Short-term outcomes of laparoscopic D2 lymphadenectomy with complete mesogastrium excision for advanced gastric cancer
Short-term outcomes of laparoscopic D2 lymphadenectomy with complete mesogastrium excision for advanced gastric cancer
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腹腔镜D2淋巴结清扫术联合胃系膜完全切除治疗晚期胃癌的短期疗效
DOI：
10.1007/s00464-016-4847-4
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发表时间：
2016-11-01
影响因子：
3.1
通讯作者：
Gong, Jianping
中科院分区：
文献类型：
--
作者：
Xie, Daxing;Yu, Chaoran;Gong, Jianping
背景D2淋巴结清扫术已被广泛接受为局部进展期胃癌外科治疗的标准方法[1，2]。然而，胃周软组织的解剖边界和切除范围均未描述[3-7]。我们以前的研究证明了胃系膜中存在播散性癌细胞[8，9]，并为胃切除术提供了可理解的胃系膜模型[10]。因此，D2淋巴结切除术加完全胃系膜切除术D2 + CME（D2 + CME）是本研究首次提出的一种新的胃癌根治术式，旨在评估其安全性、可行性和近期手术效果。华中科技大学。所有参与者均提供了参与研究的书面知情同意书。本研究已获得同济医院伦理委员会的批准。视频中的标准手术程序描述如下。用特制纱布沿着胃结肠韧带，然后向左结肠弯曲处剥离。钝性分离脂肪组织，找到筋膜平面。沿着平面暴露脾下极区。在左胃网膜血管（LGEV）的起源之前，夹闭并切割。该区域的所有动员脂肪组织均定义为左胃网膜肠系膜（LGEM）[10]。接下来，转向幽门下区。解剖右胃网膜肠系膜（RGEM）和横结肠系膜之间的筋膜平面。转向胰头，去除覆盖的脂肪组织，识别肠系膜上上级静脉，暴露右胃网膜血管（RGEV）的起源。剪下来。所有周围动员的脂肪组织均定义为RGEM [10]。将胃向头侧反折，移至胰腺上级边界，切开浆膜，用纱布经平面钝性游离。转向肝总动脉（CHA），去除粘附的脂肪组织。暴露胃左静脉根部，夹闭切断。解剖胃左动脉粗鞘，显露根部，行夹闭、切断。所有动员的侧向脂肪组织和背侧部分定义为左胃肠系膜（LGM）[10]。向右，沿CHA和肝门静脉（HPV）解剖。然后，向左移LGM并沿沿着脾动脉分离，直至到达胃后壁。移到胃前区，分离小网膜。清理脂肪组织和神经沿着胃小弯直到胃食管交界处。暴露并切割右胃血管（RGV），其中动员的脂肪组织定义为右胃肠系膜（RGM）[10]。消化道重建采用体外吻合术。术后treatments.ResultsFifty-four患者在2014年9月和2015年3月之间已被招募知情同意，并进行了腹腔镜D2 + CME由一个单一的外科医生。平均回收区域淋巴结数量为35.04 ± 10.70（范围14-55）。平均失血量为12.44 ± 22.89 ml（范围5-100）。平均腹腔镜手术时间为127.82 ± 17.63 min（范围110-165）。平均住院时间为11.09 ± 4.28天（8-28天）。住院期间无手术并发症发生。
BackgroundD2 lymphadenectomy has been widely accepted as a standard procedure of surgical treatment for local advanced gastric cancer [1, 2]. However, neither the dissection boundary nor the extent of the excision for perigastric soft tissues has been described [3–7]. Our previous researches demonstrate the existence of disseminated cancer cells in the mesogastrium [8, 9] and present an understandable mesogastrium model for gastrectomy [10]. Hence, the D2 lymphadenectomy plus complete mesogastrium excision (D2 + CME) is firstly proposed in this study, aiming to assess the safety, feasibility and corresponding short-term surgical outcomes.MethodsAll of these patients underwent laparoscopy assisted D2 + CME radical gastrectomy with a curative R0 resection, and all the operations were performed by Prof. Jianping Gong, chief of GI surgery of Tongji Hospital, Huazhong University of Science and Technology. All participants provided informed written consent to participate in the study. This study was approved by the Tongji Hospital Ethics Committee. The standard surgical procedures in the video are described as follows. Dissect along the gastrocolic ligament and then toward the left colic flexture with special made gauze. Bluntly separate the adipose tissues to find fascia plane. Expose along the plane toward the splenic inferior polar area. Precede to the origins of left gastroepiploic vessels (LGEVs), clip and cut. All the mobilized adipose tissues in this area are defined as left gastroepiploic mesentery (LGEM) [10]. Next, turn to infra-pyloric area. Dissect the fascia plane between right gastroepiploic mesentery (RGEM) and transverse mesocolon. Turn to the pancreas head, remove the covering adipose tissues, identify the superior mesentery vein and expose the origins of right gastroepiploic vessels (RGEVs). Clip and cut. All the surrounding mobilized adipose tissues are defined as RGEM [10]. Move to the superior boarder of pancreas with the stomach reflected cephalad, incise the serosa and bluntly mobilize through the plane with gauze. Turn to the common hepatic artery (CHA), remove the adherent adipose tissue. Expose the root of left gastric vein, clip and cut. Dissect the thick sheath of left gastric artery, expose at the root, trip clip and cut. All mobilized lateral adipose tissues and dorsal parts are defined as left gastric mesentery (LGM) [10]. Toward right, dissect follow the CHA and hepatic portal vein (HPV). Next, move toward the left side of LGM and dissect along the splenic artery until reaching the posterior gastric wall. Move to the anterior area of stomach and divide the lesser omentum. Clean up the adipose tissue and nerves along the lesser curvature up to the gastroesophageal junction. Expose and cut the right gastric vessels (RGVs) where the mobilized adipose tissues are defined as right gastric mesentery (RGM) [10]. Reconstruction of the alimentary tract was done by extracorporeal anastomosis. Standard recovery protocols were followed in postoperative treatments.ResultsFifty-four patients between September 2014 and March 2015 have been recruited with informed consent and underwent laparoscopic D2 + CME by a single surgeon. The mean number of retrieved regional lymph nodes was 35.04 ± 10.70 (range 14–55). The mean volume of blood loss was 12.44 ± 22.89 ml (range 5–100). The mean laparoscopic surgery time was 127.82 ± 17.63 min (range 110–165). The mean hospitalization time was 11.09 ± 4.28 days (range 8–28). No operative complication was observed during the hospitalization …