ABSTRACT
Primary lesion removal and lymph node dissection are the main constituents of radical gastrectomy. However, the high recurrence rate after D2 radical gastrectomy for advanced gastric cancer has not improved. Recently, studies have found that discrete tumor deposits in the mesogastrium may be an important factor affecting the prognosis of gastric cancer after surgery. With the development of laparoscopic equipment, the ever-expanding "submicroscopic vision" makes it possible to completely remove the mesogastrium. Professor Gong Jianping advocated "membrane anatomy" to optimize the concept of radical gastrectomy: D2- based complete mesenteric resection (CME), namely D2+CME procedure. To prevent the leakage of tumor cells into the surgical field, as histological barrier, the intact mesogastrium should be located. The essential difference between D2+CME and previous D2/D2+systematic mesogastrium excision (SME), en-bloc mesogastric excision (EME) is as follow: double-factor guiding (lymph nodes and discrete tumor deposits) vs. single factor guiding (lymph nodes only). After practicing dozens of radical gastrectomy (D2+CME) authors believe that its conceptual connotation (double factor guiding) and operational extension (above mesentery bed) cover D2. In D2+CME surgery, depending on the anatomical identification under the magnified field of view, the conformal space between gastric mesentery and mesenteric beds is unique operational plane with repeatability. These findings and considerations address one problem: where is the precise boundary of en bloc principle in radical gastrectomy? In author′s opinion, with laparoscopy and "sub-microsurgery" progression and detection of discrete tumor deposit metastasis, survival benefit from definition of en bloc boundary in radical gastrectomy will be widely recognized. Meanwhile, D2+CME procedure is an appropriate way for study. Although the development of the "membrane anatomy" concept for gastric cancer still requires many further clinical and basic researches, it is reasonable to foresee that D2+CME surgery will guide a concept-optimized era for gastric cancer surgery.