腹腔镜与开腹手术治疗胃肠间质瘤的疗效分析及不同危险度对患者预后的影响

Efficacy of laparoscopic or open surgery for gastrointestinal stromal tumors and effects of different risklevel on prognosis

目的比较腹腔镜与开腹手术治疗胃肠间质瘤（GISTs）的临床疗效，评估不同危险度对其预后的影响。方法采用回顾性队列研究方法。收集2008年1月至2013年12月复旦大学附属中山医院收治的192例GISTs患者的临床资料，其中88例行腹腔镜手术患者设为腹腔镜手术组，104例行开腹手术患者设为开腹手术组。观察指标：（1）手术情况：手术方式、手术时间、术中出血量。（2）术后恢复情况：术后胃肠功能恢复时间、术后引流管拔除时间、术后并发症情况和术后住院时间。（3）随访情况。（4）不同危险度患者的预后。采用门诊和电话方式进行随访，了解患者生存、肿瘤复发、转移情况。随访时间截至2015年6月。正态分布的计量资料以X±s表示，组间比较采用t检验。计数资料比较采用，检验。采用Kaplan-Meier法绘制生存曲线，并计算总体生存率和无复发生存率。结果（1）手术情况：腹腔镜手术组88例患者中，1例行腹腔镜胃楔形切除＋胆囊切除＋阑尾切除术，6例行腹腔镜胃楔形切除＋胆囊切除术，14例行腹腔镜辅助胃部分切除术，其余67例行腹腔镜胃楔形切除术。开腹手术组104例患者中，1例行胃部分＋脾脏切除术，2例行胃部分联合胰体尾＋脾脏切除术，2例行全胃切除术，7例行远端胃大部分切除术，7例行胃楔形切除＋部分或完全邻近器官切除术，8例行近端胃大部分切除术，8例行胃楔形切除＋胆囊切除术，其余69例行胃楔形切除术。腹腔镜手术组患者手术时间和术中出血量分别为（105±33）min和（43±16）mL，开腹手术组分别为（121±52）min和（199±81）mL，两组患者上述指标比较，差异均有统计学意义（t=-2．104，2．632，P〈0．05）。（2）术后恢复情况：腹腔镜手术组患者术后胃肠功能恢复时间、术后引流管拔除时间分别为（4．6±1．8）d、（5．8±2．2）d，开腹手术组分别为（5．2±1．6）d、（7．1±2．8）d，两组患者上述指标比较，差异均有统计学意义（t=-2．783，-3．891，P〈0．05）。腹腔镜手术组患者术后发生伤口感染、胃排空延迟、吻合口瘘、肺部感染和出血分别为1、3、0、0、0例，开腹手术组分别为0、2、2、2、1例，两组患者总体并发症发生情况比较，差异无统计学意义（X^2=0．421，P〉0．05）。腹腔镜手术组患者术后住院时间为（7．1±2．9）d，开腹手术组为（8．7±4．3）d，两组比较，差异有统计学意义（t=-3．078，P〈0．05）。（3）随访情况：192例患者中，149例获得随访。腹腔镜手术组88例患者中68例获得随访，平均随访时间为39个月；开腹组104例患者中81例获得随访，平均随访时间为51个月。随访期间腹腔镜手术组和开腹手术组患者肿瘤复发率分别为8．8％（6／68）和21．0％（17／81），两组比较，差异无统计学意义（X^2=1．888，P〉0．05）。腹腔镜手术组患者和开腹手术组患者术后1、3、5年生存率分别为98．5％、92．9％、87．4％和91．7％、85．2％、76．9％，两组比较，差异无统计学意义（X^2=1．967，P〉0．05）。（4）不同危险度患者的预后：149例获得随访的患者中，低、中、高危险患者的肿瘤复发率分别为7．0％（5／71）、13．6％（6／44）和35．3％（12／34），3者比较，差异有统计学意义（X^2=14．637，P〈0．05）。低危险患者与高危险患者、中危险患者与高危险患者的肿瘤复发率分别比较，差异均有统计学意义（χ2=13．263，6．279，P〈0．05）。低危险患者与中危险患者的肿瘤复发率比较，差异无统计学意义（χ2=0．894，P〉0．05）。低、中、高危险患者的5年无复发生存率分别为94．2％、80．0％、61．8％，3者比较，差异有统计学意义（X^2=13．547，P〈0．05）。低危险患者与高危险患者、中危险患者与高危险患者的无复发生存率分别比较，差异均有统计学意义（X^2=4．357，12．336，P〈0．05）。低危险患者与中危险患者的无复发生存率比较，差异无统计学意义（X^2=0．696，P〉0．05）。结论腹腔镜GISTs切除术近期疗效优于开腹手术。但远期预后相当。GISTs高危险患者预后不良。

