腹腔镜与开腹进展期远端胃癌D2根治术疗效对比

Efficacy comparison of laparoscopic versus open distal gastrectomy with D2 lymph dissection for advanced gastric cancer

目的探讨进展期胃癌患者行腹腔镜远端胃癌D2根治术的临床疗效。方法回顾性收集2004年1月至2010年6月间于第三军医大学西南医院普通外科行进展期远端胃癌D2根治术的678例患者的临床资料，其中行腹腔镜手术者377例（腹腔镜组），行开腹手术者301例（开腹组），随访时间截至2015年9月。比较两组患者术中及术后恢复情况、术后并发症发生情况以及远期随访结果；比较两组总体生存率及无瘤生存率。结果两组患者性别、年龄及体质指数等基线资料的比较，差异无统计学意义（均P〉0．05）。与开腹组相比，腹腔镜组术中出血少[（125±89）ml比（290±161）ml，t=-15．942，P=0．000]，术后排气早[（2．7±1．4）d比（3．6±1．6）d，t=-7．804，P=0．000]，术后进食早[（2．9±0．7）d比（4．1±1．6）d，t=-12．120，P=0．0001，术后住院时间短[（7．7±3．6）d比（10．1±4．1）d，t=8．107，P=0．000]，术后并发症发生率低[7．2％（27／377）比12．6％（38／301），χ2=5．762，P=0．016]。两组手术时间、淋巴结清扫数目及肿瘤近远切缘长度相比差异无统计学意义（均P〉0．05）。围手术期腹腔镜组有7例（1．9％）因并发症而行再次手术，1例（0．3％）因腹腔出血死亡；开腹组6例（2．0％）行再次手术，2例（0．7％）分别因腹腔感染伴肝功能衰竭和肺部感染伴呼吸衰竭死亡。中位随访时间为86（3．140）月，腹腔镜组和开腹组术后5年总体生存率分别为51．5％和49．8％，差异无统计学意义（χ2=0．142，P=0．706）；术后5年无瘤生存率分别为49．1％和47．8％，差异亦无统计学意义（χ2=0．062，P=O．803）。两组患者按肿瘤TNM分期进行分层分析，在相同TNM分期下的5年总体生存率及5年无瘤生存率相比较．差异亦均无统计学意义（均P〉0．05）。结论腹腔镜进展期远端胃癌D2根治术近期疗效优于开腹手术，远期疗效与开腹手术相当。

Objective To evaluate the long-term clinical outcomes between laparoscopic and open distal gastrectomy with D2 lymph dissection for advanced gastric cancer. Methods Clinical data of 377 cases of laparoscopie distal gastrectomy and 301 cases of open distal gastrectomy with D2 lymph dissection at the Southwest Hospital, the Third Military Medical University from January 2004 to June 2010 were retrospectively analyzed. Patients were followed up until September 2015. Surgical outcomes, postoperative complications and long-term survival were compared between the two groups. Results Compared with conventional open group, laparoscopic group was associated with lower intraoperative blood loss [（125 ± 89） ml vs. （290±161） ml, t = -15.942, P= 0.000], shorter time to oral intake [（2.9 ±0.7） days vs. （4.1 ± 1.6） days, t = -12.120, P = 0.000], quicker bowel function return[（2.7 ± 1.4） days vs. （3.6 ± 1.6） days, t = -7.804, P = 0.000], shorter postoperative hospital stay [（7.7 ± 3.6） days vs. （10.1±4.1） days, t = -8.107, P = 0.000]. In addition, there were no significant differences in the operative time [ （207 ± 57） minutes vs. （202± 43） minutes, P 〉 0.05 ], number of retrieved lymph nodes（33 ± 13 vs. 31±15, P 〉 0.05）, resection margin length（P 〉 0.05） between two groups. The postoperative complication morbidity in laparoscopie group was significantly lower than that in open group [7.2%（22/377） vs. 12.6%（38/301）, χ2 = 5.762, P = 0.016]. Within perioperative period, 7 patients underwent operation again due to eomplication and 1 ease died of peritoneal bleeding in laparoscopic group; 6 patients underwent re-operation and 2 eases died of peritoneal infeetion with hepatic failure and lung infection with respiratory failure. During the median follow-up of 86 months （range from 3 - 140 months）, relapse occurred in 171（45.4%） patients and 183 （48.5%, among them, 156 eases died of primary disease） patients died in laparoseopie group; relapse oecurred in 140 （46.5%） patients and 151 （50.2%, among them, 127 eases died of primary disease） patients died in open group. The difference in overall 5-year survival rate between two groups was not statistically significant （51.5% vs. 49.8%, χ2= 0.142, P= 0.706）. No significant difference was seen in 5-year disease-free survival rate （49.1% vs. 47.8%, χ2 = 0.062, P= 0.803）. Stratified analysis based on TNM stage also showed no significant difference in 5-year overall or disease- free survival rate （both P 〉 0.05）. Conclusion Laparoscopic distal gastreetomy with D2 lymph dissection for advanced gastric cancer has better short-term efficacy and similar long-tern efficacy as compared to open surgery.