摘要
目的：探讨腹腔镜T4a期胃癌根治术的远期疗效及其影响预后的因素。
方法：采用回顾性病例对照研究方法。收集2004年2月至2014年12月上海交通大学医学院附属瑞金医院收治的224例行腹腔镜T4a期胃癌根治术患者的临床病理资料。患者行腹腔镜T4a期胃癌根治术，淋巴结清扫范围遵循第13版日本胃癌处理规约。吻合方式包括毕Ⅰ式、毕Ⅱ式吻合、胃空肠或食管空肠Roux-en-Y吻合。术后病理学检查为T4a期胃癌患者均行5-氟尿嘧啶为基础的化疗。观察指标：（1）治疗情况。（2）术后病理学检查情况。（3）随访情况。（4）预后因素分析。采用门诊和电话方式进行随访。随访内容为患者术后肿瘤复发、转移情况，采用影像学或病理学检查证实。随访终点为患者死亡。随访时间截至2016年7月31日。正态分布的计量资料以±s表示，组间比较采用Student t检验。偏态分布的计量资料采用M（Q）表示。计数资料比较采用x2检验。采用Kaplan-Meier法绘制总体生存曲线和无病生存曲线，计算总体生存率及无病生存率，Log-rank检验进行生存分析。单因素分析采用x2检验，将单因素分析中P〈0.10的影响因素进一步纳入COX回归模型进行多因素分析。
结果：（1）治疗情况：224例患者均顺利完成手术，无一例中转开腹。224例患者中，手术方式：行腹腔镜远端胃切除术125例（联合行胆囊切除术4例、脾切除术1例、横结肠切除术1例），行腹腔镜全胃切除术99例（联合行胆囊切除术3例、脾切除术2例）；吻合方式：行毕Ⅰ式吻合85例，行毕Ⅱ式吻合29例、行胃空肠或食管空肠Roux-en-Y吻合110例。224例患者手术时间为（229±50）min，术中出血量为（229±146）mL。224例患者术后均常规于我院肿瘤科行6～8个周期5-氟尿嘧啶为基础的化疗。（2）术后病理学检查情况：224例患者淋巴结清扫数目为（25±11）枚/例，阳性淋巴结数目为13枚（8枚，25枚），均为Ro切除。224例患者肿瘤病理学诊断：肿瘤直径为（4.5±2.3）cm；肿瘤部位：29例位于近端胃1/3，64例位于中段胃1/3，122例位于远端胃1/3，9例累及〉2/3胃或全胃；肿瘤分化程度：中分化和高分化82例，低分化和未分化142例；术后病理学N分期：N0期53例，N1期46例，N2期55例，N3期70例；淋巴结转移率0为51例，1%～15%为58例，16%～40%为53例，〉40%为62例；术后T分期均为T4a期。（3）随访情况：224例患者中，212例获得随访，随访时间为7～120个月，中位随访时间为32个月。212例获得随访患者，随访期间118例生存，94例死亡。118例生存患者中，13例带瘤生存，105例无病生存。94例死亡患者中非肿瘤死亡8例，肿瘤相关死亡86例。224例患者5年总体生存率为47.2%，无病生存率为43.6%。（4）预后因素分析：单因素分析结果显示：肿瘤部位、肿瘤直径、肿瘤N分期和淋巴结转移率是影响行腹腔镜T4a期胃癌根治术患者术后5年总体生存率的相关因素（x2=6.365，3.740，32.232，48.977，P〈0.10）；也是影响5年无病生存率的相关因素（x2=9.919，8.818，34.277，45.612，P〈0.10）。多因素分析结果显示：淋巴结转移率是行腹腔镜T4a期胃癌根治术患者术后5年总体生存率和无病生存率的独立影响因素（HR=1.828，1.197，95%可信区间1.353～2.469，0.945～1.516，P〈0.05）。术后肿瘤N分期为N0、N1、N2、N3期患者5年总体生存率分别为72.5%、57.0%、41.6%、23.3%，5年无病生存率分别为70.0%、53.9%、37.0%，32.4%，不同分期比较，差异均有统计学意义（x2=32.232，34.277，P〈0.05）。
结论：腹腔镜根治术治疗T4a期胃癌的远期生存令人满意，淋巴结转移率是影响术后患者总体生存和无病生存的独立因素。
Objective：To explore the long-term outcomes and prognostic factors of laparoscopic gastrectomy for stage T4a gastric cancer.
