腹腔镜辅助全胃切除术在65岁以上胃癌患者中的应用

Application of laparoscopy-assisted total gastrectomy in elderly patients ≥65years with gastric cancer

目的探讨腹腔镜辅助全胃切除术在65岁以上老年患者中应用的安全性及可行性。方法回顾性收集北京大学肿瘤医院胃肠肿瘤中心四病区2009年4月至2016年12月期间行腹腔镜辅助全胃切除术的188例胃癌患者的临床、病理及随访资料进行回顾性队列研究。研究对象纳入标准:患者体力状况0~1级;术前胃镜检查胃部肿物,病理活检证实腺癌;影像学检查排除了远处转移;术前心肺功能正常;术前血常规、肝肾功能、凝血功能正常;术中行腹腔镜辅助全胃切除者。排除标准:术中腹腔镜探查可见腹盆腔种植转移;腹腔游离细胞学阳性者;腹腔镜手术中转开腹者。按年龄分为≥65岁组(59例)和<65岁组(129例)。比较两组患者的术前、术中、术后情况和围手术期并发症发生情况以及预后;分析≥65岁患者术后并发症的高危因素。结果所有患者均由同一手术团队完成手术。≥65岁组术前基础疾病发生率为44.1%(26/59),明显高于<65岁组的20.2%(26/129)(χ^2=11.570,P=0.001);≥65岁组贲门胃底癌发生率为64.4%(38/59),高于<65岁组的40.3%(52/129)(χ^2=16.625,P=0.001)。≥65岁组患者术中淋巴结清扫数明显少于<65岁组[(28.9±10.7)枚比(36.1±15.4)枚,t=3.271,P=0.001]。全组患者并发症总发生率为13.8%(26/188),术后30d病死率为1.6%(3/188)。其中≥65岁组术后并发症发生率和术后30d病死率分别为20.3%(12/59)和3.4%(2/59),略高于<65岁组[10.9%(14/129)和0.8%(1/129)],但差异均无统计学意义(P>0.05)。多因素Logistic回归分析显示,术前患基础疾病(OR=0.223,95%CI:0.053~0.944,P=0.041)是≥65岁患者行腹腔镜辅助全胃切除术围手术期发生并发症的独立危险因素。全组患者中位生存时间为21.3个月,5年总生存率为50.0%。≥65岁组和<65岁组5年生存率分别为45.5%和57.5%,差异无统计学意义(P=0.205)。结论腹腔镜辅助全胃切除术在≥65岁胃癌患者的治疗中具有良好的安全性及有效性,年龄不是腹腔镜全胃切除术的禁忌证。

Objective To evaluate the safety and feasibility of laparoscopy-assisted total gastrectomy in gastric cancer patients over 65 years old.Methods Clinical,pathological and follow-up data of 188 gastric cancer patients who underwent laparoscopy-assisted total gastrectomy at Department Ⅳ of Gastrointestinal Cancer Center,Peking University Cancer Hospital,from April 2009 to December 2016 were collected for a retrospective cohort study.Inclusion criteria were as follows:ECOG performance score 0-1;preoperative gastroscopy discovered gastric masses,and pathological biopsy confirmed adenocarcinoma;distant metastases were excluded by image examination;preoperative cardiopulmonary function was normal;preoperative blood routine test,liver and renal function,and coagulation function were normal;laparoscopy-assisted total gastrectomy was performed.Exclusion criteria:intraoperative laparoscopic exploration indicated abdominal and/or pelvic peritoneal metastasis;free cancer cells in peritoneal cavity;conversion to laparotomy during laparoscopic surgery. Patients were divided by age into 2 groups,≥65 years old group(59 cases)and <65 years old group (129 cases).The perioperative conditions and postoperative complications between two groups were compared,and the high risk factors of postoperative complications in patients over 65 years old were analyzed.Results All the patients were operated by the same operation team.The incidence of comorbidities was 44.1%(26/59)in the ≥65years old group,which was significantly higher than 20.2%(26/129)in the <65years old group (χ^2=11.570,P=0.001).The incidence of cardia/fundus cancer was 64.4%(38/59)in the ≥ 65 years old group,which was also significantly higher than 40.3%(52/129)in the <65 years old group (χ^2=16.625,P=0.001).The number of retrieved lymph nodes in the ≥65 years old group was significantly lower than that in the <65 years old group (28.9±10.7vs.36.1±15.4,t=3.271,P=0.001).The total morbidity of complications was 13.8%(21/188)and the mortality within 30 days after operation was 1.6%(3/188).The morbidity of postoperative complications and the mortality within 30 days after operation were 20.3%(12/59)and 3.4%(2/59,respectively)in the ≥65 years old group,which were slightly higher than those in the <65 years old group [10.9%(14/129)and 0.8%(1/129)],without significant difference(both P>0.05).Multivariate logistic regression analysis showed that preoperative comorbidities (OR=0.223, 95%CI:0.053 to 0.944,P=0.041)was an independent risk factor for postoperative complications in patients aged ≥65years old undergoing laparoscopy-assisted total gastrectomy.The median survival time was 21.3months and the overall 5-year survival rate was 50.0%.The 5-year survival rate was 45.5% and 57.5%in patients aged ≥65 and <65 years,respectively,and there was no significant difference (P=0.205).Conclusions Laparoscopy-assisted total gastrectomy is safe and effective in the treatment of gastric cancer patients ≥65years old.Age is not a contraindication of laparoscopy-assisted total gastrectomy.