摘要
目的：比较达芬奇机器人手术系统辅助与腹腔镜辅助局部进展期胃癌根治术的近期临床疗效。方法：采用回顾性队列研究方法。收集2016年9月至2017年9月陆军军医大学（第三军医大学）第一附属医院收治的162例行微创局部进展期胃癌根治术患者的临床病理资料。162例患者中，65例行达芬奇机器人手术系统辅助局部进展期胃癌根治术，设为机器人组；97例行腹腔镜辅助局部进展期胃癌根治术，设为腹腔镜组。患者均根据日本《胃癌治疗指南》推荐行相应手术治疗，对位于胃中上部肿瘤行全胃切除＋D2淋巴结清扫术，对位于胃中下部肿瘤行远端胃大部切除＋D2淋巴结清扫术；行Billroth Ⅱ式或Roux-en-Y消化道重建。观察指标：（1）手术及术后情况。（2）淋巴结检出情况。（3）随访和生存情况。采用门诊和电话方式进行随访，了解患者生存情况。随访时间截至2017年11月30日。正态分布的计量资料以±s表示，组间比较采用t检验。计数资料比较采用x2检验。等级资料采用非参数检验。结果：（1）手术及术后情况：162例患者均顺利完成手术，无中转腹腔镜或开腹，术后病理学切缘均为R0切除。机器人组患者术中出血量，术后第1、2、3天腹腔引流液淀粉酶水平，术后第1、2、3天血清淀粉酶水平分别为（123±39）mL、（557±181）U/L、（357±127）U/L、（183±86）U/L、（181±47）U/L、（123±29）U/L、（85±22）U/L，腹腔镜组分别为（142±40）mL、（793±284）U/L、（497±199）U/L、（279±157）U/L、（218±45）U/L、（162±37）U/L、（120±31）U/L，两组患者上述指标比较，差异均有统计学意义（t=-3.015，-2.817，-2.364，-2.132， -2.372，-3.338，-3.720，P〈0.05）。机器人组患者手术方式（远端胃大部切除＋D2淋巴结清扫术、全胃切除＋D2淋巴结清扫术），消化道重建方式（Billroth Ⅱ式、Roux-en-Y），手术时间（远端胃大部切除＋D2淋巴结清扫术、全胃切除＋D2淋巴结清扫术），术后并发症种类（吻合口漏、肺部感染、伤口感染或液化、胃排空障碍），术后并发症分级（Ⅱ、Ⅲ、Ⅳ、Ⅴ级），术后腹腔引流管拔除时间，术后住院时间分别为47、18例，40、 25例，（222±37）min，（274±43）min，1、1、1、1例，2、1、0、0例，（6.5±1.5）d，（10.0±4.0）d，腹腔镜组分别为74、23例，69、28例，（213±40）min，（262±39）min，2、4、1、0例，4、1、0、1例，（6.9±1.7）d，（10.0±5.0）d，两组患者上述指标比较，差异均无统计学意义（χ^2=0.326，1.628，t=1.272，0.960， χ^2=2.501，Z=-1.342， t=-1.142，-0.115，P〉0.05）。机器人组和腹腔镜组各1例患者行全胃切除＋Roux-en-Y吻合术后发生食管空肠吻合口漏，均行胃镜下置营养管支持治疗后痊愈，腹腔镜组1例行远端胃大部切除＋Billroth Ⅱ吻合术后胃空肠吻合口漏患者再次手术探查并行空肠营养管置入术。两组术后肺部感染、术口感染或液化、胃排空障碍患者经保守治疗后痊愈。机器人组和腹腔镜组患者术后第1、2、3天腹腔引流液淀粉酶水平和血清淀粉酶水平均未高于3倍正常值高限，未给予治疗干预。（2）淋巴结检出情况：机器人组和腹腔镜组患者总体淋巴结检出数目分别为（36.82±13.41）枚和（35.21±11.52）枚，两组比较，差异无统计学意义（t=0.786，P〉0.05）。进一步分析结果显示：机器人组和腹腔镜组行远端胃大部切除＋D2淋巴结清扫术患者第 2站淋巴结清扫数目分别为（6.04±3.98）枚和（4.45±3.12）枚，胰腺上区淋巴结清扫数目分别为（13.51± 6.53）枚和（11.40±5.30）枚，两组患者上述指标比较，差异均有统计学意义（t=2.461，1.986，P〈0.05）。机器人组和腹腔镜组行全胃切除＋D2淋巴结清扫术患者第7组淋巴结清扫数目分别为（5.44±2.63）枚和（3.11±1.82）枚，第8组淋巴结清扫数目分别为（2.92±1.87）枚和（1.62±1.33）枚，胰腺上区淋巴结清扫数目分别为（10.81±4.78）枚和（7.76±3.34）枚，两组患者上述指标比较，差异均有统计学意义（t=3.340，2.689，2.522，P〈0.05）。（3）随访和生存情况：162例患者中，148例获得随访，随访时间为2-14个月，中位随访时间为8个月。随访期间，两组患者均无瘤生存。结论：达芬奇机器人手术系统辅助局部进展期胃癌根治术安全可行，与腹腔镜辅助局部进展期胃癌根治术比较，其具有清晰的局部解剖视野，术中出血少，对胰腺上区的胃周淋巴结清扫数目多、胰腺损伤轻，在大血管周围及深部狭小空间中操作有一定优势。
Objective：To compare the shortterm clinical efficacies of Da Vinci robotic surgical systemassisted and laparoscopyassisted radical gastrectomy for locally advanced gastric cancer （GC）. Methods：The retrospective cohort study was conducted. The clinicopathological data of 162 patients who underwent minimally invasive radical gastrectomy for locally advanced GC in the First Affiliated Hospital of Army Medical University between September 2016 and September 2017 were collected. Of 162 patients, 65 undergoing Da Vinci robotic surgical systemassisted radical gastrectomy were allocated into the robotic group and 97 undergoing laparoscopyassisted radical gastrectomy were allocated into the laparoscopic group. According to Japanese gastric cancer treatment