Evaluating the use of three-dimensional reconstruction visualization technology for precise laparoscopic resection in gastroesophageal junction cancer

Abstract

BACKGROUND

Laparoscopic gastrectomy for esophagogastric junction (EGJ) carcinoma enables the removal of the carcinoma at the junction between the stomach and esophagus while preserving the gastric function, thereby providing patients with better treatment outcomes and quality of life. Nonetheless, this surgical technique also presents some challenges and limitations. Therefore, three-dimensional reconstruction visualization technology (3D RVT) has been introduced into the procedure, providing doctors with more comprehensive and intuitive anatomical information that helps with surgical planning, navigation, and outcome evaluation.

AIM

To discuss the application and advantages of 3D RVT in precise laparoscopic resection of EGJ carcinomas.

METHODS

Data were obtained from the electronic or paper-based medical records at The First Affiliated Hospital of Hebei North University from January 2020 to June 2022. A total of 120 patients diagnosed with EGJ carcinoma were included in the study. Of these, 68 underwent laparoscopic resection after computed tomography (CT)-enhanced scanning and were categorized into the 2D group, whereas 52 underwent laparoscopic resection after CT-enhanced scanning and 3D RVT and were categorized into the 3D group. This study had two outcome measures: the deviation between tumor-related factors (such as maximum tumor diameter and infiltration length) in 3D RVT and clinical reality, and surgical outcome indicators (such as operative time, intraoperative blood loss, number of lymph node dissections, R0 resection rate, postoperative hospital stay, postoperative gas discharge time, drainage tube removal time, and related complications) between the 2D and 3D groups.

RESULTS

Among patients included in the 3D group, 27 had a maximum tumor diameter of less than 3 cm, whereas 25 had a diameter of 3 cm or more. In actual surgical observations, 24 had a diameter of less than 3 cm, whereas 28 had a diameter of 3 cm or more. The findings were consistent between the two methods (χ² = 0.346, P = 0.556), with a kappa consistency coefficient of 0.808. With respect to infiltration length, in the 3D group, 23 patients had a length of less than 5 cm, whereas 29 had a length of 5 cm or more. In actual surgical observations, 20 cases had a length of less than 5 cm, whereas 32 had a length of 5 cm or more. The findings were consistent between the two methods (χ² = 0.357, P = 0.550), with a kappa consistency coefficient of 0.486. Pearson correlation analysis showed that the maximum tumor diameter and infiltration length measured using 3D RVT were positively correlated with clinical observations during surgery (r = 0.814 and 0.490, both P < 0.05). The 3D group had a shorter operative time (157.02 ± 8.38 vs 183.16 ± 23.87), less intraoperative blood loss (83.65 ± 14.22 vs 110.94 ± 22.05), and higher number of lymph node dissections (28.98 ± 2.82 vs 23.56 ± 2.77) and R0 resection rate (80.77% vs 61.64%) than the 2D group. Furthermore, the 3D group had shorter hospital stay [8 (8, 9) vs 13 (14, 16)], time to gas passage [3 (3, 4) vs 4 (5, 5)], and drainage tube removal time [4 (4, 5) vs 6 (6, 7)] than the 2D group. The complication rate was lower in the 3D group (11.54%) than in the 2D group (26.47%) (χ² = 4.106, P < 0.05).

CONCLUSION

Using 3D RVT, doctors can gain a more comprehensive and intuitive understanding of the anatomy and related lesions of EGJ carcinomas, thus enabling more accurate surgical planning.

Key Words: Gastroesophageal junction cancer; Endoscopy; Tumor resection; Three-dimensional reconstruction visualization; Two-dimensional imaging; computed tomography

Core Tip: Three-dimensional reconstruction visualization technology (3D RVT) provides a more comprehensive and intuitive understanding of the anatomy and related lesions at the gastroesophageal junction. This study compared the 2D group, which underwent laparoscopic resection surgery after computed tomography (CT)-enhanced scanning, with the 3D group, which underwent laparoscopic resection surgery after CT-enhanced scanning and 3D RVT. Our findings highlight the benefits of using 3D RVT to improve surgical outcomes and reduce complications in patients with gastroesophageal junction cancer.

INTRODUCTION

Esophagogastric junction (EGJ) carcinoma is a malignant tumor that occurs at the junction of the esophagus and stomach[1]. Current research has indicated a global increase in the incidence of EGJ carcinoma[2], with a nearly 2.5-fold increase since the early 1970s[3]. The development of EGJ carcinoma is complex and associated with various factors, such as diet, smoking, alcohol consumption, chronic gastritis, and Helicobacter pylori infection.

