胃癌根治手术的质量保障

Quality control of radical lymphadenectomy for gastric cancer

D2标准胃癌淋巴结清扫已经成为全球共识．第4版日本胃癌治疗指南对标准淋巴结清扫范围没有做重大调整：不推荐预防性腹主动脉旁淋巴结清扫，当幽门下组淋巴结可疑转移以及肿瘤侵犯十二指肠时，推荐清扫肠系膜上静脉旁和胰头后组淋巴结，但是缺乏循证医学证据。根据JCOG1001最新结果，网膜囊切除仍不能推荐作为cT3-4期胃癌的标准治疗。我国是胃癌大国，胃癌总体手术治疗水平不均衡，在规范淋巴结清扫范围的同时．如何保障胃癌根治术的质量是目前的重要课题。我们认为，医疗机构及外科医生的年手术量是影响手术质量的决定因素；专科化是迅速提高胃癌手术质量的捷径，也是我国未来的发展方向；专科医师培训是提高胃癌手术质量的必由之路，需要政府和学会的共同努力；离体淋巴结再分拣是胃癌精准分期、制定个体化辅助治疗方案的有效方法。

D2 lymphadeneetomy is currently the worldwide standard operation for locally advanced gastric cancer. There were no major modifications for extent of standard lymphadeneetomy in Japanese gastric cancer treatment guidelines 2014 （ver.4）. Prophylactic para-arotie lymphadenectomy is not recommended. Although there is no high level evidence, D2＋Nol4v may be beneficial to patients who are suspected to harbor metastasis to No6 node, and D2＋No13 lymphadenectomy may be an option in a potentially curative gastrectomy for tumors invading the duodenum. According to the finial results of JCOG1001, bursectomy is not recommended as a standard procedure for eT3/4 gastric cancer. Incidence of gastric cancer is quite high in China while overall operation level of gastric cancer is unequal. How to ensure the quality of radical gastrectomy is a recently important topic meanwhile the lymphadenectomy extent should be standard. Operational quantity per year in hospital and surgeons is considered as the final factors for the quality of radical gastrectomy. Centralization of gastric cancer surgery may be needed for the improvement of gastric cancer care in China. Education and training for the specialist are imperative for good outcomes of gastric cancer surgery. Ex vivo dissection for lymph nodes is effective method of precise staging and individual adjuvant treatment for gastric cancer patients.