裸眼3D腹腔镜系统在腹腔镜胃肠恶性肿瘤根治术中应用价值的初步探索

A primary investigation on application value of glasses⁃free three⁃dimensional laparoscopy system in laparoscopic radical resection of gastrointestinal malignant tumors

目的初步探讨裸眼3D腹腔镜系统在腹腔镜胃肠恶性肿瘤根治术中的应用价值。方法采用回顾性队列研究方法。收集2018年10月至2019年5月上海交通大学医学院附属瑞金医院收治的165例胃肠道恶性肿瘤患者的临床资料;男99例,女66例;中位年龄为63岁,年龄范围为28~86岁;胃癌68例,结直肠癌97例。68例胃癌患者中,16例选择裸眼3D腹腔镜系统行腹腔镜胃癌根治术,设为裸眼3D胃癌组;52例选择眼镜3D腹腔镜系统行腹腔镜胃癌根治术,设为眼镜3D胃癌组。97例结直肠癌患者中,19例选择裸眼3D腹腔镜系统行腹腔镜结直肠癌根治术,设为裸眼3D结直肠癌组;78例选择眼镜3D腹腔镜系统行腹腔镜结直肠癌根治术,设为眼镜3D结直肠癌组。观察指标:(1)胃癌患者手术情况。(2)胃癌患者术后恢复情况。(3)胃癌患者术后病理学检查情况。(4)结直肠癌患者手术情况。(5)结直肠癌患者术后恢复情况。(6)结直肠癌患者术后病理学检查情况。(7)随访情况。采用门诊或电话方式随访,了解患者并发症和生存情况,随访时间截至术后30 d。偏态分布的计量资料以M(P25,P75)或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χ2检验或Fisher确切概率法。结果(1)胃癌患者手术情况:68例胃癌患者均顺利完成腹腔镜胃癌根治术,无术中并发症及中转开腹。裸眼3D胃癌组患者胃癌手术方式(远端胃切除术、全胃切除术),手术时间,术中出血量分别为11、5例,195 min(169 min,214 min),20 mL(10 mL,90 mL);眼镜3D胃癌组患者上述指标分别为31、21例,196 min(173 min,222 min),40 mL(20 mL,100 mL),两组患者上述指标比较,差异均无统计学意义(χ2=0.432,Z=-0.362,-1.065,P>0.05)。(2)胃癌患者术后恢复情况:裸眼3D胃癌组患者术后首次肛门排气时间,术后首次进食半流质食物时间、术后住院时间分别为2 d(2 d,3 d)、6 d(5 d,7 d)、10 d(9 d,14 d);眼镜3D胃癌组患者上述指标分别为2 d(2 d,3 d)、6 d(5 d,6 d)、11 d(9 d,14 d),两组患者上述指标比较,差异均无统计学意义(Z=-0.163,-1.870,-0.570,P>0.05)。裸眼3D胃癌组患者术后并发症发生率为12.5%(2/16),其中1例十二指肠残端瘘,1例吻合口出血;眼镜3D胃癌组患者术后并发症发生率为17.3%(9/52),其中2例十二指肠残端瘘,2例胃排空障碍,1例肺部感染,1例腹腔出血,1例吻合口瘘,1例乳糜漏,1例肠梗阻。两组并发症患者经对症支持治疗后均痊愈。两组患者术后并发症发生率比较,差异无统计学意义(χ2=0.209,P>0.05)。(3)胃癌患者术后病理学检查情况:裸眼3D胃癌组患者肿瘤直径,肿瘤T分期(T1期、T2期、T3期、T4期),脉管侵犯,神经侵犯,癌结节,肿瘤N分期(N0期、N1期、N2期、N3期),淋巴结阳性数目,淋巴结清扫总数,淋巴结清扫合格数目、TNM临床分期(Ⅰ期、Ⅱ期、Ⅲ期、Ⅳ期)分别为3.0 cm(2.0 cm,5.0 cm),5、3、1、7例,8例,5例,2例,3、2、4、7例,6枚(1枚,15枚),28枚(22枚,43枚),15例,4、3、9、0例;眼镜3D胃癌组患者上述指标分别为3.5 cm(2.0 cm,6.0 cm),13、10、4、25例,19例,23例,2例,26、6、7、13例,1枚(0枚,7枚),29枚(21枚,39枚),43例,21、10、20、1例,两组患者肿瘤直径、肿瘤T分期、脉管侵犯、神经侵犯、癌结节、淋巴结清扫总数、淋巴结清扫合格数目、TNM临床分期比较,差异均无统计学意义(Z=-0.570,-0.434,χ2=0.926,0.851,1.655,Z=-0.579,χ2=1.193,Z=-1.134,P>0.05);两组患者肿瘤N分期和淋巴结阳性数目比较,差异均有统计学意义(Z=-2.167,-2.283,P<0.05)。(4)结直肠癌患者手术情况:97例结直肠癌患者均顺利完成腹腔镜结直肠癌根治术,无术中并发症及中转开腹。裸眼3D结直肠癌组患者手术方式(结肠癌根治术、直肠癌根治术),手术时间,术中出血量分别为7、12例,132 min(97 min,156 min),20 mL(10 mL,50 mL);眼镜3D结直肠癌组患者上述指标分别为40、38例,124 min(110 min,159 min),25 mL(15 mL,65 mL),两组患者上述指标比较,差异均无统计学意义(χ2=1.276,Z=-0.141,-0.863,P>0.05)。(5)结直肠癌患者术后恢复情况:裸眼3D结直肠癌组患者术后首次肛门排气时间、术后首次进食半流质食物时间、术后住院时间分别为2 d(1 d,3 d)、5 d(5 d,6 d)、8 d(7 d,10 d);眼镜3D结直肠癌组患者上述指标分别为2 d(1 d,3 d)、5 d(4 d,6 d)、8 d(6 d,10 d),两组患者上述指标比较,差异均无统计学意义(Z=-0.678,-1.751,-1.674,P>0.05)。裸眼3D结直肠癌组患者并发症发生率为15􀆰8%(3/19),其中1例低位直肠前切除术后吻合口瘘,1例切口感染,1例尿路感染;眼镜3D结直肠癌组患者并发症发生率为14.1%(11/78),其中3例低位直肠前切除术后吻合口瘘,2例肠梗阻,2例尿路感染,2例切口感染,1例吻合口出血,1例肺部感染。眼镜3D结直肠癌组1例低位直肠前切除术后吻合口瘘行补救性末端回肠造口术,术后恢复良好;两组其余并发症患者经过对症支持治疗后痊愈。两组患者术后并发症发生率比较,差异无统计学意义(χ2=0.035,P>0.05)。