Due to its unique anatomical location and highly invasive nature, it is the primary choice for most patients with EGJ carcinomas to achieve long-term survival. Compared with traditional open surgery, laparoscopic resection offers advantages such as less surgical trauma, fewer complications, and higher safety while providing comparable lymph node clearance and survival benefits[4]. However, owing to the unique location and biological behavior of EGJ carcinomas, there are significant challenges in achieving precise surgical visualization, selecting the appropriate surgical approach, improving lymph node clearance, and achieving good digestive tract reconstruction while minimizing intraoperative and postoperative complications.

With the advancement of medical imaging technology, three-dimensional reconstruction visualization technology (3D RVT) has become increasingly important for accurately assessing tumors before surgery, planning individualized surgical approaches, and facilitating the application of minimally invasive laparoscopic techniques in the treatment of EGJ carcinomas. Additionally, 3D RVT provides clear and detailed information regarding the location, size, infiltration, adjacent relationships, and lymphatic metastasis range of tumors[5].

With the emergence of clinical techniques and the widespread use of 3D RVT, studies have explored their application in preoperative evaluation, treatment planning, intraoperative complication guidance, and postoperative recovery for various diseases such as liver[6] and gastric cancers[7]. However, to the best of our knowledge, research on the use of 3D RVT in the context of EGJ carcinomas is limited. Comprehensive research on the application of this technology in the preoperative planning of EGJs is crucial. Therefore, this study aimed to evaluate the application and advantages of 3D RVT in precise laparoscopic resection of EGJ carcinomas.

MATERIALS AND METHODS

Patient characteristics

This study enrolled patients with EGJ carcinoma who were hospitalized at The First Affiliated Hospital of Hebei North University from January 2020 to June 2022. Data were obtained from electronic or paper-based medical records.

The inclusion criteria were as follows: Age between 18 and 75 years; preoperative diagnosis of Siewert type II or III EGJ carcinoma confirmed by gastroscopy, abdominal plain and enhanced computed tomography (CT) scan, and magnetic resonance imaging (MRI) with preoperative gastroscopic biopsy[8]; postoperative pathological confirmation of EGJ carcinoma; and eligibility and willingness to undergo surgery.

The exclusion criteria were as follows: severe comorbidities, such as severe heart disease and liver or kidney failure; advanced or distant metastasis before surgery; a tumor diameter of 10 cm or more; severe adhesions in the abdominal cavity discovered during surgery, with tumor infiltration into other organs; patients who received other treatment modalities before surgery; incomplete clinical data or relevant test results; and pregnant women.

According to different preoperative imaging guidelines for surgical decision-making, the 3D group (n = 52) underwent laparoscopic resection surgery based on 3D RVT after CT-enhanced scanning, while the 2D group (n = 68) underwent laparoscopic resection surgery after CT-enhanced scanning.

Specific methods

2D group: Before surgery, patients underwent comprehensive physical examinations and evaluations, including gastroscopy, gastrointestinal barium meal, CT scans, and other imaging examinations, to determine their surgical plan. The surgeon planned laparoscopic total gastrectomy preoperatively. The patients underwent standard preoperative protocols, including fasting and intestinal preparations, and received general anesthesia under the guidance of an anesthesiologist. After the surgery began, the surgeon used laparoscopy and endoscopy for intraoperative localization of tumor position and extent before its removal. This included resection of the gastric wall and esophageal mucosa to ensure complete tumor removal. Subsequently, the surgeon reconstructed the stomach and esophagus to restore gastrointestinal function. After surgery, frozen section examination was performed on the surgical margins to ensure the absence of residual cancer cells. The patients entered the postoperative recovery period and underwent standardized postoperative care and rehabilitation training.

3D group: 3D reconstruction was performed using Mimics software (Materialise Corp., Belgium), which is an interactive medical image-control system. The CT-enhanced scan data of the EGJ were saved as “DICOM” format files and imported into the 3D visualization software for editing and optimization of the 3D model. In the 3D visualized model of reconstruction, the position and size of the tumor, morphology and density of the tumor, lymph node metastasis, veins and surrounding veins, and abnormalities of other structures (such as the esophagus, stomach, liver, lung, and spleen) were clearly displayed. 3D RVT can display tumor position, vascular course, and adjacent relationships in a 360° stereo view. The software allows the doctor to rotate, zoom in and out, measure distances, and observe and analyze the anatomical data of tumors in relation to the surrounding tissues from various angles. This helps evaluate the extent of tissue resection, range of lymph node dissection, and difficulty of digestive tract reconstruction, thereby enabling more accurate surgical planning and better surgical path planning, such as thoracotomy, laparotomy, or a combined approach. The 3D model and 3D RVT guide the preoperative planning of laparoscopic resection surgery and assist with intraoperative procedures. After the surgery was completed, the patients entered the postoperative recovery period and underwent standardized postoperative care and rehabilitation training.

