完全腹腔镜与腹腔镜辅助远端胃癌根治术在老年患者中的安全性比较研究

Objective: To compare the effectiveness of total laparoscopic versus laparoscopic-assisted distal gastrectomy and investigate the safety and replicability of total laparoscopic distal gastrectomy in older patients. Methods: This was a retrospective cohort study. The inclusion criteria were as follows: (1) age ≥65 years; (2) malignant gastric tumor diagnosed pathologically preoperatively; (3) Eastern Cooperative Oncology Group performance status score 0-1; (4) Grade I-III American Society of Anesthesiologists physical status; (5) preoperative clinical tumor stage I-III; (6) total laparoscopic or laparoscopic-assisted distal gastrectomy performed; and (7) gastrointestinal tract reconstruction using uncut Roux-en-Y or Billroth-II+Braun procedure. Patients who had received neoadjuvant therapy, undergone conversion to open surgery, or had serious comorbidities or incomplete data were excluded. The clinical data of 129 patients who met the above criteria and had undergone laparoscopic surgery for gastric cancer from January 2012 to December 2021 in the Gastrointestinal Cancer Center in the Beijing Cancer Hospital were analyzed. According to the operation method, the patients were divided into total laparoscopic group and laparoscopic-assisted group. Variables studied comprised: (1) surgical procedure and postoperative recovery; (2) postoperative pathological findings; and (3) postoperative complications. Measurement data with skewed distribution are represented as mean(quartile 1, quartile 3). Comparisons between groups were evaluated using the Mann-Whitney U test. Results: After propensity score matching in a 1:1 ratio, there were 40 patients in the total laparoscopic distal gastrectomy group and 40 in the laparoscopic-assisted distal gastrectomy group. Baseline characteristics did not differ significantly between the two groups (all P>0.05).Compared with the laparoscopic-assisted group, the total laparoscopic group had shorter main incisions (4.1±1.0 cm vs. 8.5±2.8 cm, t=9.375, P<0.001), time to fluid intake [4.0 (3.0, 4.8) days vs. 5.0 (4.0, 6.0) days, Z=2.167, P=0.030], and duration of indwelling abdominal drainage catheter [6.0 (6.0, 7.0) days vs. 7.0 (6.0, 8.0) days, Z=2.323, P=0.020]. Numerical Rating Scale scores on postoperative days 1 and 2 were higher in the total laparoscopic than the laparoscopic-assisted group [2.5 (1.0, 3.0) vs. 1.5 (1.0, 2.0), Z=1.980, P=0.048; 2.0 (1.0, 3.0) vs. 1.0 (1.0, 2.0), Z=2.334, P=0.020, respectively]. However, there were no significant differences between the groups in operation time, intraoperative blood loss, white blood cell count, hemoglobin concentration, or albumin concentration on postoperative day 1, time to ambulation, mean time to bowel movement, postoperative admission to the intensive care unit, length of postoperative hospital stay, or Numerical Rating Scale scores on postoperative day 3 (all P>0.05). There were also no significant differences between the two groups in maximum tumor diameter, pathological tumor type, total number of lymph nodes dissected, or total number of positive lymph nodes (all P>0.05). The incidence of postoperative complications was 15.0% (6/40) in the total laparoscopic group and the laparoscopic-assisted group; these differences are not significant (χ2<0.001, P>0.999). Conclusions: Compared with laparoscopic-assisted radical gastrectomy for distal gastric cancer, total laparoscopic surgery has the advantages of shorter incision, shorter time to fluid intake, and shorter duration of indwelling abdominal drainage catheter in older patients (age ≥65 years). Total laparoscopic radical gastrectomy for distal gastric cancer does not increase the risk of postoperative complications and could therefore be performed more frequently.目的： 对比完全腹腔镜与腹腔镜辅助远端胃癌根治术的近期临床疗效，探讨完全腹腔镜远端胃癌根治术在老年患者中的安全性及可推广性。 方法： 采用回顾性队列研究方法。病例纳入标准：（1）年龄≥65岁；（2）术前病理结果诊断为胃恶性肿瘤；（3）美国东部肿瘤协作组（ECOG）体力评分0~1分：（4）美国麻醉医师协会（ASA）分级Ⅰ~Ⅲ级；（5）术前肿瘤临床分期为Ⅰ~Ⅲ期；（6）手术方式为完全腹腔镜或腔镜辅助下根治性远端胃切除术；（7）消化道重建方式为uncut Roux-en-Y或Billroth-Ⅱ+Braun手术。排除新辅助治疗、中转开腹、有其他重要器官严重合并症以及病例资料不完整者。根据上述标准，分析北京大学肿瘤医院胃肠肿瘤中心2012年1月至2021年12月间129例行腹腔镜胃癌手术老年患者的临床资料，根据手术方式分为完全腹腔镜组与腹腔镜辅助组。观察指标：（1）手术及术后恢复情况；（2）术后病理情况；（3）术后并发症发生情况。偏态分布的计量资料以M（Q1，Q3）表示，组间比较采用Mann-Whitney U检验。 结果： 运用1∶1倾向评分匹配（PSM）后，两组各有40例入选，两组患者基线资料比较差异无统计学意义（均P>0.05）。与腹腔镜辅助组相比，完全腹腔镜组手术主切口长度更短［（4.1±1.0）cm比（8.5±2.8）cm，t=9.375，P<0.001］，术后首次进流食时间更早［4.0（3.0，4.8）d比5.0（4.0，6.0）d，Z=2.167，P=0.030］，术后引流管留置时间更短［6.0（6.0，7.0）d比7.0（6.0，8.0）d，Z=2.323，P=0.020］，但术后第1天和第2天疼痛评分更高，分别为［2.5（1.0，3.0）分比1.5（1.0，2.0）分，Z=1.980，P=0.048］和［2.0（1.0，3.0）分比1.0（1.0，2.0）分，Z=2.334，P=0.020］。两组患者在手术时间、术中出血量、术后第1天白细胞计数、术后第1天血红蛋白水平、白蛋白水平以及术后首次下床时间、术后首次排粪时间、术后入住重症监护室、术后总住院时间和术后第3天疼痛评分方面比较，差异均无统计学意义（均P>0.05）。两组患者在肿瘤最大径、肿瘤病理类型、淋巴结清扫总数目和淋巴结阳性总数目方面比较，差异均无统计学意义（均P>0.05）。完全腹腔镜组与腹腔镜辅助组术后并发症发生率均为15.0%（6/40），差异无统计学意义（χ2<0.001，P>0.999）。 结论： 与腹腔镜辅助技术相比，老年远端胃癌患者行完全腹腔镜根治手术具有切口更小、术后首次进流食时间更早以及术后腹腔引流管留置时间更短的优势，且不增加并发症发生的风险，值得应用和推广。.