Methods：The retrospective case-control study was conducted. The clinicopathological data of 224 patients who underwent laparoscopic gastrectomy of gastric cancer and D2 lymph node dissection in the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between February 2004 and December 2014 were collected. Lymph node dissection followed the Japanese Gastric Cancer Treatment Guidelines （13th edition）. Anastomotic methods included Billroth Ⅰ, Billroth Ⅱ and Roux-en-Y gastro-jejunostomy or esophagojejunostomy. Patients who were diagnosed in stage T4a by postoperative pathological examination underwent 5-fluorouracil chemotherapy. Observation indicators： （1） treatment; （2） postoperative pathological examination; （3） follow-up; （4） prognostic factors analysis. Follow-up using outpatient examination and telephone interview was performed to detect the postoperative tumor recurrence or metastases up to death （end of follow-up） or July 31, 2016. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using Student-t test. Measurement data with skewed distribution were described as M （Q）. Comparisons of count data were analyzed using the chi-square test. The overall and disease-free survival curves, overall and disease-free survival rates were respectively drawn and calculated using the Kaplan-Meier method. The survival analysis was done by the Log-rank method. The univariate analysis was done by the chi-square test, and COX regression model which included affecting factors （P〈0.10） in the univariate analysis was used for the multivariate analysis.
Results：（1） Treatment： all the 244 patients underwent successful operation, without conversion to open surgery. Surgical method： laparoscopic-assisted distal gastrectomy （4 combined with cholecystectomy, 1 with splenectomy and 1 with transverse colectomy） were detected in 125 patients and laparoscopic-assisted total gastrectomy in 99 patients （3 combined with cholecystectomy and 2 with splenectomy）. Anastomotic method： Billroth Ⅰ, Billroth Ⅱ and Roux-en-Y gastrojejunostomy or esophago-jejunostomy were respectively applied to 85, 29 and 110 patients. Operation time and volume of intraoperative blood loss were （229±50）minutes and （229±146）mL. All patients underwent 6 or 8 cycles 5-fluorouracil chemotherapy. （2） Postoperative pathological examination： numbers of lymph node dissected and positive lymph nodes were 25±11 per case and 13 （8, 25）, with Ro resection. Tumor pathological diagnosis of 224 patients： tumor diameter was （4.5±2.3）cm. Tumors in 29, 64, 122 and 9 patients respectively located in 1/3 proximal stomach, 1/3 middle segment of stomach, 1/3 distal stomach and involving 2/3 or total stomach. Tumor differentiation： moderate- and high-differentiated tumors and low- and un-differentiated tumors were detected in 82 and 142 patients, respectively. Postoperative N staging： 53, 46, 55 and 70 patients were detected in staging N0, N1, N2 and N3, respectively. Lymph node metastasis rates of 51, 58, 53 and 62 patients were 0, 1%-15%, 16%-40% and 〉40%, respectively. Postoperative staging was T4a staging. （3） Follow-up： 212 of 224 patients were followed up for 7-120 months, with a median time of 32 months. Of 212 follow-up patients, 118 were survived and 94 died. Of 118 survived patients, 13 and 105 were respectively survived with tumors and without tumor. Of 94 deaths, causes of 8 and 86 were respectively non-tumor and tumor-related deaths. The 5-year overall and disease-free survival rates of 224 patients were respectively 47.2% and 43.6%. （4） Prognostic factors analysis： results of univariate analysis showed that tumor location, tumor diameter, N staging and lymph node metastasis rate were related factors affecting the postoperative 5-year overall and disease-free survival rates of patients undergoing laparoscopic gastrectomy of stage T4a gastric cancer （x2=6.365, 3.740, 32.232, 48.977, P〈0.10; x2=9.919, 8.818, 34.277, 45.612, P〈0.10）. Results of multivariate analysis showed that lymph node metastasis rate was an independent factor affecting the postoperative 5-year overall and disease-free survival rates of patients undergoing laparoscopic gastrectomy of stage T4a gastric cancer （HR=1.828, 1.197, 95% confidence interval： 1.353-2.469, 0.945-1.516, P〈0.05）. Postoperative 5-year overall and disease-free survival rates were respectively 72.5%, 57.0%, 41.6%, 23.3% and 70.0%, 53.9%, 37.0%, 32.4%in staging N0, N1, N2 and N3 patients, with statistically significant differences in different staging （x2=32.232, 34.277, P〈0.05）.
Conclusion： There are good long-term outcomes in laparoscopic gastrectomy for stage T4a gastric cancer, and lymph node metastasis rate is an independent factor affecting postoperative overall and disease-free survival of patients.
出处
《中华消化外科杂志》
CAS
CSCD
北大核心
2017年第12期1210-1216,共7页
Chinese Journal of Digestive Surgery
关键词
胃肿瘤
T4a期
远期疗效
腹腔镜检查
Gastric neoplasms, staging T4a
Long-term outcomes
Laparoscopy