Observation indicators

Observation indicators included the deviation between tumor-related information based on 3D RVT and clinical practice. Indicators included the maximum tumor diameter and infiltration length. It also included a comparison of surgical outcomes between the 3D and 2D groups.

Intraoperative indicators were the operative time, intraoperative blood loss, number of lymph node dissections, and R0 resection rate. Postoperative indicators were the postoperative hospital stay, postoperative gas evacuation time, drainage tube removal time, and complications such as incision infection, anastomotic fistula, lung infection, adhesive intestinal obstruction, and anastomotic bleeding.

Statistical analysis

Statistical analyses were performed using SPSS software version 32.0 (IBM Corp., New York, United States). Normally distributed continuous data were presented as mean ± SD; a t-test was used for analysis when comparing two groups. Non-normally distributed continuous data were expressed as interquartile ranges (IQRs); the Mann-Whitney U test was used for analysis when comparing two groups. Categorical data were reported as frequencies and percentages, and the χ² test was used for analysis when comparing two or more groups. The kappa test was used for consistency analysis, with higher values indicating better consistency. In this study, a Pearson’s correlation analysis was employed. A P value of less than 0.05 was considered statistically significant.

RESULTS

This study consisted of two parts: the deviation between tumor-related information based on 3D RVT and clinical practice and the surgical outcome indices between the 3D and 2D groups (Figure 1).

Figure 1 Flowchart of the research scheme. 3D: Three-dimensional; 2D: Two-dimensional.

Clinical characteristics

A total of 112 patients were enrolled in the study. There were no statistically significant differences between the clinical characteristics of the two groups (all P > 0.05), suggesting that the data were well-balanced and the study results were reliable and comparable (Table 1).

Table 1 Analysis of patient characteristics in each group, n (%).

Variables	3D group (n = 52)	2D group (n = 68)	χ2/t value	P value
Age (yr, mean ± SD)	51.96 ± 8.30	50.28 ± 9.10	1.042	0.300
BMI (kg/m2, mean ± SD)	21.68 (19.62, 24.92)	22.06 (20.45, 23.92)	-0.172	0.863
Sex			2.631	0.105
Male	38 (73.08)	40 (58.82)
Female	14 (26.92)	28 (41.18)
Pathological pattern			0.502	0.778
Squamous cell carcinoma	15 (28.85)	18 (26.47)
Adenocarcinoma	24 (46.15)	29 (42.65)
Other	13 (25.00)	21 (30.88)
Helicobacter pylori infection			0.900	0.343
Yes	12 (23.08)	21 (30.88)
No	40 (76.92)	47 (69.12)
Siewert type			1.222	0.269
II	23 (44.23)	37 (54.41)
III	29 (55.77)	31 (45.59)
Scope of resection			0.351	0.554
Whole stomach	27 (51.92)	39 (57.35)
Proximal stomach	25 (48.08)	29 (42.65)
Operative route			0.2115	0.643
Transthoracic approach	35 (67.31)	43 (63.24)
Transabdominal	17 (32.69)	25 (36.76)
Maximum tumor diameter			0.543	0.461
< 3 cm	24 (46.15)	36 (52.94)
≥ 3 cm	28 (53.85)	32 (47.06)
Infiltration length			1.211	0.271
< 5 cm	20 (38.46)	33 (48.53)
≥ 5 cm	32 (61.54)	35 (51.47)

BMI: Body mass index; 3D: Three-dimensional; 2D: Two-dimensional.

3D RVT of the tumor and clinical practice

Among 52 patients who underwent 3D RVT, 27 had a maximum tumor diameter of less than 3 cm, whereas 25 had a maximum diameter of 3 cm or more. In actual surgical observations, 24 patients had a maximum tumor diameter of less than 3 cm, whereas 28 had a maximum diameter of 3 cm or more. For the infiltration length in the 3D RVT, 23 patients had a length of less than 5 cm, while 29 had a length of 5 cm or more. In the actual surgical observations, 20 had a length of less than 5 cm, while 32 had a length of 5 cm or more. These findings were consistent between the two methods (P > 0.05). The kappa consistency coefficients were 0.808 and 0.486, respectively. Pearson’s correlation analysis showed a positive correlation, with a coefficient of 0.814 for one set and 0.490 for the other set (Table 2 and Figure 2).

