基于倾向性评分匹配的机器人和腹腔镜直肠癌根治术的对比研究

Comparative study of clinical outcomes of robot versus laparoscopic radical surgery for rectal cancer based on propensity score matching

目的比较机器人和腹腔镜直肠癌根治术的近期及远期临床疗效。方法回顾性收集2015年1—12月南昌大学第一附属医院普通外科实施的机器人或腹腔镜直肠癌根治术106例患者的临床资料。应用倾向性评分匹配法对机器人和腹腔镜直肠癌根治术的患者进行1∶1匹配,成功匹配机器人组和腹腔镜组各32例患者。机器人组男性15例,女性17例,年龄(56.2±7.5)岁;腹腔镜组男性19例,女性13例,年龄(55.5±7.6)岁。采用t检验、Mann-WhitneyU检验、重复测量方差分析、χ^2检验、Fisher确切概率法或Wilcoxon秩和检验比较两组患者的临床疗效。采用Kaplan-Meier曲线法绘制生存曲线,Log-rank检验对比两组生存曲线的差异。结果匹配后两组患者一般资料具有可比性(P值均>0.05)。64例患者均顺利完成机器人或腹腔镜手术,无中转开腹和围手术期死亡患者。与腹腔镜组对比,机器人组总手术时间更长[(135.7±12.1)min比(124.9±23.2)min,t=2.341,P=0.024],第253组淋巴结清扫时间更短[(11.6±2.7)min比(13.2±2.7)min,t=-2.354,P=0.022],术中出血量更少[(66.8±10.2)ml比(74.8±13.9)ml,t=-2.621,P=0.011],术后尿管留置时间更短[3.0(1.0)d比4.0(2.0)d,Z=-2.743,P=0.006],术后24hC反应蛋白更低[(50.9±7.7)μg/L比(55.9±6.7)μg/L,F=7.902,P=0.007]。两组患者的体内游离时间、淋巴结清扫数目、术后肛门首次排气时间、术后住院时间、术后并发症发生率、术后并发症Clavien-Dindo分级的差异均无统计学意义(P值均>0.05)。两组患者3年总体生存率差异无统计学意义(P>0.05)。结论机器人直肠癌根治术安全性和有效性好,近期疗效好,能获得与腹腔镜直肠癌根治术相似的远期疗效。

Objective To compare the short-term and long-term outcomes of robotic rectectomy and laparoscopic rectectomy for rectal cancer based on propensity score matching. Methods The clinical data of 106 patients who underwent robotic or laparoscopic radical resection of rectal cancer at Department of General Surgery, the First Affiliated Hospital of Nanchang University from January 2015 to December 2015 were retrospectively collected. Propensity score matching method was used to perform 1∶1 matching between robot and laparoscopic rectal cancer radical surgery. Thirty-two patients in robot group and 32 patients in laparoscopic group were successfully matched. There were 15 males and 17 females in the robotic group, aging (56.2±7.5) years, 19 males and 13 females in the laparoscopic group, aged (55.5±7.6) years. The clinical outcome of the two groups were compared using t-test or Mann-Whitney U test for continuous variables, repeated measures analysis of variance,χ^2 test, Fisher exact test or Wilcoxon rank sum test for dichotomous variables. The overall survival curve was drawn by Kaplan-Meier curve and the difference of survival curve was compared by Log-rank method. Results The general data of the two groups of patients were comparable after matching. Sixty-four patients successfully completed robotic or laparoscopic operation without conversion to open surgery or perioperative death case. The total operative time, the lymph node namely No. 253 group dissection time, intraoperative blood loss, postoperative urethral catheter retention time, the serum C-reactive protein levels of 24 hours after surgery were (135.7±12.1) minutes,(11.6±2.7) minutes,(66.8±10.2) ml, 3.0(1.0) d,(50.9±7.7)μg/L, respectively, while in laparoscopic group were (124.9±23.2) minutes,(13.2±2.7) minutes,(74.8±13.9) ml, 4.0(2.0) d,(55.9±6.7)μg/L respectively. The differences were statistically significant (t=2.341, t=-2.354, t=-2.621, Z=-2.743, F=7.902, respectively, P<0.05). There were no statistical differences in separation time, numbers of retrieved lymph nodes, time to first flatus, postoperative hospital stay, postoperative complication and Clavien-Dindo classification of postoperative complications (t=0.336, t=0.714, t=-0.568, Z=-1.766, Fisher Z=-0.586, respectively, all P>0.05). Conclusions Robotic surgery not only has similar safety and feasibility but also has advantages of short-term outcomes compared with laparoscopic rectectomy for rectal cancer. The long-term outcomes were similar between two groups.