"双眼看世界"——腹腔镜胃癌根治术膜解剖复制体会与思考  

"See fine world"-copy experience and thinking of membrane anatomy in laparoscopic radical gastrectomy (D2+CME)

作　　者：毕然 魏玉哲[1] 王宽[1] Bi Ran;Wei Yuzhe;Wang Kuan(Department of Gastrointestinal Surgery, Harbin Medical University Cancer Hospital, Harbin 150086, China)

机构地区：[1]哈尔滨医科大学附属肿瘤医院胃肠外科150086

出　　处：《中华胃肠外科杂志》2019年第5期418-422,共5页Chinese Journal of Gastrointestinal Surgery

基　　金：哈尔滨市科技创新人才基金(2015RAXYJ059);哈尔滨医科大学附属肿瘤医院海燕基金(JJED2016-02).

摘　　要：原发病灶移除和淋巴结清扫是胃癌外科治疗的主要内容。然而进展期胃癌D2根治性术后的高复发率并未得到改观。研究发现,潜在存在于胃系膜内的离散癌结节可能是胃癌预后的重要影响因素。随着腹腔镜设备发展,不断放大的"亚微视野"使系膜完整切除成为可能。龚建平教授倡导"膜解剖"优化胃癌根治手术理念:D2基础上增加完整系膜切除(CME),即D2+CME手术。通过完整胃系膜的组织学屏障作用,以期达到防止肿瘤细胞泄露残留于手术野的目的。D2+CME与既往的D2/D2+系统性胃系膜切除术(SME)、全胃系膜切除(EME)等理念本质区别在于:双重因素导向(淋巴结和离散癌结节)对比单一因素导向(淋巴结)。实践D2+CME手术数十例后,笔者认为,其在理念内涵上(双重因素导向)和操作外延上(系膜床的理解)均大于D2。D2+CME手术中,依赖放大视野下的解剖辨识,视胃系膜与系膜床的贴合面为唯一操作平面,具可重复性。探讨胃癌根治术整块切除确切边界问题是时代发展的必然,兼顾淋巴结转移及离散癌结节转移双重导向的D2+CME手术是探索整块切除精准边界的适宜途径。虽然胃癌"膜解剖"理论的发展中尚有待大量的临床与基础研究需要深入探讨,但有理由预见,随着离散癌结节和"亚微外科"被逐步认知与关注,胃癌根治术中整块切除边界确定及其生存获益关系研究的深入,D2+CME手术将引领胃癌治疗理念优化的新时代。Primary lesion removal and lymph node dissection are the main constituents of radical gastrectomy. However, the high recurrence rate after D2 radical gastrectomy for advanced gastric cancer has not improved. Recently, studies have found that discrete tumor deposits in the mesogastrium may be an important factor affecting the prognosis of gastric cancer after surgery. With the development of laparoscopic equipment, the ever-expanding "submicroscopic vision" makes it possible to completely remove the mesogastrium. Professor Gong Jianping advocated "membrane anatomy" to optimize the concept of radical gastrectomy: D2- based complete mesenteric resection (CME), namely D2+CME procedure. To prevent the leakage of tumor cells into the surgical field, as histological barrier, the intact mesogastrium should be located. The essential difference between D2+CME and previous D2/D2+systematic mesogastrium excision (SME), en-bloc mesogastric excision (EME) is as follow: double-factor guiding (lymph nodes and discrete tumor deposits) vs. single factor guiding (lymph nodes only). After practicing dozens of radical gastrectomy (D2+CME) authors believe that its conceptual connotation (double factor guiding) and operational extension (above mesentery bed) cover D2. In D2+CME surgery, depending on the anatomical identification under the magnified field of view, the conformal space between gastric mesentery and mesenteric beds is unique operational plane with repeatability. These findings and considerations address one problem: where is the precise boundary of en bloc principle in radical gastrectomy? In author′s opinion, with laparoscopy and "sub-microsurgery" progression and detection of discrete tumor deposit metastasis, survival benefit from definition of en bloc boundary in radical gastrectomy will be widely recognized. Meanwhile, D2+CME procedure is an appropriate way for study. Although the development of the "membrane anatomy" concept for gastric cancer still requires many further clinical and basic researches, it is reasona

关 键 词：胃肿瘤 膜解剖 胃癌D2根治术 完整系膜切除术 

分 类 号：R735.2[医药卫生—肿瘤]