guidelines, patients with upper GC and with middle or lower GC underwent respectively total gastrectomy ＋ D2 lymph node dissection and distal subtotal gastrectomy ＋ D2 lymph node dissection, and then Billroth Ⅱ or Roux-en-Y digestive tract reconstruction. Observation indicators： （1） surgical and postoperative situations; （2） detection of lymph node; （3） followup and survival situations. Measurement data with normal distribution were represented as ±s, and comparisons between groups were analyzed using the t test. Comparisons of count data were done using the chisquare test. Ordinal data were analyzed by the nonparametric test.
Results：（1） Surgical and postoperative situations： all 162 patients underwent successful surgery, without conversion to laparoscopic or open surgery, and pathological resection margins were confirmed as Ro. Volume of intraoperative blood loss, levels of amylase in peritoneal drainage fluid at day 1, 2 and 3 postoperatively, levels of serum amylase fluid at day 1, 2 and 3 postoperatively were respectively （123±39）mL, （557±181）U/L, （357±127）U/L, （183±86）U/L, （181±47）U/L, （123±29）U/L, （85±22）U/L in the robotic group and （142±40）mL, （793±284）U/L, （497±199）U/L, （279±157）U/L, （218±45）U/L, （162±37）U/L, （120±31）U/L in the laparoscopic group, with statistically significant differences between groups （t=-3.015,-2.817,-2.364,-2.132,-2.372,-3.338,-3.720, P〈0.05）. Cases with distal subtotal gastrectomy ＋ D2 lymph node dissection and with total gastrectomy ＋ D2 lymph node dissection, cases with Billroth Ⅱ and Roux-en-Y of digestive tract reconstruction, time of distal subtotal gastrectomy ＋ D2 lymph node dissection, time of total gastrectomy ＋ D2 lymph node dissection, cases with anastomotic leakage, pulmonary infection, wound infection or liquefaction and delayed gastric emptying, cases in grading Ⅱ, Ⅲ, Ⅳ and Ⅴof postoperative complications, time of postoperative drainagetube removal and duration of postoperative hospital stay were respectively 47, 18, 40, 25, （222±37）minutes, （274±43）minutes, 1, 1, 1, 1, 2, 1, 0, 0, （6.5±1.5）days, （10.0±4.0）days in the robotic group and 74, 23, 69, 28, （213±40）minutes, （262±39）minutes, 2, 4, 1, 0, 4, 1, 0, 1, （6.9±1.7）days, （10.0±5.0）days in the laparoscopic group, with no statistically significant difference between groups （x2=0.326, 1.628, t=1.272, 0.960, χ^2=2.501, Z=-1.342, t=-1.142,-0.115, P〉0.05）. One and 1 patients in the robotic and laparoscopic groups who were complicated with esophagusjejunum anastomotic leakage after total gastrectomy ＋ RouxenY anastomosis were cured by nutrition support therapy using feeding tube placement under gastroscopy, and 1 patient in the laparoscopic group who were complicated with gastrojejunal anastomosis leakage after distal subtotal gastrectomy ＋ Billroth Ⅱ anastomosis received the second