(6)结直肠癌患者术后病理学检查情况:裸眼3D结直肠癌组患者肿瘤直径,肿瘤T分期(T1期、T2期、T3期、T4期),脉管侵犯,神经侵犯,癌结节,肿瘤N分期(N0期、N1~2期),淋巴结阳性数目,淋巴结清扫总数,淋巴结清扫合格数目、TNM临床分期(Ⅰ期、Ⅱ期、Ⅲ期、Ⅳ期)分别为5.0 cm(3.0 cm,6.0 cm),3、2、7、7例,3例,2例,1例,8、11例,0枚(0枚,4枚),17枚(14枚,23枚),18例,2、3、12、2例;眼镜3D结直肠癌组患者上述指标分别为4.0 cm(3.0 cm,5.0 cm),7、16、43、12例,14例,12例,7例,46、32例,0枚(0枚,1枚),16枚(13枚,19枚),74例,14、17、40、7例。两组患者上述指标比较,差异均无统计学意义(Z=-0.768,-1.135,χ2=0.049,0.292,0.278,1.762,Z=-0.694,-1.349,χ2=0.001,Z=-1.011,P>0.05)。(7)随访情况:165例患者均获得随访,无短期内再手术及术后30 d内死亡。结论裸眼3D腹腔镜系统与眼镜3D腹腔镜系统在腹腔镜胃肠恶性肿瘤根治术中疗效差异无统计学意义,其临床价值需进一步研究。

Objective To primarily investigate the application value of glasses⁃free three⁃dimensional(3D)laparoscopy system in laparoscopic radical resection of gastrointestinal malignant tumors.Methods The retrospective cohort study was conducted.The clinical data of 165 patients with gastrointestinal malignant tumors who were admitted to the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between October 2018 and May 2019 were collected.There were 99 males and 66 females,aged from 28 to 86 years,with a median age of 63 years.There were 68 of 165 patients with gastric cancer and 97 with colorectal cancer.Sixteen patients with gastric cancer who underwent laparoscopic radical gastrectomy using the glasses⁃free 3D laparoscopy system were divided into glasses⁃free 3D gastric cancer group,and 52 patients with gastric cancer who underwent laparoscopic radical gastrectomy using the polarized glasses 3D laparoscopy system were divided into polarized glasses 3D gastric cancer group.Nineteen patients with colorectal cancer who underwent laparoscopic radical colectomy or proctectomy using the glasses⁃free 3D laparoscopy system were divided into glasses⁃free 3D colorectal cancer group,and 78 patients with colorectal cancer who underwent laparoscopic radical colectomy or proctectomy using the polarized glasses 3D laparoscopy system were divided into polarized glasses 3D colorectal cancer group.Observation indicators:(1)operative situations of patients with gastric cancer;(2)postoperative recovery of patients with gastric cancer;(3)postoperative pathological examination results of patients with gastric cancer;(4)operative situations of patients with colorectal cancer;(5)postoperative recovery of patients with colorectal cancer;(6)postoperative pathological examination results of patients with colorectal cancer;(7)follow⁃up.Follow⁃up was conducted by outpatient examination or telephone interview to detect complications and survival of patients up to the postoperative 30th day.Measurement data with skewed distribution were represented as M(P25,P75)or M(range),and comparison between groups was analyzed by the Mann⁃Whitney U test.Count data