机器人辅助与腹腔镜胰十二指肠切除术治疗胰腺癌的效果与安全性比较

Comparison of efficacy and safety of robotic-assisted versus laparoscopic pancreaticoduodenectomy for pancreatic cancer

背景与目的:微创外科以切口小、创伤轻、痛苦少、恢复快等优点迅速在外科各专业领域得以推广应用,手术机器人的出现,使微创外科的发展进入了一个新的时代,且符合加速康复外科理念(ERAS)的理念。本研究探讨达芬奇机器人手术系统在胰腺癌胰十二指肠切除术(PD)中的实用性与应用价值。方法:回顾性分析中南大学湘雅三医院普通外科2016年1月-2019年5月间61例行微创PD治疗的胰腺癌患者临床资料。其中24例行达芬奇机器人辅助下的PD术(RPD组),37例行传统腹腔镜下的PD术(LPD组),比较两组患者围手术期相关临床指标。结果:两组患者术前一般资料无统计学差异(均P>0.05)。与LPD组比较,RPD组中转开腹率降低(4.2%vs.8.1%,χ^2=4.565,P=0.033)、术中出血量减少(255.0 mL vs.380.0 mL,Z=-5.813,P<0.001)、术中淋巴结清扫个数增加(17.0枚vs.11.0枚,Z=-6.133,P<0.001),但手术时间明显延长(466.5 min vs.375.0 min,Z=-6.568,P<0.001)。两组患者术后病理回报切缘均为阴性,两组术后病理情况无统计学差异(P>0.05);两组术后24 h引流量、肛门首次排气时间、术后进食时间、下床时间、术后拔尿管时间及术后拔伤口引流管时间差异均无统计学意义(均P>0.05);RPD组的住院花费明显多于LPD组(114154.84元vs.86749.59元,Z=-5.863,P<0.001),但RPD组的患者术后住院时间明显短于LPD组(14.0 d vs.18.0 d,Z=-5.930,P<0.001);两组术后VAS疼痛评分及术后并发症发生率均无统计学差异(均P>0.05)。RPD组21例与RPD组33例术后随访22个月,两组3年生存率无统计学差异(20.8%vs.24.3%,P>0.05)。结论:达芬奇机器人辅助能够显著提高PD手术质量,缩短患者恢复时间,安全可行,符合ERAS理念,但治疗费用较高,在选择手术方案时应充分考虑患者家庭经济情况。

Background and Aims:Minimally invasive surgery has been rapidly adopted in all surgical specialties,due to its advantages of small incision,reduced trauma and pain as well as quick recovery.The rise of surgical robots brings the minimally invasive surgery into a new era of development,which also conforms to the concept of enhanced recovery after surgery(ERAS).This study was conducted to evaluate the practicability and application value of using da Vinci robot operation system in pancreaticoduodenectomy(PD)for pancreatic cancer.Methods:The clinical data of 61 patients undergoing minimally invasive PD for pancreatic cancer from January 2016 to May 2019 in the Department of General Surgery of the Third Xiangya Hospital,Central South University were analyzed retrospectively.Of the patients,24 cases underwent a da Vinci robot-assisted PD(RPD group)and 37 cases underwent the conventional laparoscopic PD(LPD group).The main clinical variables during the perioperative period were compared between the two groups of patients.Results:There were no significant differences in the preoperative data between the two groups of patients(all P>0.05).In RPD group compared with LPD group,the open conversion rate was significantly decreased(4.2%vs.8.1%,χ^2=4.565,P=0.033),the intraoperative blood loss was significantly reduced(255.0 mL vs.380.0 mL,Z=–5.813,P<0.001),and the number of resected lymph nodes was significantly elevated(17.0 vs.11.0,Z=–6.133,P<0.001),but the operative time was significantly prolonged(466.5 min vs.375.0 min,Z=–6.568,P<0.001).All the surgical margins in both groups were negative reported by postoperative pathology,and there were no significant difference in the pathological results between the two groups(P>0.05);There were no significant differences in the amount of 24-h drainage,and the times to the first postoperative anal gas passage,food intake and ambulation as well as the time for the urinary catheter and wound drainage tube removal between the two groups(all P>0.05);the hospitalization cost of RPD group was significantly higher than that of LPD group(114154.84 yuan vs.86749.59 yuan,Z=–5.863,P<0.001),but the length of hospital stay of RPD group was significantly shorter than that of LPD group(14.0 d vs.18.0 d,Z=–5.930,P<0.001).Twenty-one cases in RPD group and 33 cases in LPD group were followed up for 22 month,and the 3-year survival rates showed no significant difference between the two groups(20.8%vs.24.3%,P>0.05).Conclusion:The assistance of da Vinci robot can improve the quality of PD operation,shorten the recovery time of patients,and is safe and feasible,in line with the concept of ERAS.However,the treatment cost is high,so the family economic situation of patients should be fully considered in choosing this operation.