surgical exploration and jejunal feeding tube placement. Patients with pulmonary infection, wound infection or liquefaction and delayed gastric emptying were cured by conservative treatment. Levels of amylase in peritoneal drainage fluid and serum amylase fluid at day 1, 2 and 3 postoperatively were not higher than 3 times of upper limit of normal, without treatment interventions. （2） Detection of lymph node： overall number of lymph nodes detected in the robotic and laparoscopic groups were respectively 36.82±13.41 and 35.21±11.52, with no statistically significant difference between groups （t=0.786, P〉0.05）. Results of further analysis showed that numbers of lymph node dissected in the 2nd station and upper region of pancreas in patients undergoing distal subtotal gastrectomy ＋ D2 lymph node dissection were respectively 6.04±3.98, 13.51±6.53 in the robotic group and 4.45±3.12, 11.40±5.30 in the laparoscopic group, with statistically significant differences between groups （t=2.461, 1.986, P〈0.05）. Numbers of lymph node dissected in No 7 and 8 groups and upper region of pancreas in patients undergoing total gastrectomy ＋ D2 lymph node dissection were respectively 5.44±2.63, 2.92±1.87, 10.81±4.78 in the robotic group and 3.11±1.82, 1.62±1.33, 7.76±3.34 in the laparoscopic group, with statistically significant differences between groups （t=3.340, 2.689, 2.522, P〈0.05）. （3） Followup and survival situations： of 162 patients, 148 were followed up for 2-14 months, with a median time of 8 months. During the followup, patients in the 2 groups had tumorfree survival. Conclusions：Da Vinci robotic surgical systemassisted radical gastrectomy is safe and feasible. Compared with laparoscopyassisted radical gastrectomy for locally advanced GC, it has advantages of clear vision of the local anatomy, less intraoperative bleeding, more numbers of lymph nodes dissected in the upper region of pancreas and lighter pancreatic injure, meanwhile, it has also certain operating advantages around the great vessels and in the deep and narrow spaces.
作者
申旭旗
赵永亮
苏崇宇
王晓松
段伟
付小龙
钱锋
郝迎学
石彦
余佩武
Shen Xuqi;Zhao Yongliang;Su Chongyu;Wang Xiaosong;Duan Wei;Fu Xiaolong;Qian Feng;Hao Yingxue;Shi Yan;Yu Peiwu.(Department of General Surgery and Center of Minimal lnvasive Gastrointestinal Surgery, the First Affiliated Hospital, Army Medical University （ Third Military Medical University）, Chongqing 400038, Chin)
出处
《中华消化外科杂志》
CAS
CSCD
北大核心
2018年第6期581-587,共7页
Chinese Journal of Digestive Surgery
基金
国家自然科学基金（81372560）
重庆市社会事业与民生保障科技创新项目（cstc2017shmsA10003）：重庆市科技攻关计划项目（CSTC2012gg-yyjs10029）
陆军军医大学西南医院军事医学与战创伤救治临床新技术计划项目（SWH2016JSTSYB-27）
关键词
胃肿瘤
进展期
根治术
D2淋巴结清扫
达芬奇机器人手术系统
腹腔镜检查
疗效
近期
Gastric neoplasms
Advanced stage
Radical resection
D2 lymph node dissection
Da Vinci robotic surgical system
Laparoscopy
Short-term outcomes