Objective To compare the efficacy of laparoscopic or open surgery for gastrointestinal stromal tumors （GISTs） and investigate effects of different risk level on prognosis. Methods The retrospective cohort study was adopted. The clinical data of 192 patients with GISTs who were admitted to Zhongshan Hospital of Fudan University from January 2008 to December 2013 were collected. Among the 192 patients, 88 undergoing laparoscopic surgeries were allocated into the laparoscopic surgery group, 104 patients undergoing open surgeries were allocated into the open surgery group. The following indicators were observed ： （ 1 ） operative status ： surgical procedure, operation time, volume of intraoperative blood loss. （2） Status of postoperative recovery： time of gastrointestinal function recovery, time of drainage tube removal, complications and duration of hospital stay. （ 3 ） Folh）w-up status. （4） Prognosis of patients in different risk level. The follow-up using outpatient examination and telephone interview was performed to assess patients＇ survival, tumor recurrence and metastasis until June 2015. Measurement data with normal distribution were presented as x -＋ s and comparison between groups was evaluated by the t test. Comparison of count data was analyzed by the chi-square test. The Kaplan-Meier method was used to draw survival curve and calculate the overall survival rate and relapse-free survival rate. Results （ 1 ） Operative status： of the 88 patients in the laparoscopic surgery group, 1 underwent laparoscopic wedge gastrectomy ＋ cholecystectomy ＋ appendectomy, 6 underwent laparoscopic wedge gastrectomy ＋ cholecystectomy, 14 underwent laparoscopic assisted partial gastrectomy, 67 underwent laparoscopic wedge gastrectomy. Of the 104 patients in the open surgery group, 1 underwent partial gastrectomy ＋ splenectomy, 2 underwent partial gastrectomy combined with distal pancreatectomy ＋ splenectomy, 2 underwent total gastrectomy, 7 underwent distal subtotal gastrectomy, 7 underwent wedge gastrectomy ＋ partial or total adjacent organ resection, 8 underwent proximal subtotal gastrectomy, 8 underwent wedge gastrectomy ＋ cholecystectomy, 69 underwent wedge gastrectomy. The operation time and volume of intraoperative blood loss were （ 105 ± 33 ） minutes and （43 ± 16） mL in the laparoscopic surgery group, （ 121 ± 52） minutes and （ 199 ± 81 ） mL in the open group, respectively, with statistically significant differences between the 2 groups （t = - 2. 104, 2. 632, P 〈 0.05）. （2） Status of postoperative recovery ： the time of gastrointestinal function recovery, time of drainage tube removal and duration of hospital stay were （4.6 ± 1.8 ） days, （5.8 ± 2.2） days, （7.1± 2.9 ） days in the laparoscopic surgery group and （ 5.2 ± 1.6） days, （7.1 ± 2.8 ） days, （ 8.7 ± 4.3 ） days in the open surge,＇y group, respectively, with statistically significant differences between the 2 groups （t = - 2. 783, - 3. 891, - 3. 078, P 〈 0.05） . Wound infection, gastric emptying delay, anastomotic leakage, lung infection and bleeding were detected in 1, 3, 0, 0, 0 patients in the laparoscopic surgery group and in 0, 2, 2, 2, 1 patients in the open surgery group, respectively, with no statistically significant difference between the 2 groups （X^2 = O. 421, P 〉 0.05 ）. （3） Follow-up status ： Of the 192 patients, 149 received follow-ups. Of 88 patients in the laparoscopic surgery group, 68 were followed up for an average time of 39 months. Of 104 patients in the open surgery group, 81 were followed up for an average time of 51 months. During the follow-up, tumor recurrence rate in the laparoscopic surgery group and open surgery group was respectively 8.8 % （6/68） and 21.0% （ 17/81 ）, with no statistically significant difference between the 2 groups （X^2= 1. 888, P 〉 0.05 ）. Postoperative 1-, 3-, 5 year survival rates were 98.5%, 92.9%, 87.4% and 91.7%, 85.2%, 76.9% in the laparoscopic surgery group and open surgery group, respectively, with no statistically significant difference between the 2 groups （X^2 = 1. 967, P 〉 O. 05 ）. （4） Prognosis of patients in different risk level： of the 149 who received the follow-up, the tumor recurrence rate of patients in low, intermediate and high recurrence risk was 7.0% （ 5/71 ）, 13.6% （ 6/44 ） and 35.3% （ 12/34 ）, respectively, with a statistically significant difference among the above indexes （X^2 = 14. 637, P 〈 O. 05 ） , showing statistically significant differences between low risk and high risk patients and between intermediate risk and high risk patients （X^2= 13. 263, 6. 279, P 〈 0.05 ）, while no statistically significant difference between low risk and intermediate risk patients （X^2= O. 894, P 〉 O. 05 ）. Five-year relapse-free survival rate of low, intermediate and high risk patients was 94.2%, 80.0% and 61.8% respectively, with a statistically significant difference （X^2= 13. 547, P 〈0.05）, showing statistically significant differences between low risk and high risk patients, intermediate risk and high risk patients （X^2 = 4. 357, 12. 336, P 〈 0. 05 ）, while no statistically significant difference between low risk and intermediate risk patients （X^2 = 0. 696, P 〉 0.05 ）. Conclusions Compared to open resection, laparoscopic GISTs resection offers better short-term outcomes, however, the two surgical techniques offer equal long-term outcomes. Patients of high risk have poor prognosis.