[Practical membrane anatomy of en bloc mesogastrium excision in lymph node dissection of gastric cancer]

Abstract

Gastric cancer is a common malignant tumor of digestive system. D2 procedure is recognized as the standard operation for advanced gastric cancer at present. However, controversies still exist in the standardization and quality control of surgical procedures. Total mesorectal excision (TME) and complete mesocolic excision (CME) based on the membrane anatomy perfectly solve these problems in the treatment for colorectal cancer. However, the complexity of mesogastrium determines that TME and CME cannot be easily transplanted to the treatment of gastric cancer. The practical membrane anatomy in gastric cancer surgery is just emerging and its impact on the treatment of gastric cancer is immeasurable. By reviewing the evolution and embryonic development of digestive system, and combining with actual operation, this paper analyzes and redefines several key issues such as traditional Toldt space, Gerota fascia and complete mesenteric excision. On this basis, we propose a novel and feasible surgical procedure named regional en bloc mesogastrium excision (rEME) for distal gastric cancer. The concept of en bloc mesogastrium excision (EME) based on membrane anatomy may have some influences on the lymph node grouping from the 'Japanese Classification of Gastric Carcinoma'. Performance of EME may reduce the controversies about the group of lymph nodes and their borders. EME in the infra-pyloric region weakens the significance of subdivision of No.6 lymph nodes into No.6a, No.6v and No.6i. More studies are needed in the construction of a mature theoretical system for practical membrane anatomy in gastric surgery.

Keywords: Gastric mesentery; Gastric neoplasms; Membrane anatomy; Regional en bloc mesogastrium excision (rEME).