机器人和腹腔镜辅助根治性全胃切除术在体质指数高于正常值胃癌患者中的应用

Application of robotic and laparoscopic radical total gastrectomy to gastric cancer patients with body mass index ≥24 kg/m^2

目的比较机器人与腹腔镜辅助根治性全胃切除术在体质指数（BMI）高于正常值胃癌患者中的应用。方法回顾性收集2016年4月至2017年4月期间，在解放军总医院接受机器人和腹腔镜根治性全胃切除术的93例胃癌患者的临床资料，进行回顾性队列研究。纳入标准：经胃镜和活检病理明确诊断为原发性胃癌；术前BMI≥24 kg/m^2；无既往腹部手术史；无既往化疗或放疗史；术前和术中探查未发现远处转移或邻近器官侵犯；行根治性全胃切除术；开腹辅助操作阶段完成食管空肠Roux-en-Y吻合。根据微创方式的不同，分为机器人手术组24例，腹腔镜手术组69例。比较两组术中情况（总手术时间、气腹下操作时间、开腹辅助操作时间、术中出血量、术中输血率、清扫总淋巴结数和清扫转移淋巴结数等）及术后短期疗效（术后首日引流量、术后首次排粪时间、术后总并发症发生情况以及术后住院时间等）。结果全组93例患者，其中男性77例，女性16例，年龄（60.0 ± 10.6）岁，BMI为（26.8 ± 1.7）kg/m^2，其中机器人手术组BMI为（26.9 ± 1.6）kg/m^2，腹腔镜手术组为（26.8 ± 1.7）kg/m^2。两组患者在术前年龄、性别、BMI、术前ASA评分、术后病理结果和临床分期的差异无统计学意义（均P 〉 0.05），具有可比性。机器人手术组总手术时间和开腹辅助操作时间均长于腹腔镜手术组[（301.2 ± 68.9）min比（247.3 ± 59.6）min，P = 0.000；（141.5 ± 26.3）min比（92.5 ± 36.7）min，P = 0.029]，机器人手术组总费用高于腹腔镜手术组[（17.5 ± 9.7）万元比（10.0 ± 2.3）万元，P = 0.001]。两组的气腹下操作时间、术中出血量、术中输血率、总淋巴结清扫数、转移淋巴结清扫数目以及术后短期疗效方面的差异均无统计学意义（均P 〉 0.05）。机器人手术组气腹下操作时间与总手术时间呈正相关关系（r = 0.708，P = 0.010），总费用与术后住院时间呈正相关关系（r = 0.493，P = 0.000），开腹辅助操作时间与术后首次排粪时间呈负相关关系（r = -0.962，P = 0.038）。腹腔镜手术组总费用与总手术时间呈正相关关系（r = 0.411，P = 0.046），术后首日引流量与清扫总淋巴结数呈正相关关系（r = 0.540，P = 0.006），术后住院时间与术中出血量呈正相关关系（r = 0.574，P = 0.003），总费用与术中出血量、术后住院时间呈正相关关系（r = 0.609，P = 0.002；r = 0.865，P = 0.000），术后首日引流量与BMI呈正相关关系（r = 0.533，P = 0.007）。结论BMI ≥24 kg/m^2的胃癌患者中，机器人根治性全胃切除术比腹腔镜组手术时间长、费用高，但受BMI变化影响更小，更有利于快速康复外科理念的实现。

ObjectiveTo compare the short-term outcomes between robotic and laparoscopic radical total gastrectomy in gastric cancer patients with BMI index ≥24 kg/m^2.MethodClinical data of 93 gastric cancer patients who underwent robotic and laparoscopic radical total gastrectomy at PLA General Hospital from April 2016 to April 2017 were retrospectively analyzed. The retrospective cohort study was adopted. Inclusion criteria： preoperatively definite diagnosis of primary gastric cancer by endoscopy and biopsy; preoperative BMI ≥ 24 kg/m^2; no previous abdominal surgery; no previous chemotherapy and radiotherapy; no distant metastasis or invasion into adjacent organs before operation or during operation; receiving radical gastrectomy; Roux-en-Y reconstruction of digestive tract in open procedure. According to approaches of minimally invasive surgery, 24 patients underwent robotic surgery and 69 underwent laparoscopic surgery. The intraoperative parameters （overall operative time, pneumoperitoneal time, open procedure time, intraoperative blood loss, transfusion rate, number of total retrieved lymph nodes and metastatic lymph nodes） and postoperative parameters （drainage in the first postoperative day, the first defecation time, morbidity of postoperative complication and hospital stay） were compared between two groups. Correlation of the above parameters were analyzed.ResultsOf 93 patients, 77 were male and 16 female with an average age of （60.0±10.6） years. The average BMI was （26.8 ± 1.3） kg/m^2 in whole patients, （26.9 ± 1.6） kg/m^2 in robotic group and （26.8 ± 1.7） kg/m^2 in laparoscopic group. No significant differences in age, gender, BMI, preoperative ASA class, postoperative pathological findings and clinical classification were observed between two groups, which made short-term parameters between two groups comparable. The robotic group had a significantly longer overall operative time [ （301.2 ± 68.9） minutes vs. （247.3 ± 59.6） minutes, P = 0.000], longer open procedure time [ （141.5±26.3） minutes vs. （92.5±36.7） minutes, P = 0.029] and higher cost than laparoscopy group[ （17.5 × 104 ± 9.7 × 104） yuan vs. （10.0 × 104 ± 2.3 × 104） yuan, P = 0.001]. Pneumoperitoneal operative time, intraoperative blood loss, transfusion rate, number of total retrieved lymph nodes, number of harvested metastatic lymph nodes and postoperative short-term efficacy were similar between the two groups （all P 〉 0.05） . In robotic group, pneumoperitoneal operative time was positively correlated with overall operative time （r = 0.708, P = 0.010） ; total cost was positively correlated with postoperative hospital stay （r = 0.493, P = 0.000） and open procedure time was negatively correlated with the first defecation time （r = -0.962, P = 0.038） . In laparoscopy group, total cost was positively correlated with overall operative time （r = 0.411, P = 0.046） , drainage volume in the first postoperative day was positively correlated with the number of total dissected lymph node （r = 0.540, P = 0.006） , postoperative hospital stay was positively correlated with intraoperative blood loss （r = 0.574, P = 0.003） , total cost was positively correlated with intraoperative blood loss and hospital stay （r = 0.609, P = 0.002; r = 0.865, P = 0.000） , drainage volume in the first postoperative day was positively correlated with BMI （r = 0.533, P = 0.007） .ConclusionFor gastric cancer patients with BMI ≥24 kg/m^2, robotic radical total gastrectomy is associated with longer operative time and higher cost, but is less vulnerable to the change of BMI and more in favor of the realization of enhanced recovery after surgery （ERAS） than laparoscopic radical total gastectomy.