胃不利部位胃肠间质瘤两种手术方式临床疗效对比研究

Comparative study on clinical efficacy of two surgical methods for gastric gastrointestinal stromal tumors at unfavorable position

目的探讨腹腔镜手术治疗胃不利部位胃肠间质瘤(GIST)的安全性和可行性。方法采用回顾性队列研究方法,分析2008年6月至2018年6月期间,就诊于重庆陆军军医大学附属西南医院和恩施湖北民族大学附属民大医院、经手术治疗(腹腔镜或开腹)、术后经病理证实为胃不利部位GIST患者的临床资料。胃不利部位定义为食管胃结合部、胃小弯侧近贲门、胃幽门部、胃后壁和胃窦。病例排除标准:(1)术前行化疗或伊马替尼治疗;(2)肿瘤直径>10 cm;(3)肿瘤出现远处转移或合并其他恶性肿瘤疾病。入组患者244例(西南医院238例,民大医院6例),男性122例,女性122例,年龄41~70岁。根据患者意愿采用手术方式,其中腹腔镜手术组146例,开腹手术组98例。比较两组术中出血量、手术时间、术后首次排气时间、术后首次进食时间、住院时间、术后并发症及1年、3年和5年的无复发生存率(RFS)和总体生存率(OS)的差异。结果腹腔镜手术组与开腹手术组患者性别、年龄和肿瘤直径、肿瘤危险度分级及肿瘤生长方式比较,差异均无统计学意义(均P>0.05),两组具有可比性。腹腔镜手术组与开腹手术组相比,术中出血量[(31.4±2.3)ml比(143.9±3.7)ml,t=292.800,P<0.001]少,首次进食时间[(2.1±0.5)d比(2.3±1.7)d,t=1.339,P=0.020]、首次排气时间[(2.1±0.7)d比(3.8±0.8)d,t=17.550,P<0.001]和住院时间[(8.6±2.6)d比(13.6±3.2)d,t=13.410,P<0.001]短,术后并发症发生率[16例(11.0%)比21例(21.4%),χ^2=4.996,P=0.025]低;但两组的手术时间相近[(124.7±15.8)min比(120.9±14.5)min,t=1.903,P=0.058]。全组中位随访43(1~119)个月,腹腔镜手术组与开腹手术组患者1、3和5年RFS分别为94.5%比93.9%、91.1%比90.8%以及82.2%比81.6%;OS分别为98.6%比95.9%、95.9%比94.9%以及91.1%比88.8%,差异均无统计学意义(均P>0.05)。结论在有经验的胃肠外科治疗中心,胃不利部位GIST腹腔镜手术是安全、可行的,可以达到与开腹手术相当的疗效。

Objective To investigate the safety and feasibility of laparoscopic operation in thetreatment of gastric gastrointestinal stromal tumor (GIST) at unfavorable positions. Methods A retrospective cohort study was conducted to analyze the clinical data of patients with gastric GIST at unfavorable positions confirmed by pathology after surgery (laparoscopy or laparotomy) at the Southwest Hospital of the Army Medical University and the Minda Hospital of Hubei Minzu University from June 2008 to June 2018. The unfavorable positions of stomach are defined as the esophagogastric junction, the proximal cardia of gastric lesser curvature, the pylorus of stomach, the posterior wall of stomach and the antrum of stomach.Exclusion criteria:(1) preoperative chemotherapy or imatinib therapy;(2) diameter of tumor > 10 cm;(3) tumor metastasis or concurrence of other malignant tumors. A total of 244 patients (238 in Southwest Hospital and 6 in Minda Hospital) were enrolled, including 122 males and 122 females with age of 41-70years. Operative methods should be adopted according to patients' wishes. There were 146 cases in the laparoscopic surgery group and98 cases in the open surgery group. The intraoperative blood loss, operative time, postoperative first flatus time, postoperative firstfeeding time,average hospital stay, morbidity of postoperative complication,1-,3-,and 5-year recurrence free survival(RFS) and overall survival (OS)rate were compared between the two groups. Results There were no significant differences in sex, age, tumor size, tumor risk grade or growth pattern between the laparoscopic and the open surgery groups (all P>0.05),and these two groups were comparable. Compared with open group, laparoscopic group had less intraoperative blood loss [(31.4±2.3) ml vs.(143.9±3.7) ml, t=292.800, P<0.001], shorter postoperative first flatus time [(2.1±0.7) days vs.(3.8±0.8) days, t=17.550,P<0.001], shorter postoperative first feeding time [(2.1±0.5) days vs.(2.3±1.7) days, t=1.339,P=0.020], shorter hospital stay [(8.6±2.6) days vs.(13.6±3.2) days, t=13.410, P<0.001], and lower morbidity of postoperative complication [16(11.0%) vs. 21(21.4%),χ^2=4.996,P=0.025], whose differences were statistically significant. While the operation time was similar in two groups [(124.7±15.8) minutes vs.(120.9±14.5) minutes, t=1.903,P=0.058]. The median follow-up of all the patients was 43 (1 to 119) months.In laparoscopic group and open group, the 1-, 3- and 5-year RFS were 94.5% vs. 93.9%, 91.1% vs. 90.8%,and 82.2% vs. 81.6%, respectively, and 1-, 3- and 5-year OS were 98.6% vs. 95.9%, 95.9% vs. 94.9%,and 91.1% vs. 88.8%, respectively, whose differences were not statistically significant (all P>0.05). Conclusion In the experienced gastrointestinal surgery center, laparoscopic resection of gastric GIST at unfavorable position is safe and feasible, achieving the same efficacy of open surgery.