腹腔镜胃癌根治术治疗老年进展期胃癌的临床疗效

Clinical efficacy of laparoscopic radical gastrectomy in elderly patients with advanced gastric cancer

目的探讨腹腔镜胃癌根治术治疗老年进展期胃癌的临床疗效。方法回顾性分析2012年1月至2014年6月宁波市第一医院收治的85例老年进展期胃癌患者的临床资料。其中行腹腔镜胃癌根治术46例，设为腹腔镜组；行开腹胃癌根治术39例，设为开腹组。两组患者均行胃癌原发灶切除＋D2淋巴结清扫术，术后根据加速康复理念制订术后恢复方案。分析两组患者的术中出血量、淋巴结清扫数目、手术时间、术中PaCO2、术后肛门排气时间、胃管留置时间、离床活动时间、进食流质食物时间、术后Hb、住院时间及并发症发生情况等指标。采用电话或门诊进行随访，随访时间截至2014年8月。计数资料比较采用χ^2检验和Fisher确切概率法；正态分布的计量资料用x±s表示，采用t检验，如果两组资料方差不齐，则采用t’检验。结果两组患者手术过程均顺利，无围术期死亡，腹腔镜组患者无一例中转开腹。腹腔镜组和开腹组患者肿瘤切缘呈阴性，手术时间分别为（239±68）min和（227±50）min，淋巴结清扫数目分别为（27±10）枚和（26±10）枚，两组比较，差异无统计学意义（t=0．919，0．179，P〉0．05）；腹腔镜组患者术中PaCO：为（414±）mmHg（1mmHg=0．133kPa）高于开腹组的（36±5）mmHg，两组比较，差异有统计学意义（t=4．745，P〈0．05）。腹腔镜组患者术中出血量为（102±44）mL，明显少于开腹组的（200±120）mL，而腹腔镜组患者术后Hb为（110±15）g／L，高于开腹组的（98±27）g／L，两组比较，差异有统计学意义（t’=-4．807，2．471，P〈0．05）。腹腔镜组患者术后肛门排气时间、胃管留置时间、离床活动时间、进食流质食物时间、住院时间分别为（2．6±0．7）d、（2．1±0．7）d、（1．1±0．3）d、（4．1±0．7）d、（11±4）d，均明显早于开腹组的（4．8±1．5）d、（4．0±1．8）d、（4．5±0．6）d、（5．9±1．8）d、（18±3）d，两组上述指标比较，差异均有统计学意义（t’=-8．415，-6．206，-33．831，-5．879，t=9．632，P〈0．05）。腹腔镜组和开腹组患者术后分别有8例和15例发生并发症，并发症发生率分别为17．4％（8／46）和38．5％（15／39），两组比较，差异有统计学意义（χ^2=4．748，P〈0．05）。腹腔镜组和开腹组患者分别有44例和36例获得随访，随访时间为2～25个月，腹腔镜组1例患者死亡，开腹组2例患者死亡，其余患者术后恢复良好，生活自理。结论与开腹胃癌根治术比较，腹腔镜胃癌根治术在保证肿瘤根治性切除和手术安全的同时，能明显促进老年进展期胃癌患者的术后康复，降低术后并发症发生率。

Objective To investigate the clinical efficacy of laparoscopic radical gastrectomy in elderly patients with advanced gastric cancer. Methods The clinical data of 85 elderly patients with advanced gastric cancer who were admitted to the Ningbo First Hospital from January 2012 to June 2014 were retrospectively analyzed. Laparoscopic radical gastrectomy was performed on 46 patients （ LRG group） and open radical gastrectomy on 39 patients （ ORG group）. All the patients underwent primary tumor resection for gastric cancer ＋ D2 lymph node dissection , and the postoperative recovery plans were done according to enhanced recovery program. The volume of blood loss, number of lymph node dissected, operation time, intraoperative arterial partial pressure of carbon dioxid （PaCO2 ）, time to anal exsufflation, indwelling time of gastric tube, time for out-off-bed activity, time for fluid diet intake, postoperative hemoglobin, duration of hospital stay and occurrence of complications in the 2 groups were analyzed. The follow-up by outpatient examination and telephone interview was carried out on patients up to August 2014. The count data were analyzed by the chi-square test and Fisher exact probability. The measurement data with normal distribution were presented as x±s and analyzed using the t test. The t＇ test was used if the data were deficient. Results Surgical procedures in the 2 groups were successfully carried out and no perioperative death occurred. There was no conversion to open surgery in the LRG group. The resection margins in all the patients were negative. The operation time and number of lymph node dissection in the LRG group were （239±68）minutes and 27 ± 10, compared with （227 ±50）minutes and 26 ± 10 in the ORG group, with signifi- cant differences （t=0.919, 0. 179, P〉0.05）. PaCO2 in the LRG group was （41±5）mmHg （1 mmHg= 0. 133 kPa）, which was significantly higher than（36 ± 5 ） mmHg in the ORG group （ t = 4. 745, P 〈 0.05 ）. The volume of blood loss was （102 ± 44）mL in the LRG group, which was significantly less than （200 ± 120）mL in the OPG group （t＇ =- 4. 807, P 〈 0.05）. The postoperative level of hemoglobin in the LRG was（ 110 ± 15）g/L, which was significantly higher than （98 ±27）g/L in the ORG group （t＇ =2. 471, P 〈0.05）. The time to anal exsufflation, indwelling time of gastric tube, time for out-off-bed activity, time for fluid diet intake, duration of hospital stay in the LRG group were （2.6 ± 0.7） days, （2.1 ± 0.7 ） days, （ 1.1 ± 0.3 ） days, （4.1 ± 0.7 ） days and （ 11 ± 4） days, which were significantly different from （4.8± 1.5 ） days, （4.0 ± 1.8 ） days, （4.5 ± 0.6） days, （5.9± 1.8） days and （ 18 ± 3） days in the ORG group （t＇ = - 8. 415, - 6. 206, - 33. 831, - 5. 879, t = 9. 632, P〈0.05）. Eight patients in the LRG group and 15 patients in the ORG group had complications, with the incidence of complications of 17.4% （8/46） and 38.5% （15/39） , respectively, showing a significant difference （χ^2 = 4. 748, P 〈 0.05 ）. Forty-four patients in the LRG group and 36 patients in the ORG gorup were followed up for 2-25 months, 1 patient in the LRG group and 2 patients in the ORG group died and others had full recovery. Conclusions Laparoscopic radical gastrectomy could provide a safe and complete tumor resection for elderly patients with advanced gastric cancer compared with open radical gastrectomy, meanwhile, it can improve post- operative recovery and reduce postoperative complications in elderly patients with advanced gastric cancer.