吲哚菁绿荧光成像在腹腔镜胃癌根治术淋巴结清扫中的应用价值

Application value of indocyanine green fluorescence imaging in lymphadenectomy of laparoscopic radical gastrectomy for gastric cancer

目的探讨吲哚菁绿(ICG)荧光成像在腹腔镜胃癌根治术淋巴结清扫中的应用价值.方法采用回顾性队列研究方法.收集2017年4-12月福建医科大学附属协和医院收治的702例原发性胃癌行腹腔镜胃癌根治术D2淋巴结清扫患者的临床病理资料;男517例,女185例;平均年龄为61岁,年龄范围为22~91岁.702例患者中,39例术中使用ICG成像系统设为ICG组;663例术中未使用ICG成像系统设为非ICG组.观察指标:(1)手术情况和术后恢复情况.(2)术后并发症发生情况.(3)人均淋巴结清扫数目和人均阳性淋巴结数目.(4)随访情况.按站别将第1站(第1~7组)和第2站(第8~12组)淋巴结数目分别合计进行分析.采用门诊或电话方式进行随访,了解患者并发症情况,随访时间截至2018年6月.正态分布的计量资料以Mean±SD表示,组间比较采用t检验;偏态分布的计量资料以M(范围)表示,组间比较采用Mann-Whitney U检验;计数资料以绝对数或百分比表示,组间比较采用χ^2检验.等级资料比较采用Mann-Whitney U检验.结果(1)手术情况和术后恢复情况:702例患者均顺利行腹腔镜胃癌根治术D2淋巴结清扫,术中均未损伤重要血管和邻近脏器,无联合脏器切除,无中转开腹.ICG组患者行根治性全胃切除术21例,远端胃大部切除术16例,近端胃大部切除术2例;食管-空肠Roux-en-Y吻合21例,BillrothⅠ吻合3例,BillrothⅡ吻合13例,胃-空肠Roux-en-Y吻合2例,无食管残胃吻合;手术时间为(173±28)min,术中出血量为40mL(5~200mL),术后下床活动时间为(2.1±0.6)d,术后首次肛门排气时间为(3.5±1.4)d,术后首次进食流质食物时间为(4.8±1.3)d,术后住院时间为(8.6±3.6)d.非ICG组上述指标分别为363、299、1例;363、27、267、1、5例;(174±41)min,50mL(0~1750mL),(2.2±0.8)d,(3.4±1.1)d,(4.6±1.5)d,(9.4±5.0)d.两组患者手术类型和消化道重建方式比较,差异均有统计学意义(χ^2=9.550,11.388,P<0.05);而手术时间、术中出血量、术后下床活动时间、术后首次肛门排气时间、术后首次进食流质食物时间、术后住院时间比较,差异均无统计学意义(t=0.221,Z=-0.651,t=0.492,-0.826,-0.842,0.995,P>0.05).(2)术后并发症发生情况:702例患者中,92例发生术后并发症,无并发症死亡患者.ICG组和非ICG组并发症发生率分别为15.38%(6/39)和12.97%(86/663),两组比较,差异无统计学意义(χ^2=0.188,P>0.05).ICG组6例(1例Ⅳ级、2例Ⅲa级、3例Ⅰ级)和非ICG组86例(6例Ⅳ级、16例Ⅲ级、61例Ⅱ级、3例Ⅰ级)发生并发症患者经对症支持治疗后均痊愈出院.(3)人均淋巴结清扫数目和人均阳性淋巴结数目:702例患者人均淋巴结清扫数目和人均阳性淋巴结数目分别为37枚(3~112枚)和1枚(0~68枚).ICG组患者人均淋巴结清扫数目和人均阳性淋巴结数目分别为38枚(24~70枚)和2枚(0~42枚);非ICG组上述指标分别为37枚(3~112枚)和1枚(0~68枚),两组患者上述指标比较,差异均无统计学意义(Z=-1.454,-0.514,P>0.05).分层分析:ICG组患者第1~7组人均淋巴结清扫数目和人均阳性淋巴结数目分别为34枚(16~67枚)和2枚(0~38枚),第8~12组人均淋巴结清扫数目和人均阳性淋巴结数目分别为11枚(4~22枚)和0枚(0~13枚);非ICG组上述指标分别为33枚(3~91枚)、1枚(0~56枚)、9枚(0~31枚)、0枚(0~25枚),两组患者第8~12组人均淋巴结清扫数目比较,差异有统计学意义(Z=-1.984,P<0.05);而第1~7组人均淋巴结清扫数目和人均阳性淋巴结数目以及第8~12组人均阳性淋巴结数目比较,差异均无统计学意义(Z=-1.302,-0.463,-0.758,P>0.05).(4)随访情况:702例患者均获得随访,随访时间为6~14个月,中位随访时间为10个月.两组患者均无因术后并发症再次入院治疗.结论ICG荧光成像在腹腔镜胃癌根治术中的运用有利于胃周淋巴结清扫,可以提高淋巴结检出数目,且不增加手术时间和术后并发症发生率.

