达芬奇机器人手术系统保留迷走神经胃癌根治术的临床疗效

Clinical effect of vagus nerve-preserving Da Vinci robot-assisted radical gastrectomy for gastric cancer

目的：探讨达芬奇机器人手术系统保留迷走神经胃癌根治术的安全性和可行性。方法：采用回顾性横断面研究方法。收集2015年1月至2016年11月第三军医大学西南医院收治的12例行达芬奇机器人手术系统保留迷走神经胃癌根治术患者的临床病理资料。患者均行达芬奇机器人手术系统保留迷走神经胃癌根治术，术中注意幽门上区、贲门右侧区域、胰腺上缘区域淋巴结清扫，其他操作同传统机器人手术系统胃癌手术。观察指标：（1）术中及术后情况：手术方式、消化道重建方式、手术时间、术中出血量、淋巴结清扫数目，术后病理学检查结果，术后胃肠功能恢复时间、进食流质饮食时间，术后住院时间，近期手术相关并发症（术后出血、吻合口瘘、梗阻及腹腔感染）。（2）随访情况：术后远期并发症（胃潴留、碱性反流性胃炎、倾倒综合征、胆囊病变、胆石症），术后生命质量（饮食情况、上腹部不适、恶心、呕吐、腹泻），术后营养状况（体质量、Hb、TP、Alb）及肿瘤复发情况。采用电话和门诊方式进行随访；电话随访患者了解患者饮食情况，消化道症状及体质量；门诊随访患者检测血常规、肝功能、肾功能、肿瘤标志物，行胸部X线片、腹部CT或彩色多普勒超声及胃镜等检查诊断肿瘤复发或转移情况。随访时间截至2016年12月。正态分布的计量资料以±s表示，偏态分布采用M（范围）表示。结果：（1）术中及术后情况：12例患者均成功施行达芬奇机器人手术系统保留迷走神经远端胃癌根治术，无中转腹腔镜及开腹手术，其中D1根治术 2例，D 1＋根治术2例，D2根治术8例；5例消化道重建行Billroth Ⅰ式吻合，7例行Billroth Ⅱ式吻合。12例患者手术时间为（247±34）min，术中出血量为（94±23）mL，淋巴结清扫数目为（27±7）枚。术后病理学检查显示：12例患者远近切缘均为阴性，达到R0切除；共清扫淋巴结326枚，6例未见淋巴结转移，6例共检出18枚阳性淋巴结。12例患者术后胃肠功能恢复时间和进食流质饮食时间分别为（57±14）h和（64±14）h，术后住院时间为（7.3±0.9）d。12例患者均未出现近期手术相关并发症。（2）随访情况：12例患者均获得电话随访（10例获门诊随访），中位随访时间为9个月（1～20个月）。12例患者远期并发症中，食欲减退 2例，腹泻1例，未发生胆囊结石、胆囊炎、胃潴留、倾倒综合征。10例获门诊随访患者，术后1个月体质量为（56±12）kg，Hb为（126±10）g/L，TP为（69.9±5.1）g/L，Alb为（43.2±3.3）g/L，CEA为阴性；术后3个月体质量为（52±13）kg，Hb为（126±10）g/L，TP为（72.1±2.4）g/L，Alb为（45.2±1.6）g/L，CEA为阴性。 12例患者均未出现肿瘤复发或转移。结论：达芬奇机器人手术系统保留迷走神经胃癌根治术安全可行，并未影响淋巴结清扫和增加手术并发症，且能改善患者术后生命质量、维持良好营养状况。

Objective：To explore the safety and feasibility of vagus nervepreserving Da Vinci robot assisted radical gastrectomy for gastric cancer. Methods：The retrospective crosssectional study was conducted. The clinicopathological data of 12 gastric cancer patients who underwent vagus nervepreserving Da Vinci robot assisted radical gastrectomy at the Southwest Hospital of the Third Military Medical University from January 2015 to November 2016 were collected. All patients underwent vagus nervepreserving Da Vinci robotassisted radical gastrectomy for gastric cancer. During operation, lymph node dissection of the pyloric region, the right side of the cardia and the superior margin of the pancreas were noticed, and other surgical procedures were the same as the traditional Da Vinci robotassisted radical gastrectomy. Observation indicators： （1） intra and postoperative situations： surgical methods, digestive tract reconstruction, operation time, volume of intraoperative blood loss, number of lymph node dissected, results of postoperative pathological examination, recovery time of gastrointestinal function, time for liquid diet intake, duration of postoperative hospital stay, shortterm surgeryrelated complications （postoperative bleeding, anastomotic fistula, obstruction and intraabdominal infection）; （2） followup situations： postoperative longterm complications （gastric retention, alkaline reflux gastritis, dumping syndrome, gallbladder disease and cholelithiasis）, postoperative quality of life （diet, upper abdominal discomfort, nausea, vomiting and diarrhea）, postoperative nutritional status [body weight, hemoglobin （Hb）, total protein （TP）, albumin （Alb）] and tumor recurrence. Followup using telephone interview and outpatient examination was performed up to December 2016. Telephone interview included detecting diet of patients, digestive tract symptoms and body weight. Routine blood test, liver and kidney functions, tumor markers, chest Xray, abdominal computed tomography （CT） or color Doppler ultrasound and gastroscopy of outpatient examinations were performed to detect tumor recurrence and metastasis. Measurement data with normal distribution were represented as ±s and measurement data with skewed distribution were described as M （range）. Results：（1） Intra and postoperative situations： all the 12 patients underwent successful vagus nervepreserving Da Vinci robotassisted radical gastrectomy for gastric cancer, without conversion to laparoscopic surgery or open surgery, including 2 patients with D1 lymphadenectomy, 2 patients with extended D1 lymphadenectomy and 8 patients with D2 lymphadenectomy. Five and 7 patients underwent respectively Billroth Ⅰ anastomosis and Billroth Ⅱ anastomosis of digestive tract reconstruction. Operation time, volume of intraoperative blood loss and number of lymph node dissected of 12 patients were （247±34）minutes, （94±23）mL and 27±7, respectively. Results of postoperative pathological examination showed that distal and proximal surgical margins of 12 patients were negative and achieved R0 resection; 326 lymph nodes were dissected, 6 patients didn′t have lymph node metastasis and 18 positive lymph nodes were detected in 6 patients. Recovery time of gastrointestinal function, time for liquid diet intake and duration of postoperative hospital stay in 12 patients were （57±14）hours, （64±14）hours and （7.3±0.9）days, respectively. There was no occurrence of shortterm surgeryrelated complications. （2） Followup situations： 12 patients were followed up by telephone interview （10 receiving outpatient examinations） for 9 months （range, 1-20 months）. Of 12 patients with longterm complications, 2 had loss of appetite, 1 had diarrhea, without occurrence of cholelithiasis, cholecystitis, gastric retention and dumping syndrome. Of 10 patients receiving outpatient examinations, body weight, Hb, TP and Alb were （56±12）kg, （126±10）g/L, （69.9±5.1）g/L, （43.2±3.3）g/L at 1 month postoperatively and （52±13）kg, （126±10）g/L, （72.1±2.4）g/L, （45.2±1.6）g/L at 3 months postoperatively, respectively, with negative carcinoembryonic antigen. There was no tumor recurrence and metastasis in 12 patients. Conclusion：Vagus nervepreserving Da Vinci robotassisted radical gastrectomy is safe and feasible for gastric cancer, which has not affected the lymph node dissection and incidence of surgeryrelated complications, and it also can improve the postoperative quality of life and maintain good nutritional status.