腹腔镜辅助胃癌D2根治术学习曲线研究

Learning curve of laparoscopic-assisted radical D2 gastrectomy for gastric cancer

目的探索腹腔镜辅助胃癌D2根治术(LAG-D2)治疗进展期胃癌的学习曲线规律及影响因素。方法回顾性分析江苏大学附属人民医院普外科腔镜中心自2011年5月至2012年5月由同一团队进行的100例LAG-D2病人的临床资料,按手术日期先后连续分为5组(A、B、C、D、E),每组20例为一手术阶段,每例均在腹腔镜下完成胃癌D2淋巴结清扫,胃周血管的离断,辅助小切口重建消化道。结果各组病人在年龄、性别、胃切除部位、消化道重建方式、术后病理分期、术后住院天数差异无统计学意义(P>0.05)。5组之间手术时间(F=4.610,P=0.002)、术中出血量(F=7.626,P=0.000)差异有统计学意义,A、B、C组之间差异无统计学意义(P>0.05),D、E组之间差异无统计学意义(P>0.05),A、B、C各组与D、E各组之间差异有统计学意义(P<0.05)。淋巴结清扫均枚数(方差齐性,P=0.903):A、B组差异无统计学意义(P>0.05),C、D、E组差异无统计学意义(P>0.05),A、B与C、D、E各组之间差异有统计学意义(P<0.05)。A、B组中转开腹各2例,C组1例,总中转开腹率5%,A、B、C组术中损伤各2例。结论成熟期手术时间明显缩短,出血量明显减少,无术中误损伤,无中转开腹,淋巴结清扫均枚数趋于稳定。改良围手术期处理方式,适当的手术频率(60例左右),对于开腹胃癌D2根治术和腹腔镜胆囊切除术技术成熟的术者可望快速安全渡过该手术学习曲线。

Objective To explore learning curve regularity and influence factors of laparoscopic-assisted radical D2 gastrectomy for gastric cancer（LAG-D2）. Methods The clinical data of 100 cases of LAG-D2 performed by the same team from May 2011 to May 2012 in Department of General Surgery （Laparoscopic Center）, Affiliated People＇s Hospital of Jiangsu University were analyzed retrospectively. According to the date of operation, all the cases were divided into 5 groups （A-E） successively. Twenty cases were set in each group as an operation stage. Each case was dissected D2 lymph node of the gastric cancer, disconnected gastric peripheral vascular in the endoscopy, reconstructed digestive tract with assisted small incision. Results There was no statistical difference in age, sex, resection site of the stomach, digestive tract reconstruction, postoperative pathologic staging, postoperative hospital staying of every group （P〉0.05）. There were statistical difference in the operation time （F=4.610, P=0.002）, intraoperative bleeding volume（F=7.626, P=0.000） between the five groups. There was no statistical difference between A, B and C group （P〉0.05）. There was no statistical difference between D and E group （P〉0.05）. There were statistical difference between A,B,C group and E,D group （P 〈 0.05）.Lymph node dissection were gold number （homogeneity of variance P=0.903 ）： there was no statistical difference between A and B group（P〉0.05）; there was no statistical difference between C,D and E group （P〉0.05）; there were statistical difference between A and B group, and the same difference between C,D and E group （P 〈 0.05）. Two cases of A and B group respectively and l case of C group were transferred to laparotomy. The total rate of conversion to laparotomy was 5%. Two cases each group in A, B and C had intraoperative injury. Conclusion During mature period, the operation time is shortened significantly, and bleeding is decreased siguificantly without intraoperative accident injury or conversion to laparotomy. The mean number of dissected lymph nodes becomes stable. Improving processing way in perioperative period, appropriate operation frequency （ 60 cases or so） can help the operator with the mature technique for open radical D2 gastrectomy for gastric cancer （OG-D2） and laparoscopic cholecystectomy （LC）to pass through the learning curve of the operation safely.