Objective To investigate the application value of indocyanine green ( ICG) fluorescence imaging in lymphadenectomy of laparoscopic radical gastrectomy for gastric cancer. Methods The retrospective cohort study was conducted. The clinicopathological data of 702 patients with primary gastric cancer who underwent laparoscopic radical gastrectomy and D2 lymphadenectomy in the Fujian Medical University Union Hospital between April and December 2017 were collected. There were 517 males and 185 females, aged from 22 to 91 years, with an average age of 61 years. Of the 702 patients, 39 using ICG fluorescence imaging in the surgery and 663 not using ICG fluorescence imaging were allocated into ICG group and non-ICG group, respectively. Observation indicators:(1) surgical situations and postoperative recovery;( 2) postoperative complications;( 3) average number of lymph node dissected and positive lymph nodes;(4) follow-up situations. The number of lymph node dissected in the first station (No.1-7 group) and second station (No.8-12 group) were analyzed respectively. Follow-up using outpatient examination and telephone interview was performed to detect complications of patients up to June 2018. Measurement data with normal distribution were represented as Mean±SD, comparison between groups was analyzed using the t test. Measurement data with skewed distribution were described as M ( range), comparison between groups was analyzed using the Mann-Whitney U test. Count data were represented as absolute number or percentage, comparison between groups was analyzed using the chi-square test. Comparisons of ordinal data were analyzed by the Mann-Whitney U test. Results (1) Surgical situations and postoperative recovery: 702 patients underwent successfully laparoscopic radical gastrectomy and D2 lymphadenectomy, without injuries of important vessels and adjacent organs, without combined multiple organs resection or conversion to open surgery. Of 39 patients in the ICG group, cases undergoing total radical gastrectomy, distal subtotal gastrectomy and proximal subtotal gastrectomy, cases with Roux-en-Y esophagojejunostomy, Billroth Ⅰ anastomosis, Billroth Ⅱ anastomosis, Roux-en-Y gastrojejunostomy and esophagogastric anastomosis, operation time, volume of intraoperative blood loss, time for out-of-bed activities, time to initial anal exsufflation, time to first fluid diet intake and duration of postoperative hospital stay were 21, 16, 2, 21, 3, 13, 2, 0,(173±28)minutes, 40 mL (range, 5-200 mL),(2. 1±0. 6)days,(3. 5±1. 4)days,(4. 8±1. 3)days,(8. 6±3. 6) days. The above indexes were 363, 299, 1, 363, 27, 267, 1, 5,(174±41)minutes, 50 mL( range, 0-1 750 mL),(2. 2±0. 8) days,(3. 4±1. 1) days,(4. 6±1. 5) days,(9. 4±5. 0) days in the non-ICG group. There were statistically significant differences in the surgical type and digestive reconstruction method (χ^2 = 9. 550, 11. 388, P < 0. 05) and no statistically significant difference in the operation time, volume of intraoperative blood loss, time for out-of-bed activities, time to initial anal exsufflation, time to first fluid diet intake and duration of postoperative hospital stay (t = 0. 221, Z=-0. 651, t = 0. 492,-0. 826,-0. 842, 0. 995, P>0. 05).(2) Postoperative complications: 92 out of the 702 patients had postoperative complications, without death of complications. The incidence of complication was 15. 38%(6 / 39) and 12. 97%(86 / 663) in the ICG group and non-ICG group, with no statistically significant difference between the two groups (χ^2 = 0. 188, P>0. 05). Six patients with complications (1 of Clavien-Dindo Ⅳ, 2 of Clavien-Dindo Ⅲa, 3 of Clavien-Dindo Ⅰ) in the ICG group and 86 (6 of Clavien-Dindo Ⅳ, 16 of ClavienDindo Ⅲ, 61 of Clavien-Dindo Ⅱ, 3 of Clavien-Dindo Ⅰ) in the non-ICG group were cured after symptomatic treatment.(3) Average number of lymph node dissected and positive lymph nodes: the average number of lymph node dissected and positive lymph nodes was 37 ( range, 3 - 112) and 1 ( range, 0 - 68) of 702 patients, 38 (range, 24-70) and 2 (range, 0-42) in the ICG group, 37 (range, 3-112) and 1 (range, 0-68) in the nonICG group, with no statistically significant difference between the two groups (Z =-1. 454,-0. 514, P>0. 05). Stratified analysis: the average number of No.1-7 group lymph nodes dissected and positive lymph nodes was 34 (range, 16-67) and 2 (0-38) in the ICG group, 33 ( range, 3-91) and 1 ( range, 0-56) in the non-ICG group. The average number of No.8-12 group lymph nodes dissected and positive lymph nodes was 11 (range, 4- 22) and 0 (range, 0-13) in the ICG group, 9 ( range, 0-31) and 0 ( range, 0-25) in the non-ICG group. There was a statistically significant difference in the average number of No. 8 - 12 group lymph nodes dissected between the two groups (Z=- 1. 984, P< 0. 05). There was no statistically significant difference in the average number of No.1-7 group lymph nodes dissected, positive No.1-7 group lymph nodes and the average number of positive No.8-12 group lymph nodes between the two groups (Z =- 1. 302,- 0. 463,- 0. 758, P> 0. 05).( 4) Follow-up situations: 702 patients were followed up for 6-14 months, with a median time of 10 months. There was no readmission caused by postoperative complications in the two groups. Conclusion ICG fluorescence imaging in lymphadenectomy of laparoscopic radical gastrectomy for gastric cancer is beneficial to dissection of perigastric lymph nodes and increase number of lymph nodes dissected, but cannot increase operation time and incidence of postoperative complications.