腹腔镜胃癌D2手术学习曲线

Learning curve of laparoscopic D2 gastrectomy for gastric cancer

目的针对已熟练掌握腹腔镜结直肠癌手术技术的胃肠外科医生,探索开展腹腔镜胃癌D2手术并平稳渡过学习曲线的规律。方法回顾分析我院自2004年7月至2009年7月共70例均由同一团队进行的腹腔镜胃癌D2手术患者临床资料,将其按手术日期先后分为连续的7组(A-G组),每组10例设定为一手术阶段,每例均完成胃切除重建、D2站淋巴结清扫,比较各阶段的平均手术时间、术中失血量、中转开腹率、淋巴结清扫数量、手术并发症、术后恢复指标(肛门排气时间、恢复流质时间、术后住院时间)。结果各组病例在年龄、性别、胃切除部位、淋巴结清扫数目、术中失血量、肛门排气时间、术后住院时间方面无显著差异(均P>0.05);手术时间7组之间有差异(F=8.578,P=0.000),A、B组之间无差异(P=0.999),A、B组和C、D、E、F、G组之间有显著差异(均P<0.05),C、D、E、F、G组之间无差异(均P>0.05),A、B两组手术时间长于其他各组(P<0.05);A组恢复流质时间较其他各组显著延长(P<0.05);B组发生2例中转开腹,其余各组均未发生,中转率2.86%;术中并发症发生在B组(2例)、C组(2例),术后并发症1例发生在C组,并发症总发生率7.14%。结论对于那些已熟练掌握腹腔镜结直肠癌手术技术的胃肠外科医生,遵循一定的科学规律和手术步骤,开展20例左右的腹腔镜胃癌D2手术后,可望顺利、安全、快速渡过该学习曲线。

Objective To analyze the learning curve for an experienced laparoscopic colorectal surgeon in performing to laparoscopic D2 gastrectomy for gastric cancer. Methods From July 2004 to July 2009, 70 patients undergoing laparoscopic D2 gastrectomy performed by a single surgical team were retrospectively evaluated. The patients were divided into groups A to G （n=10） based on the surgery date, and the operation time, estimated blood loss （EBL）, conversion to open surgery, number of lymph nodes harvested, complications, and recovery indicators were compared. Results No statistical differences were found among the groups in age, gender, gastrectomy approach, EBL, number of lymph nodes harvested, time to flatus, or postoperative hospital stay （P0.05）. No significant differences were found in the operation time between groups A and B （P=0.999） or among the other 5 groups （P0.05）, but the operation time in groups A （300.00±104.59 min） and B （261.00± 40.50 min） were significantly longer than that in the other 5 groups （C： 191.30±23.11 min, D： 188.60±31.38min, E： 181.10± 20.18 min, F： 167.50±32.81min, and G： 161.30±29.03 min）. Compared with that in group A, the time to liquid diet decreased significantly in the remaining 6 groups （P0.05）. Conversion to open surgery occurred in two cases （2.86%, both in group B）, 2 patients in group B and another 2 in group C developed intraoperative complications, and one in group C had postoperative complication, with the total incidence of complication of 7.14% in this series. Conclusion A well-trained laparoscopic colorectal surgeon, by following the standard surgical procedures, are likely to overcome the learning curve smoothly after performing approximately 20 cases of laparoscopic D2 gastrectomy for gastric cancer.