腹腔镜与开腹胃癌根治术后并发症的Clavien-Dindo分级及危险因素分析

Clavien-Dindo classification and risk factor analysis of complications after laparoscopic and open radical gastrectomy for gastric cancer

目的探讨腹腔镜与开腹胃癌根治术病人术后并发症发生情况的差异,评价腹腔镜应用于胃癌根治术病人的安全性。方法回顾性分析2009年2月至2016年3月西京消化病医院行腹腔镜胃癌根治术及开腹胃癌根治术的2966例病人的资料。并发症按Clavien-Dindo分级系统,腹腔镜组与开腹组病人按1∶1比例行倾向评分匹配后比较两组的并发症发生情况及严重程度。多因素分析采用Logistic回归模型。结果共有2966例病人纳入研究,其中腹腔镜组687例,开腹组2279例。匹配后共1354例病人纳入研究(两组各677例),研究结果显示:腹腔镜组总体并发症发生率低于开腹组(17.0%比24.2%,P=0.001),严重并发症(Clavien-Dindo分级≥Ⅲa级)发生率差异无统计学意义(5.8%比6.1%,P=0.818)。按性别、年龄、美国麻醉医师协会(ASA)分级、TNM分期、体质量指数、分化程度、胃切除范围、肿瘤长径、手术时间、送检淋巴结数目分别进行亚组分析显示,在大多数层内也呈现出相同的规律。多因素分析显示腹腔镜手术为术后并发症减少的保护性因素,年龄≥60岁、ASA分级Ⅲ级、术中出血≥200 ml为胃癌根治术后总体并发症的独立危险因素,年龄≥60岁、T分期为T 2~T 4a期、术中出血≥200 ml是严重并发症发生的独立危险因素。结论与传统开腹手术比较,腹腔镜胃癌根治术后总体并发症发生率低,术中出血量少,安全可行且具有微创优势。

Objective To investigate the difference of postoperative complications between laparoscopic and open radical gastrectomy for gastric cancer and evaluate the safety of laparoscopic radical gastrectomy for gastric cancer.Methods The data of 2966 patients who underwent laparoscopic radical gastrectomy and open radical gastrectomy from February 2009 to March 2016 were analyzed retrospectively.According to Clavien-Dindo grading system,the incidence and severity of complications were compared between laparoscope group and laparotomy group after propensity score matching in a ratio of 1∶1.A logistic regression model was used for multivariate analysis.Results A total of 2966 patients were enrolled in the study,including 687 in the laparoscopic group and 2279 in the open group.After matching,a total of 1354 patients were included in the study(677 patients in each group).The study results showed that the total incidence of complications in laparoscope group was lower than that in laparotomy group(17.0%vs.24.2%,P=0.001),and there was no significant difference in the incidence of severe complications(Clavien-Dindo grade≥Ⅲa)(5.8%vs.6.1%,P=0.818).Subgroup analysis by sex,age,ASA(American Society of Anesthesiologists)grade,TNM(Tumor-Lymph Node-Metastasis)stage,BMI(body mass index),differentiation,extent of gastrectomy,tumor length,operation time,and number of submitted lymph nodes showed that the same pattern within most stratia.Multivariate analysis revealed that laparoscopic surgery is a protective factor for the reduction of postoperative complications,age≥60 years,ASA classificationⅢand estimated blood loss≥200 ml were confirmed as independent predictors of overall complications.Age≥60,stage T 2-T 4a,estimated blood loss≥200 ml were confirmed as independent risk factors for severe complications.Conclusion Compared with traditional laparotomy,laparoscopic radical gastrectomy for gastric cancer has the advantages of low incidence of complications,less intraoperative blood loss,safety,feasibility and minimally invasive advantages.