RESUMEN
The posterior gastric mesentery is one of the six mesenteries of the stomach in the membrane anatomy theory. It locates in the upper area of the pancreas, surrounds the posterior gastric vessels, and is adjacent to the short gastric mesentery by the left side, and is adjacent to the left gastric mesentery by the right side, which fixes the fundus body to the posterior abdominal wall of the upper area of pancreas. Due to its anatomical structure, in complete mesentery excision (CME)+D2 surgery, it is a surgical approach to deal with gastric mesentery in the upper area of pancreas; the second step of the "Huang's three-step method" corresponds to the posterior gastric mesentery in the theory of membrane anatomy. In the surgery of benign diseases of the stomach, laparoscopic sleeve gastrectomy (LSG) and laparoscopic Nissen fundoplication, if the short gastric vessels are difficult to be exposed and safely divided, we can dissect the posterior gastric mesentery firstly, and then hoist the fundus of the stomach in order to help dissection of the short gastric vessels. The membrane anatomy theory, as a frontier theory, provides us the new surgical perspectives and paths in gastric surgery.
Asunto(s)
Humanos , Gastrectomía , Laparoscopía , Escisión del Ganglio Linfático , Mesenterio/cirugía , Neoplasias Gástricas/cirugíaRESUMEN
In radical gastrectomy, D2 systemic lymphadenectomy, which includes complete resection of the bursa sac and omentum, and D2 extended lymphadenectomy outside the bursa sac, is a standard procedure accepted by gastrointestinal surgeons generally. However, a series of clinical trials showed that both D2 extended lymphadenectomy and bursectomy could not improve oncologic benefit, but increase surgical risk. These findings showed a lot of conflicts in gastric cancer surgery, gastrointestinal surgery, even in oncological surgery. It was demonstrated that bursa sac and greater omentum were neither mesogastrium nor the proximal segment of dorsal mesogastrium (PSDM), which has been identified recently. Local physiological structures (such as blood vessels and lymphatic nodes) and pathological events (such as lymph nodes metastasis and metastasis V) only occur in mesentery in broad sense (i.e. PSDM). Broken PSDM during radical gastrectomy can result in cancer cell leakage into the operational field. Therefore, complete PSDM excision in the D2 field (D2+CME) is suggested as a better procedure for local advanced gastric cancer, which can get benefits not only in surgical hazard, but also in oncologic result. The results of PSDM research could lead to three changes: (1) resolving some long standing problems in gastric cancer surgery, gastrointestinal surgery, and even oncologic surgery; (2) opening an new era for finding and utilizing extra-intestinal mesentery in broad sense; (3) formulating the theory of membrane anatomy which may update, iterate and upgrade related information of classical anatomy, pathology, surgery and oncology.
Asunto(s)
Humanos , Gastrectomía , Escisión del Ganglio Linfático , Metástasis Linfática , Mesenterio , Neoplasias Gástricas/cirugíaRESUMEN
Objective@#To investigate short-term efficacy of laparoscopic spleen-preserving splenic hilus lymphadenectomy and left epigastrium mesogastric excision for advanced proximal gastric cancer based on mesangial anatomy.@*Methods@#A case series study was carried out. Case inclusion criteria: (1) patient was confirmed as gastric adenocarcinoma by gastroscopic biopsy before operation; (2) locally advanced gastric cancer was confirmed by abdominal CT before operation; (3) no distant metastases such as liver, lung, and posterior peritoneal lymph nodes, and no tumor directly invading the pancreas, spleen, liver, and colon were verified by superficial lymph node ultrasound, chest and abdominal CT before operation;(4) total gastrectomy or proximal gastrectomy plus D2 lymphadenectomy were performed, and R0 resection was confirmed by postoperative pathology. Exclusion criteria: (1) intraperitoneal dissemination or distant metastasis was found during laparoscopic exploration; (2) No.10 lymph nodes were significantly enlarged or fused into clusters; (3) pathological diagnostic data were incomplete. According to above criteria, the clinicopathological data of 36 patients who underwent laparoscopic spleen-preserving No.10 lymphadenectomy and left epigastrium mesogastric excision based on interspace anatomy for advanced proximal gastric cancer in The First Affiliated Hospital of Zhengzhou University from June 2017 to March 2018 were retrospectively collected and analyzed. The intraoperative conditions, postoperative recovery and complications of patients were analyzed.