托出式胰后入路脾门淋巴结清扫在腹腔镜胃癌根治术中的临床应用

Laparoscopic spleen-preserving splenic hilar lymph nodes dissection through retropancreatic and extruded approach in radical gastrectomy for advanced gastric carcinoma

目的探讨经腹腔镜胰后入路脾托出式脾门淋巴结清扫术在近端胃癌根治术中应用的可行性、安全性,并初步分析其解剖特点。方法采用回顾性队列研究方法,收集2014年6月至2017年1月宜宾市第二人民医院收治的84例进展期近端胃癌患者的临床资料。其中44例为观察组,采用经腹腔镜托出式胰后入路法;40例为对照组,采用经腹腔镜左侧入路法。所有手术均由同一团队完成。观察并比较2组患者手术情况、术后情况、随访情况。结果 84例患者均顺利完成根治性全胃切除术(D2根治术),成功保留脾,完成第10组淋巴结清扫,未中转开腹。观察组与对照组术中出血量分别为(107.9±52.9)m L和(153.1±72.2)m L,手术时间分别为(228.8±27.7)min和(244.7±31.3)min,第10组淋巴结清扫数量分别为(5.0±2.2)枚和(2.9±1.3)枚。2组术中出血量、手术时间、第10组淋巴结清扫数量比较差异有统计学意义(P<0.05)。观察组与对照组术后首次下床活动时间分别为(1.6±0.4)d和(1.5±0.4)d,术后肛门排气时间分别为(2.9±0.8)d和(2.6±0.5)d,术后住院时间分别为(7.5±1.4)d和(7.0±1.3)d。观察组术后发生并发症4例,对照组术后发生并发症5例,均经非手术治疗痊愈。2组术后首次下床时间、肛门排气时间、术后住院时间、并发症发生率比较差异无统计学意义(P>0.05)。84例患者中共82例获得随访,随访时间为6~36个月,中位随访时间为15.5个月,随访中2组分别有1例因癌性腹水死亡。结论经腹腔镜胰后入路脾托出式脾门淋巴结清扫术可行性较高,与常规腹腔镜左侧入路相比,能减少术中出血量,缩短手术时间,增加第10组淋巴结清扫率。

Objective To investigate the feasibility and safety of laparoscopic spleen-preserving splenic hilar lymph nodes dissection through retropancreatic and extruded approach in radical gastrectomy for proximal gastric carcinoma,and to preliminarily analyzed the anatomical features.Methods Adopted a retrospective cohort study.The clinical data of 84 patients with proximal gastric carcinoma who underwent radical resection in our hospital from June 2014 to January 2017 were collected.Among the 84 patients,44 case who underwent spleen extruded-retroperitoneal approach were regarded as the observation group,and the other 40 patients underwent conventional left approach were allocated into the control group.All the patients underwent laparoscopic D2 radical total gastrectomy and spleen-preserving N0.10 nodes dissection by the same operation team.The clinical situation of the two groups before operation,after operation and during the follow-up were observed.Results All the 84 patients successfully completed the radical gastrectomy without conversion to open surgery.In the observation group and the control group,the volume of intraopertative blood loss were respectively(107.9±52.9)mL and(153.1±72.2)mL;the operation time were respectively(228.8±27.7)min and(244.7±31.3)min;the number of dissected N0.10 lymph node were respectively(5.0±2.2)and(2.9±1.3).There were statistically significant differences in all the above indexs(P<0.05).In the observation group and the control group,the time for initial out-of-bed activity were respectively(1.6±0.4)days and(1.5±0.4)days;the time of initial anal exsufflation were respectively(2.9±0.8)days and(2.6±0.5)days;the duration of hospital stay were respectively(7.5±1.4)days and(7.0±1.3)days.Postoperative complications occured 4 cases in the observation group and 5 cases in the control group.There was no statistically significant difference in terms of time for initial out-of-bed activity,time of initial anal exsufflation,duration of hospital stay and postoperative complications(P>0.05).A total of 82 patients were followed up for 6 to 36 months,with a median time of 15.5 months.Conclusion Compared with the conventional left approach,laparoscopic spleen-preserving splenic hilar lymph nodes dissection through retropancreatic and extruded approach is safe and feasible for laparoscopic radical resection of proximal gastric carcinoma.And it can shorten the operation time,reduce the volume of intraopertative blood loss,and increase the clearance of N0.10 lymph nodes.