Figure 2 Actual tumor conditions under three-dimensional reconstruction visualization and in clinical practice. A: Maximum tumor diameter; B: infiltration length. 3D: Three-dimensional; 2D: Two-dimensional.

Table 2 Tumor conditions under three-dimensional reconstruction visualization and clinical practice, n (%).

	3D (n = 52)	Clinical practice (n = 52)	χ2/t value	P value
Maximum tumor diameter			0.346	0.556
< 3 cm	27 (51.92)	24 (46.15)
≥ 3 cm	25 (48.08)	28 (53.85)
Infiltration length			0.357	0.550
< 5 cm	23 (44.23)	20 (38.46)
≥ 5 cm	29 (55.77)	32 (61.54)

3D: Three-dimensional.

Intraoperative indices in the 3D and 2D groups

The 3D model group had a shorter operative time and less intraoperative blood loss than the 2D model group; however, the number of lymph node dissections and the R0 resection rate were higher in the 3D model group (P < 0.05) (Table 3).

Table 3 Comparison of intraoperative indices between the three- and two-dimensional groups (mean ± SD).

Variables	3D group (n = 52)	2D group (n = 68)	χ2/t value	P value
Operative time (min)	157.02 ± 8.38	183.16 ± 23.87	-8.381	< 0.001
Intraoperative blood loss (mL)	83.65 ± 14.22	110.94 ± 22.05	-8.212	< 0.001
Number of lymph node dissections (n)	28.98 ± 2.82	23.56 ± 2.77	10.539	< 0.001
R0 resection rate (%)	80.77% (42/52)	61.64% (42/68)	5.068	0.024

3D: Three-dimensional; 2D: Two-dimensional.

Postoperative indices in the 3D and 2D groups

The 3D group had a significantly shorter hospitalization time, exhaust time, and drainage tube removal time than the 2D group (P < 0.05) (Table 4).

Table 4 Comparison of postoperative indices between the three- and two-dimensional groups.

Variables	3D group (n = 52)	2D group (n = 68)	Z value	P value
Postoperative hospital stay (d, IQR)	8 (8, 9)	13 (14, 16)	-9.341	< 0.001
Postoperative gas evacuation time (d, IQR)	3 (3, 4)	4 (5, 5)	-7.402	< 0.001
Drainage tube removal time (d, IQR)	4 (4, 5)	6 (6, 7)	-8.413	< 0.001

IQR: Interquartile range; 3D: Three-dimensional; 2D: Two-dimensional.

Complications

A total of 18 patients in the 2D group experienced complications such as incision infection, anastomotic fistula, lung infection, adhesive intestinal obstruction, and anastomotic bleeding. Six patients in the 3D group developed postoperative complications; hence, the percentage of complications in the 3D group (11.54%) was lower than that in the 2D group (26.47%) (Figure 3).

Figure 3 Stacking diagram of the proportion of complications in the three-dimensional and two-dimensional groups. ^aP < 0.05. 3D: Three-dimensional; 2D: Two-dimensional.

DISCUSSION

The factors influencing radical resection of EGJ carcinomas can be summarized as anatomical, physiological, and biological characteristics of the tumor and choice of surgical approach. The anatomical location of the EGJ determines the difficulty and feasibility of the surgery. The biological properties of the tumor such as tumor size, extent of invasion, and lymph node metastasis also influence the feasibility of surgery. Moreover, the choice of surgical approach and the specific location of the tumor has a significant impact on its complete resection, radical lymph node clearance, and gastrointestinal reconstruction. Therefore, accurate preoperative assessment of patients with EGJ carcinomas and selection of the appropriate surgical approach to ensure the effectiveness and safety of the surgery has become both the focus and difficulty in their treatment.

Since the 1970s, new imaging technologies have provided effective methods for observing tissue and organ function. Traditional 2 imaging methods lack the ability to provide precise preoperative assessment and planning, limiting their use in qualitative disease analysis. In contrast, 3D reconstruction utilizes computer image processing technology to analyze, calculate, segment, extract, and merge data from 2D imaging. This advanced technology offers accurate and visually intuitive data support, thereby enabling improved surgical planning and evaluation[5,9,10]. 3D reconstruction uses computer image-processing technology to analyze, calculate, segment, extract, and fuse traditional 2D imaging data. More importantly, this technology provides virtual surgical demonstration and 3D image measurement capabilities, allowing surgeons to use medical 3D surgical simulations, intraoperative navigation systems, and other operating systems for accurate surgical assessment and planning[11,12].