@*Results@#In 36 patients, the mean age was (59.8±8.0) years, the mean BMI was (23.9±3.5) kg/m2, and 8 cases (22.2%) received preoperative chemotherapy. All the patients underwent successfully the laparoscopic spleen-preserving splenic hilus lymphadenectomy and left epigastrium mesogastric excision. In the examination of postoperative resected specimens, it was found that the mesangial boundary of the upper and posterior part of the stomach was smooth, indicating the efficiency of complete mesangial resection. No case was converted to open operation. The mean time of lymph node dissection and mesangial resection was (34.2±11.4) minutes. The mean blood loss during operation was (44.8±21.3) ml. The mean number of lymph node dissection per patient was 45.6±17.6. The mean number of No. 11p+11d lymph node dissection was 3.1± 2.8 per patient, and 7 patients were pathologically positive with metastasis rate of 19.4% (7/36). The mean number of No.10 lymph node dissection was 2.9±2.5 per patient, and 2 patients were pathologically positive with metastasis rate of 5.6% (2/36). The time to postoperative flatus was (3.8±0.6) days, time to removal of nasogastric was (1.9±0.7) days, time to the first intake of fluid was (3.0±0.4) days, time to removal of drainage tube was (6.0±1.2) days. Postoperative mean hospital stay was (12.8±4.0) days. One case (2.7%) developed pulmonary embolism and 1 case (2.7%) developed gastroplegia after operation. The morbidity of postoperative complication was 5.6% (2/36). No operative site infection, postoperative bleeding and death within postoperative 30-day were observed. All the 36 patients were followed up and the median follow-up was 18 months (12-28 months). Seven patients died of tumor relapse and metastasis (3 cases died within postoperative 1 year) and another 1 case developed colonic cancer 17 months after operation.@*Conclusion@#Laparoscopic spleen-preserving splenic hilus lymphadenectomy and left epigastrium mesogastric excision for advanced proximal gastric cancer based on mesangial anatomy is safe and feasible.
RESUMEN
RESUMEN El pseudoquiste pancreático representa el 75% de las lesiones quísticas del páncreas. Solo el 10% tiene su origen en un trauma. Se trata de una paciente femenina de 32 años de edad, con antecedentes de traumatismo cerrado de abdomen de hace 2 meses, que acudió a consulta de Cirugía General del Hospital Regional de Huambo, Angola, por presentar un aumento de volumen visible y palpable en mesogastrio, por lo que se ingresó con el diagnóstico de tumor abdominal. Se diagnosticó un pseudoquiste pancreático, el cual fue drenado percutáneamente con evolución satisfactoria sin recidivas. En el manejo de esta paciente, el drenaje percutáneo demostró ser útil como primera elección.
ABSTRACT Pancreatic pseudocysts represent the 75% of cystic pancreatic lesions. Only 10% are originated after trauma. We report a 32 years old female patient, with a history of a closed abdominal trauma two months ago, who attended the General Surgery consultation office at the Regional Hospital of Huambo, Angola. She visibly presented a palpable focal increase of volume in mesogastrium. She was admitted with the diagnosis of abdominal tumor. A pancreatic pseudocyst was identified, and a percutaneous drainage was carried out with complete resolution and uneventful evolution, without relapses to the present. In this patient, the percutaneous drainage proved to be useful as the first choice approach.
RESUMEN
The most common metastasis modality of gastric cancer is the perigastric lymph node metastasis. Complete dissection of regional lymph nodes of the stomach is the core surgical treatment strategy of gastric cancer, and is closely related to the prognosis of gastric cancer patients. Infrapyloric lymph node metastasis is common in gastric cancer,and its incomplete dissection is associated with tumor recurrence. Meanwhile, anatomical variations of vessels and complex mesentery layers of infrapyloric area increase the difficulty of lymphadenectomy during the operation. So, infrapyloric lymph node (No. 6) is an important station. Based on the theory of embryonic development and complete mesogastrium excision, operation across the anatomical space among mesentery layers can ensure en bloc resection of the infrapyloric lymph nodes.
RESUMEN
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.