胃癌D2淋巴结清扫术后标本淋巴结分拣的经验分享

Method and experience of lymph node examination after gastrectomy with D2 lymphadenectomy for gastric cancer

胃癌术后标本的淋巴结检出数目不足,可降低淋巴结转移分期的准确性,从而影响预后评估和辅助治疗策略的制定.在规范完成D2淋巴结清扫的前提下,胃癌标本淋巴结检出数目主要依赖于检取方法.本中心从2013年开始成立专门的淋巴结挑检团队,当年本中心平均每例标本淋巴结检取数目为46枚,较之前明显增加(2004—2012年平均18枚/例).2014年经过持续质量改进及定期进行质量控制,平均每例标本检取淋巴结数目达到62枚.因此,本文总结南方医院普通外科的胃癌标本淋巴结检取方法和经验.本中心的胃癌淋巴结检取团队的整体构建主要包括3个部分:即成立专门的淋巴结挑检团队、行之有效的标准操作流程(SOP)和长效持续的质量控制.专门的淋巴结挑检团队由不参与手术、但由经过手术医生专业培训的研究生组成.标准操作流程包括胃周解剖的理论储备、手术观摩以对应标本离体和在体状态、标准化的标本处理流程.长效持续的质量控制要求定期进行淋巴结挑检数据的上报和对流程持续的反馈优化.利用纳米碳和吲哚菁绿染料剂染色等进行术中淋巴结示踪导航和标本淋巴结强化,再按照传统方法进行检取,可提高淋巴结、尤其是微小淋巴结的检取率.随着"精准医学"概念的提出,淋巴结示踪方法研究的跨学科合作将会成为热点.

The insufficiency of the examined number of lymph nodes after surgery for gastric cancer may undermine the stage of lymph node metastasis, which would have a significant impact on prognostic evaluation and strategy formulation of adjuvant therapy. Under the premise of standard D2 lymphadenectomy, the number of harvested lymph nodes is mainly dependent on the procedures of lymph node examination. Since 2013, our center has set up a special lymph node examination team. In the same year, the average number of harvested lymph nodes in each sample was 46, which was significantly higher than before (average 18 nodes/case in 2004-2012). After continuous quality improvement and regular quality control in 2014, average number of retrieved lymph nodes was 64 per specimen. Therefore, this paper summarizes the methods and experience of lymph node examination in gastric cancer specimens of general surgery in Southern Hospital. The overall construction of the lymph node examination team of gastric cancer in our center mainly includes three parts: establishment of a specialized lymph node examination team, effective standard operating procedures (SOP), and long-term and sustained quality control. The specialized lymph node examination team consists of postgraduate students who are not involved in surgery but have been trained by surgeons. Standard procedures include theoretical reserve of gastric anatomy, surgical observation to correspond to specimens in vitro and in vivo , and standardized specimen processing procedures. Long?term and sustained quality control requires periodic report of lymph node examination data and continuous feedback optimization of the process. Intraoperative lymph node tracing navigation and specimen lymph node intensification are carried out with nanocarbon and indocyanine green dye staining, and then lymph nodes are harvested based on the traditional methods, which can improve the examination rate of lymph nodes, especially for small lymph nodes. Research on lymph node tracing methods, requires multidisciplinary cooperation in particular, will become a hot topic.