An Optimal Surgical Approach for Suprapancreatic Area Dissection in Laparoscopic D2 Gastrectomy with Complete Mesogastric Excision
An Optimal Surgical Approach for Suprapancreatic Area Dissection in Laparoscopic D2 Gastrectomy with Complete Mesogastric Excision
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腹腔镜 D2 胃切除术中胰上区域解剖的最佳手术方法
DOI：
10.1007/s11605-019-04467-8
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发表时间：
2020-01-02
影响因子：
3.2
通讯作者：
Gong, Jianping
中科院分区：
文献类型：
--
作者：
Cao, Beibei;Xiao, Aitang;Gong, Jianping
背景胰上区是胰腺癌根治术中解剖结构复杂的区域，其淋巴结清扫技术难度大、要求高。(1-4)以前，我们已经证明了胃系膜中存在播散性癌细胞（5，6），并提出了胃切除术的胃系膜模型。(7)因此，腹腔镜D2淋巴结清扫加完全胃系膜切除术（D2+CME）被认为是进展期胃癌外科治疗的新概念。(8)与传统的D2胃切除术相比，D2+CME手术与更少的游离腹膜内癌细胞数量相关，并且具有更好的无病生存率。(9)在胃系膜模型的概念下，建议的D2+CME手术可以帮助外科医生更好地定义胰上胃系膜的解剖边界，从而使用它来实现胰上区夹层的完整和标准切除。在这里，我们简要介绍了我们的病例系列腹腔镜根治性胃大部切除术和D2+CME与R 0切除术的围手术期结果，并提供了一个视频，详细介绍了腹腔镜D2+CME方法的技术方面的胰上区域剥离。方法所有患者均行腹腔镜胃大部切除术（D2+CME），并行根治性R 0切除。本研究已获得同济医院伦理委员会批准（唯一参考编号：TJ-IRB 20180811）。视频中的程序描述如下。基于我们先前的胃系膜模型（也称为“桌子模型”，补充图1），胰上胃系膜分别附着于胃小弯或胃后壁并延伸至胰上区域。(7)外科医生站在患者左侧，助手将胃向上和头侧抬起，以暴露胰上胃系膜，包括左胃系膜（LGM）、右胃系膜（RGM）和后胃系膜（PGM）。首先，向胰上区左侧，LGM的“三连接”点暴露。使用能量装置，外科医生打开浆膜层并识别胃后间隙。LGM和PGM被钝性地游离，其间显示融合的胃后间隙。底界和后界均为光滑的固有筋膜表面所覆盖，互为“中间层”。其次，在十二指肠内侧，外科医生沿着胃十二指肠动脉（GDA）向上钝性分离辅助组织，暴露右胃肠系膜（RGM）。接下来，在游离左胃肠系膜后，外科医生去除粘附在肝总动脉（CHA）上的脂肪组织，并在用三夹剥离血管周围鞘后暴露左胃动脉的根部。然后，外科医生沿着CHA和门静脉（HPV）朝向胰上区域右侧解剖RGM;之后，识别并结扎右侧胃血管和RGM。最后，解剖脾血管的上级边界。PGM的前叶被结扎的胃后血管抬高。值得注意的是，在某些情况下，胃后血管可能不存在。消化道重建采用Roux-en-Y法。结果回顾性分析2017年8月28日至2018年12月27日期间107例接受腹腔镜根治性胃大部切除术（D2+CME）R 0切除的患者。采用D2+CME技术暴露胰上胃系膜（包括RGM、PGM和LGM）后，整块切除LN和7、9、8a、12 a和11 p附近的脂肪组织。这项研究招募了67名男性和40名女性。中位年龄为55岁，体重指数（BMI）为23.0 kg/m2（补充表1）。取出的区域淋巴结的中位数为31个（范围25-41），包括22个（范围17-27.5）胰上淋巴结。中位失血量为14 ml（范围6-34）。中位总手术时间为287分钟（范围265.5-313.5），腹腔镜手术时间为132分钟（范围116-142）（补充表2）。术后发病率为9.3%，死亡率为0%（补充表3）。中位随访时间为10个月（范围8-13）。随访期间无患者丢失（补充表4）。结论腹腔镜下胃大部切除联合D2+CME手术可完整、规范地切除胰上区夹层。
Background During the radical operation, the suprapancreatic area is featured by anatomical complexity, and the lymph node dissection for this area is technically difficult and demanding.(1-4) Previously, we have demonstrated the presence of disseminated cancer cells in the mesogastrium(5,6) and presented a mesogastrium model for gastrectomy.(7) As a consequence, laparoscopic D2 lymphadenectomy plus complete mesogastric excision (D2+CME) was proposed as a new concept in the surgical treatment of advanced gastric cancer.(8) D2+CME procedure has been shown to be associated to lower number of free intraperitoneal cancer cells and with a better disease-free survival than conventional D2 gastrectomy.(9) Under the concept of mesogastrium model, the proposed D2+CME procedure could help surgeons better define the anatomical boundaries of suprapancreatic mesogastrium, thus using it to achieve a complete and standard excision of the suprapancreatic area dissection. Here, we briefly present perioperative results of our case series with the laparoscopic curative subtotal gastrectomy and D2+CME with a R0 resection and present a video to detail the technical aspects of a laparoscopic D2+CME approach for suprapancreatic area dissection. Methods All patients in this study underwent laparoscopic subtotal gastrectomy (D2+CME) with a curative R0 resection. This study was approved by the Tongji Hospital Ethics Committee (Unique Reference Number: TJ-IRB20180811). The procedures in the video are described as follows. Based on our previous mesogastrium model (also named "Table model", Supplemental Figure 1), the suprapancreatic mesogastrium is attached to the lesser curvature or the posterior gastric wall and extended to the suprapancreatic area, respectively.