机器人在残胃上的癌手术治疗中的临床应用

Application of robotic surgery to treat carcinoma in the remnant stomach

目的探讨达芬奇机器人对于残胃上的癌（CRS）切除术中的技术方法及其可行性。方法收集2012年11月至2017年10月期间，陆军军医大学西南医院微创胃肠外科中心行达芬奇机器人治疗的20例CRS患者的临床资料，分析手术方式、方法、难点及技术要领，并评价临床疗效。结果20例CRS患者中男性14例，女性6例；平均年龄59.9岁，平均体质指数19.7 kg/m2。17例曾行开腹手术，3例曾行腹腔镜胃癌根治手术；18例曾行远端胃大部切除Billroth Ⅱ式吻合，2例行远端胃大部切除BillrothⅠ式吻合。病灶位置：吻合口15例，胃底贲门5例。术前分期：T2NxM0 2例，T3NxM0 1例，TxNxM0 2例，T4aNxM0 15例。全组患者在机器人下成功完成残胃切除16例，均行Roux-en-Y消化道重建。中转开腹4例行姑息性残胃全切除术，其中1例病变侵犯膈肌、1例病变侵犯横结肠、2例与周围组织粘连致密。全组患者手术用时（255±35）min，术中失血量（230±50）ml，清扫淋巴结数量（19.5±3.0）枚，术后胃肠功能恢复时间（2.3±1.0）d，进食时间（2.3±1.0）d，下床活动时间（2.5±0.5）d。术后病理：低分化腺癌12例，中分化腺癌6例，黏液腺癌2例。术后病理分期：ⅠB期1例，ⅡA期2例，ⅡB期5例，ⅢA期5例，ⅢB期4例，ⅢC期3例。1例病例术后2周因多器官功能衰竭死亡，1例因脾动脉分支出血，再次手术止血后痊愈出院。另有2例病例术后发生吻合口漏、1例术后发生十二指肠残端漏、1例术后切口感染，均经保守治疗后康复出院。经5～60个月的随访，10例死亡，10例存活，最长1例至今已存活6年。结论机器人CRS切除术是安全可行的，近期疗效较好，远期疗效有待进一步观察。

Objective To explore the surgical techniques and feasibility of robotic surgery for carcinoma in the remnant stomach （CRS）. Methods Clinicopathological data of 20 CRS patients undergoing robotic surgery at the Minimally Invasive Center for Gastrointestinal Surgery, Army Medical University Southwest Hospital from November 2012 to October 2017 were retrospectively collected. The surgical methods, procedures, main difficulties, and key techniques were analyzed, and the clinical efficacy was evaluated. Results Among 20 CRS patients, 14 were male and 6 were female with mean age of 59.9 years and mean BMI of 19.7 kg/m2. For the primary diseases, 17 patients underwent laparotomy, 3 underwent laparoscopic radical resection of gastric cancer; 18 cases received distal subtotal gastrectomy plus Billroth 11 anastomosis, 2 received distal subtotal gastrectomy plus Billroth I anastomosis. CRS located in anastomotic stoma in 15 cases and in the gastric fundus and cardiac part in 5 cases. Preoperative staging revealed 2 cases of T2NxM0, 1 of T3NxM0, 2 of TxNxM0 and 15 of T4aNxM0. Sixteen patients received robotic surgery with Roux-en-Y reconstruction successfully, and 4patients were converted to laparotomy for palliative total gastrectomy, including 1 case with diaphragm invasion, 1 case with transverse colon invasion, and 2 cases with tight adhesions. The mean surgery time was （255±35） minutes, mean blood loss was （230±50） ml, mean number of dissected bmph nodes was 19.5±3.0, mean recovery time to gastrointestinal function was （2.3±1.0） days, mean time to feeding was （2.3±1.0） days, and mean time to ambulatory activity was （2.5±0.5） days. Pathological examinations revealed 12 patients with poorly differentiated adenocarcinoma, 6 patients with moderately differentiated adenocarcinoma, and 2 patients with mucinous adenoeareinoma. Postoperative pTNM staging was identified as follows： stage I B for 1 patient, stage I1 A for 2 patients, stage IIB for 5 patients, stage m A for 5 patients, stage III B for 4 patients, and stage m c for 3 patients. One patient died 2 weeks after operation due to multiple organ failure. One patient received another hemostasis operation due to hemorrhage of splenic artery and recovered postoperatively. Two patients experienced anastomotic leakage, 1 patient developed duodenal stump fistula and 1 patient experienced incision site infection postoperatively, and all of them recovered after conservative treatment. During 5-60 months follow-up, 10 cases died and 10 cases survived, including 1 case for 6 years. Conclusions Robotic surgery for CRS is feasible with satisfactory short-term efficacy. However, the long-term efficacy requires further study.