were represented as absolute numbers or percentages,and comparison between groups was analyzed using the chi⁃square test or Fisher exact probability.Results(1)Operative situations of patients with gastric cancer:all the 68 gastric cancer patients received successfully laparoscopic radical gastrectomy,without intraoperative complication or conversion to laparotomy.Cases with distal gastrectomy or total gastrectomy(surgical methods),operation time,volume of intraoperative blood loss were 11,5,195 minutes(169 minutes,214 minutes),20 mL(10 mL,90 mL)in patients of the glasses⁃free 3D gastric cancer group,and 31,21,196 minutes(173 minutes,222 minutes),40 mL(20 mL,100 mL)in patients of the polarized glasses 3D gastric cancer group,with no significant difference between the two groups(χ2=0.432,Z=-0.362,-1.065,P>0.05).(2)Postoperative recovery of patients with gastric cancer:the time to first flatus,time to initial semi⁃fluid diet intake,duration of postoperative hospital stay were 2 days(2 days,3 days),6 days(5 days,7 days),10 days(9 days,14 days)in patients of the glasses⁃free 3D gastric cancer group,and 2 days(2 days,3 days),6 days(5 days,6 days),11 days(9 days,14 days)in patients of the polarized glasses 3D gastric cancer group,with no significant difference between the two groups(Z=-0.163,-1􀆰870,-0.570,P>0.05).The postoperative complication incidence of the glasses⁃free 3D gastric cancer group was 12.5%(2/16),including 1 case with duodenal stump fistula,1 case with anastomotic bleeding.The postoperative complication incidence of the polarized glasses 3D gastric cancer group was 17.3%(9/52),including 2 cases with duodenal stump fistula,2 cases with delayed gastric emptying,1 case with pulmonary infection,1 case with abdominal bleeding,1 case with anastomotic leakage,1 case with chylous fistula,1 case with intestinal obstruction.All the patients with complications were cured after symptomatic supportive treatment.There was no significant difference in the complication incidence between the two groups(χ2=0.209,P>0.05).(3)Postoperative pathological examination results of patients with gastric cancer:the tumor diameter,cases in stage T1,T2,T3,T4(tumor T staging),cases with vascular invasion,cases with nerve invasion,cases with tumor nodule,cases in stage N0,N1,N2,N3(tumor N staging),the number of positive lymph node,the number of lymph node dissected,cases with qualified lymph node dissected,cases in stageⅠ,Ⅱ,Ⅲ,Ⅳ(TNM clinical staging)were 3.0 cm(2.0 cm,5.0 cm),5,3,1,7,8,5,2,3,2,4,7,6(1,15),28(22,43),15,4,3,9,0 in patients of the glasses⁃free 3D gastric cancer group,and 3.5 cm(2.0 cm,6.0 cm),13,10,4,25,19,23,2,26,6,7,13,1(0,7),29(21,39),43,21,10,20,1 