(7) Surgeon stands on patient left side, and the assistant lifts the stomach upward and cephalic to expose the suprapancreatic mesogastrium including left gastric mesentery (LGM), right gastric mesentery (RGM) and posterior gastric mesentery (PGM). First of all, towards to the left side of the suprapancreatic area, the "tri-junction" point of LGM is exposed. Using an energy devise, surgeon opens serosa layer and identifies the retrogastric space. The LGM and PGM are mobilized bluntly, between which a fusion retrogastric space is revealed. Both the LGM and PGM are covered by smooth and shiny surfaces of fascial propria and regarded as the "meso-bed" mutually. Secondly, at the inner side of duodenum, surgeon bluntly separates the adjuvant tissues along gastro-duodenal artery (GDA) upward and exposes right gastric mesentery (RGM). Next, after mobilizing the left gastric mesentery, surgeon removes the adipose tissue adherent to the common hepatic artery (CHA) and exposes the root of the left gastric artery after dissecting the perivascular sheath with triple-clips. Then, surgeon dissects RGM along the CHA and portal vein (HPV) towards the right side of the suprapancreatic area; afterwards, the right gastric vessels and RGM are identified and ligated. Lastly, the superior border of splenic vessels is dissected. The anterior lobe of the PGM is raised up with ligated posterior gastric vessels. Remarkably, posterior gastric vessels may be absent in some cases. Reconstruction of the alimentary tract is Roux-en-Y method. Standard recovery protocols are followed in postoperative treatments.Results Between August 28th 2017 and December 27th 2018, 107 patients receiving laparoscopic curative subtotal gastrectomy (D2+CME) with a R0 resection were retrospective collected in this study. After exposing the suprapancreatic mesogastrium including RGM, PGM and LGM with D2+CME procedure, the LNs and fat tissues around 7, 9, 8a, 12a and 11p were removed en bloc in all patients. This study recruited 67 males and 40 females. The median age was 55 years, with body mass index (BMI) 23.0 kg/m(2) (Supplemental Table 1). The median number of retrieved regional lymph nodes was 31 (range 25-41), including 22 (range 17-27.5) suprapancreatic lymph nodes. The median volume of blood loss was 14 ml (range 6-34). The median total operation time was 287 min (range 265.5-313.5) and laparoscopic surgery time was 132 min (range 116-142) (Supplemental Table 2). Postoperative morbidity occurred at a rate of 9.3 %, and the mortality rate was 0% (Supplemental Table 3). The median follow-up was 10 months (range 8-13). No patient was lost during follow-up (Supplemental Table 4). Conclusion A laparoscopic subtotal gastrectomy with D2+CME procedure provides for a complete and standardized en bloc excision of the suprapancreatic area dissection.