The results of this study indicate that 3D RVT provides accurate measurements of tumor characteristics and extent of infiltration, which is consistent with actual surgical observations. This is in line with previous studies[13] suggesting that 3D RVT have high reliability and accuracy in tumor diagnosis and surgical planning. Zeng et al[14] demonstrated that preoperative 3D RVT can shorten surgical time and reduce intraoperative blood loss. These positive outcomes can be attributed to the improved localization of tumors and enhanced understanding of their interactions with the surrounding tissues provided by 3D reconstruction[14,15]. We observed similar results in this study, with the 3D group exhibiting a shorter operative time, less intraoperative blood loss, a higher R0 resection rate, and a lower incidence of complications. This confirms the guiding and predictive capabilities of 3D RVT. Possible reasons for these findings include the fact that 3D RVT can provide more comprehensive anatomical information and allow for virtual surgical rehearsals preoperatively, helping surgeons to become familiar with the surgical steps and operative pathways, thereby reducing the operative time. Furthermore, 3D RVT can provide more comprehensive information on vascular structures, enabling surgeons to preoperatively understand the distribution and location of blood vessels, thereby reducing the risk of vascular injury and intraoperative blood loss. Additionally, 3D RVT can accurately display the location and quantity of lymph nodes, helping surgeons in determining the extent of lymph node dissection, and enhancing the precision of resection.

A meta-analysis conducted on the use of 3D RVT in tumor surgery demonstrated significant reductions in operative time, intraoperative blood loss, and incidence of complications[16]. In addition, previous studies on liver cancer and hilar cholangiocarcinoma showed that 3D RVT improved the accuracy and safety of surgery while reducing intraoperative blood loss and complications, shortening the postoperative intestinal gas discharge time, and increasing the rates of R0 resection and lymph node dissection[17,18]. In our study, the incidence of complications was lower in the 3D group than in the 2D group (11.54% vs 26.47%). This finding may be attributed to the clearer and more stereoscopic views of anatomical structures provided by 3D RVT, which aided the surgeons to more accurately evaluate the surgical area prior to surgery and formulate more precise surgical plans, thereby reducing intraoperative accidents and complications. Additionally, 3D RVT enhanced the accuracy of surgery, potentially shortening the operative time, reducing surgical trauma, and lowering the risk of infection and complications. Patients recovered faster, leading to a shorter hospital stay, improved quality of life, and reduced postoperative discomfort and long-term health problems. Nevertheless, other studies have reported inconsistent results. A study on the repair of total extraperitoneal inguinal hernia reported that the use of 3D RVT did not significantly reduce the operative time, hospital stay, or pain score; however, there were fewer peritoneal tears[19]. Another study on complex lower lobe resection showed that the use of 3D RVT did not significantly affect intraoperative blood loss, postoperative drainage volume, postoperative hospital stay, pneumonia/pulmonary atelectasis, and hemoptysis but shortened the operative time[20]. This may be due to differences in tumor types and surgical procedures. We believe that the application prospects of 3D RVT in tumor surgery are very broad but require more time and financial investment. Moreover, for some complex surgeries, the effect of 3D RVT may not be as expected. Further research is required to confirm its application in surgeries of different types and complexities. Simultaneously, we need to explore more surgical techniques and methods to further improve the safety and accuracy of surgery.

This study had certain limitations that should be acknowledged. First, the retrospective design restricted the exploration of data not routinely documented in medical records. Second, the use of specific inclusion criteria might have introduced selection bias, potentially affecting the generalizability of findings. Finally, the absence of long-term follow-up data hindered the assessment of long-term safety and surgical intervention outcomes. Further research is necessary to validate the results and address the limitations and challenges that may be encountered in practical applications. For instance, 3D RVT may require additional equipment and software support, which may increase the complexity and cost of surgeries. Physicians who are unfamiliar with this technology may also need additional training and time to master such technology. The images generated by 3D RVT may require specialized knowledge to interpret them correctly, necessitating interdisciplinary collaboration between radiologists and surgeons. Nonetheless, these challenges can be overcome to realize the potential benefits by providing dedicated training courses and workshops for physicians to quickly learn 3D RVT. Developing standardized workflows for 3D RVT can aid physicians in utilizing these tools more effectively and ensure consistency in surgical planning. While there may be initial investments, 3D RVT may reduce the overall healthcare costs in the long run by reducing complications, shortening hospital stays, and improving surgical success rates.

CONCLUSION

The findings of this study align with those of previous studies and provide additional evidence for the efficacy of 3D RVT in surgery for EGJ carcinomas.