Universalization of the operative strategy by systematic mesogastric excision for stomach cancer with that for total mesorectal excision and complete mesocolic excision colorectal counterparts

Hisashi Shinohara, Yasunori Kurahashi, Shusuke Haruta, Yoshinori Ishida, Mitsuru Sasako, Hisashi Shinohara, Yasunori Kurahashi, Shusuke Haruta, Yoshinori Ishida, Mitsuru Sasako

Abstract

Gastrointestinal cancer surgery aims at en bloc removal of the primary tumor with its lymphatic drainage by excising organ-specific mesentery as an "intact package". This concept was advocated in colorectal cancer surgery as total mesorectal excision (TME) or complete mesocolic excision (CME) procedures, but is not directly applicable to stomach cancer as a result of the morphological complexities of the gastric mesentery. In this review, we discuss the unique anatomical features of the mesogastrium by introducing its embryology, disclose its similarity to the mesosigmoid, and then propose a theoretical concept to mesentery-based D2 gastrectomy, namely systematic mesogastric excision, which can universalize the operative strategy of stomach cancer with that of TME and CME colorectal counterparts.

Keywords: D2 gastrectomy; dissectable layer; gastric cancer; mesenteric excision; stomach.

Figures

Figure 1
Figure 1
(A) Outlines of the gastric mesenteries during development. Arrows indicate concrescences of the mesenteries. (B) After development of the mesogastrium, mesoduodenum, and their derivatives. CA, celiac axis; DMG, dorsal mesogastrium; GO, greater omentum; MD, mesoduodenum; SPL, spleen, TM, transverse mesocolon; VMG, ventral mesogastrium
Figure 2
Figure 2
(A) Three‐dimensional overview of the mesogastrium to show mesenteric association of regional lymph stations. The omental bursa has already been opened and the right gastroepiploic artery (RGEA) and vein (RGEV) are divided. The dorsal mesogastrium (DMG) is colored green, the ventral mesogastrium (VMG) is colored blue, and the mesoduodenum (MD) is colored yellow. Numbers in circles represent regional lymph nodes. (B) Intraoperative findings of the reversed mesogastrium. (C) Image of mesogastrium with embryonic concrescences restored. The gastric mesentery can be divided into three sectors: root (R), intermediate (I), and perigastric (P) sectors. (D) Surgical concept of systematic mesogastric excision to achieve D2 lymphadenectomy by resection of the mesogastrium while sparing the pancreas and major branches of the celiac axis (CA) is shown. ASPDA, anterior superior pancreatoduodenal artery; CHA, common hepatic artery; CL, caudate lobe; DP, dorsal pancreas; GDA, gastroduodenal artery; IPA, infrapyloric artery; LGA, left gastric artery; LGEA, left gastroepiploic artery; PGA, posterior gastric artery; PHA, proper hepatic artery; RGA, right gastric artery; SGA, short gastric artery; SMA, superior mesenteric artery; SPA, splenic artery; TM, transverse mesocolon; VP, ventral pancreas
Figure 3
Figure 3
(A) Logical basis for carrying out systematic excision of the mesogastrium. Target mesentery is adherent to the landmark organs through loose connective‐tissue spaces providing surgically dissectable layers (DL). Similar areolar spaces named intramesenteric DL (iDL) exist inside the mesentery surrounding the mesenteric components, such as arteries (A), veins (V), and the pancreas (P). By sharp dissection of the DL, the target mesentery is mobilized with an “intact fascial package”. (B) Histological cross‐section (Masson's stain) of soft tissue attached with a surgical specimen. The circumferential margin is covered in a bilayered way not only on the peritoneal (arrows) but also on the detachment side by a dense connective tissue film (arrowheads), which is stained blue. F, fat tissue; LN, lymph node
Figure 4
Figure 4
(A) Illustrated tomography of the mesogastrium indicating theoretical steps for systematic mesogastric excision: release of the mesogastric fixation from the parietal wall or adjacent mesenteries by dissociating embryological dissectable layers (DL, dashed blue arrows), followed by preservation of the pancreas and major branches of the celiac trunk by tracing intramesenteric DL (iDL, dashed red arrows). IVC, inferior vena cava; SMV, superior mesenteric vein; SPA, splenic artery. (B,C) Representative intraoperative findings after mesenterization of the mesoduodenum (MD) including the (B) no. 6 nodes, and the (C) dorsal mesogastrium (DMG) including node nos. 7, 8, 9, 11p and 12a. GO, greater omentum; IVC, inferior vena cava; LGA, left gastric artery; LGV, left gastric vein; RGA, right gastric artery; SMA, superior mesenteric artery; SPA, splenic artery, TM; transverse mesocolon
Figure 5
Figure 5
(A) Schematic illustration of excluding the pancreas and its associated vessels by tracing the intramesenteric dissectable layer with the mesogastrium. Red broken line indicates transection route of the mesogastrium when carrying out distal gastrectomy. (B) An operative finding of lymph node‐containing mesentery which was removed by tracing the intramesenteric dissectable layer along the common and proper hepatic, and splenic arteries. CHA, common hepatic artery; LGA, left gastric artery; LGEA, left gastroepiploic artery; RGA, right gastric artery; SPA, splenic artery
Figure 6
Figure 6
(A) Rear view of a representative specimen after total gastrectomy. (B) Frontal view of a representative specimen after distal gastrectomy. (C,D) Theoretical specimens after (A) total gastrectomy and (B) distal gastrectomy, drawn based on our systematic mesogastric excision concept. Numbers in circles represent regional lymph nodes. LGA, left gastric artery; LGEA, left gastroepiploic artery; LGV, left gastric vein; PGA, posterior gastric artery; RGA, right gastric artery; RGEA, right gastroepiploic artery; SGA, short gastric artery; SPA, splenic artery
Figure 7
Figure 7
Allocations of lymph nodes in the root, intermediate and periorgan (peri) sectors of the mesogastrium and mesosigmoid. Photograph shows a representative specimen harvested after sigmoidectomy based on the complete mesocolic excision concept. IMA, inferior mesenteric artery

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