摘要
全系膜切除作为肿瘤外科的一种手术理念,目前已得到外科同道的广泛接受。而对于不同的器官,所谓全系膜的范围或标准是什么,除结直肠以外尚未完全明确。针对胃而言,其系膜构造复杂,且胚胎期系膜与成体后的解剖学系膜差异也较大,即使按照其解剖学系膜的范围来施行切除术，与目前推广的标准D2根治术相比，范围也相对过大。为此,我们提出外科系膜这一概念,即全系膜切除的实质应为全外科系膜切除。在临床实践中我们发现,胃与结直肠存在许多的对称相似性，通过对胃的延展、折叠等变形，即可在某种程度上实现其向结直肠的转变。转变后的胃不仅在形态、而且在血管分布、淋巴回流和系膜构成等方面均与结直肠存在惊人的吻合。在此基础上，我们提出胃的外科系膜范围，即肝胃韧带、肝十二指肠韧带、肝胰皱襞、脾胰皱襞、胃膈韧带、脾胃韧带、胃结肠韧带及大网膜等。这个范围与目前推广的D2根治术的范围也相吻合。本文还进一步探讨了胃癌的N分期。我们通过胃与结直肠的对照研究，将胃所属淋巴结重新归纳,即胃周、中间和根部3群，从而弥合了东西方学者长期存在的歧义。另外，我们也认同外科系膜以外淋巴转移的存在,即所谓的侧方转移。我们认为，关于胃肠癌的N分期,首先要界定系膜内、外淋巴结转移,如果存在系膜外淋巴结转移（侧方转移），应直接归入M1期，除非有证据显示侧方转移存在，否则不提倡进行扩大的侧方清扫。对于系膜内淋巴结转移,可依照目前NCCN规定的按淋巴结转移数量来划分（N1-3）。
As a surgical oncology coneept, complete mesenteric excision has been widely accepted. As to different organs, in addition to the rectum and the colon, the range or the criteria of the so-called complete mesenterium is not yet entirely clear. For the stomach, the mesogastric structure is so complicated, and the embryology and anatomy of the mesogastrium or the perigastric ligaments differed significantly. Even to perform a resection in accordance with the anatomy plane of mesogatrium, the mesogastric plane is still extended as compared to the current standard D2 radical resection. We therefore propose the concept of surgical mesogastrium, which means that the essence of en bloc mesogastric excision （EME） should be surgical mesogastric resection. In clinical practice, we found that a lot of symmetric similarity exists in stomach and colon, the morphological transformation from stomach to the colon can be accomplished to some extent by extension and folding of the stomach, and striking match exists in the morphology, distribution of the blood vessels, lymphatic drainage and mesenterium （mesogastrium or mesocolon）. On this basis, we propose the plane of the surgical mesogastrium, which includes the gastrohepatic ligament, hepatoduodenal ligament, hepatopanc-reatic folds, splenicpancreatic folds, gastrophrenic ligament, gastrosplenic ligament, gastrocolic ligament （supracolic omentum） and omentum. This surgical mesogastric plane coincides with the current plane of D2 radical resection. This paper further discussed the N staging of gastric cancer. By comparative study of the stomach and the colon, we could re-classify the stomach-associated lymph nodes into three groups, the perigastric, the middle and the loots, which may resolve the long-standing controversy between the Eastern and Western regarding this issue. In addition, we also agree with the presence of lymph node metastasis in the plane outside of the surgical mesogastrium, the so- called lateral lymph node metastasis. As for the N staging of gas
出处
《中华胃肠外科杂志》
CAS
CSCD
2013年第1期8-11,共4页
Chinese Journal of Gastrointestinal Surgery
关键词
胃肿瘤
外科系膜
全胃系膜切除术
Stomach neoplasms
Surgicalmesogastrium
En bloc mesogastric excision
