[Thinking of the application of membrane anatomy in gastric cancer surgery after neoadjuvant therapy]

The standard treatment for advanced gastric cancer remains surgery-based comprehensive treatment. The D2 radical surgery has made outstanding contributions to the standarlization of gastric cancer surgery, which has improved patients' prognosis and quality of life. In recent years, neoadjuvant chemotherapy has achieved a certain effect on the treatment of advanced gastric cancer. With the continuous development of the concept of membrane anatomy in gastric cancer surgery, new surgical challenges have also been raised. For patients after neoadjuvant therapy, there is heated controversy in the possibility of completing radical gastrectomy with membrane anatomical concept for gastric cancer. We believe that if neoadjuvant therapy pushes mesenteric cancer cell back into the mesentery, theoretically membrane anatomy combined with neoadjuvant therapy is beneficial to the treatment efficacy of advanced gastric cancer. However, membrane anatomy has two important problems when combined with neoadjuvant therapy: (1) After neoadjuvant chemotherapy, there are varying degrees of edema around the stomach tissue, which will affect the visualization of anatomic planes. In addition, because the patients' coagulation function is damaged to a certain extent, it is difficult to avoid bleeding or minimize bleeding during the operation. Therefore, it is still controversial whether the patients with gastric cancer after neoadjuvant chemotherapy can undergo radical gastrectomy with membrane anatomy. (2) For patients with complete pathological remission, whether to obtain the maximum rate of pathological remission through intensive neoadjuvant therapy, or to obtain the survival benefit of patients with membrane anatomy surgery in clinic is still controversial. Faced with these confusions, multi-center clinical researches on the application of membrane anatomy surgery after neoadjuvant therapy is the only solution.

进展期胃癌的标准治疗方式仍然是以手术为主的综合治疗，以D(2)根治术为代表的外科手术对规范胃癌的外科治疗，改善患者预后和生活质量等方面做出了突出的贡献。近年来，新辅助化疗对进展期胃癌的治疗取得一定的疗效，随着胃癌外科领域的膜解剖理念的不断发展，对胃癌的手术方式也提出了新的挑战。对于接受新辅助治疗后的胃癌患者，是否能够完成膜解剖胃癌根治术是当下值得探讨的热点问题之一。我们认为，如果新辅助治疗使系膜边癌推向系膜内，理论上膜解剖手术联合新辅助治疗是有利于提高进展期胃癌疗效的。但膜解剖在新辅助治疗患者中存在两个重要问题：（1）新辅助治疗胃癌患者术中胃周组织普遍存在不同程度的水肿，干扰到层次的解剖，由于患者凝血功能的破坏造成出血明显，很难达到"微出血"或者"无血"，因此，对于新辅助化疗后胃癌患者是否能够实施膜解剖的胃癌根治术，尚存争议；（2）对于病理完全缓解的患者，是否需要行膜解剖手术，临床中是通过强化新辅助治疗来获得最大的病理缓解率，还是以膜解剖手术获取患者的生存获益，尚存争议。开展膜解剖手术在新辅助治疗患者中应用的多中心临床研究是解决众多临床困惑的唯一途径。.

Keywords: D2 radical surgery; Membrane anatomy; Neoadjuvant chemotherapy; Stomach neoplasms.