on a discussion about this study.
TS have get in on a discussion about this study.
YS have given final approval of the version to be published.
All authors read and approved the final manuscript.
Ethical approval and patient consent
This study was approved (approval No. 13-B-344) by the Research Ethics Committee of the International University of Health and Welfare, Tochigi, Japan.
We obtained consent from both of the patients for publishing this case report.
Funding sources
None to declare.
Registration of Research Studies
In accordance with the Declaration of Helsinki 2013, all research involving human participants has to be registered in a publicly accessible database. Please enter the name of the registry and the unique identifying number (UIN) of your study.
You can register any type of research at http://www.researchregistry to obtain your UIN if you have not already registered. This is mandatory for human studies only. Trials and certain observational research can also be registered elsewhere such as: ClinicalTrials.gov or ISRCTN or numerous other registries.
Provenance and peer review
Not commissioned, externally peer reviewed.
Declaration of competing interest
The authors declare no conflicts of interest including the manufacturer of the clips.
The authors were not involved at all in manufacture of the clips.
Acknowledgements
None.
Footnotes
Appendix ASupplementary data to this article can be found online at https://doi.org/10.1016/j.amsu.2020.04.026.
Appendix A.Supplementary data
The following is the Supplementary data to this article:
Multimedia component 1:
Click here to view.(25K, docx)Multimedia component 1
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