in patients of the polarized glasses 3D gastric cancer group.There was no significant difference in the tumor diameter,tumor T staging,cases with vascular invasion,cases with nerve invasion,cases with tumor nodule,the number of lymph node dissected,cases with qualified lymph node dissected,TNM clinical staging between the two groups(Z=-0.570,-0.434,χ2=0.926,0.851,1.655,Z=-0.579,χ2=1.193,Z=-1.134,P>0.05).There were significant differences in the tumor N staging and the number of positive lymph node between the two groups(Z=-2.167,-2.283,P<0.05).(4)Operative situations of patients with colorectal cancer:all the 97 colorectal cancer patients received successfully laparoscopic radical colectomy or proctectomy,without intraoperative complications or conversion to laparotomy.Cases with radical colectomy or proctectomy(surgical methods),operation time,volume of intraoperative blood loss were 7,12,132 minutes(97 minutes,156 minutes),20 mL(10 mL,50 mL)in patients of the glasses⁃free 3D colorectal cancer group,and 40,38,124 minutes(110 minutes,159 minutes),25 mL(15 mL,65 mL)in patients of the polarized glasses 3D colorectal cancer group,with no significant difference between the two groups(χ2=1.276,Z=-0.141,-0.863,P>0.05).(5)Postoperative recovery of patients with colorectal cancer:the time to first flatus,time to initial semi⁃fluid diet intake,duration of postoperative hospital stay were 2 days(1 days,3 days),5 days(5 days,6 days),8 days(7 days,10 days)in patients of the glasses⁃free 3D colorectal cancer group,and 2 days(1 days,3 days),5 days(4 days,6 days),8 days(6 days,10 days)in patients of the polarized glasses 3D colorectal cancer group,with no significant difference between the two groups(Z=-0.678,-1.751,-1.674,P>0.05).The complication incidence of the glasses⁃free 3D colorectal cancer group was 15.8%(3/19),including 1 case with anastomotic leakage after low anterior proctectomy,1 case with incision infection,1 case with urinary tract infection.The complication incidence of the polarized glasses 3D colorectal cancer group was 141%(11/78),including 3 cases with anastomotic leakage after low anterior proctectomy,2 cases with intestinal obstruction,2 cases with urinary tract infection,2 cases with incision infection,1 case with anastomotic bleeding,1 case with pulmonary infection.One of the 3 cases with anastomotic leakage after low anterior proctectomy in the polarized glasses 3D colorectal cancer group was cured after remedial terminal ileostomy.The other patients with complications were cured after symptomatic supportive treatment.There was no significant difference in the complication incidence between the two groups(χ2=0.035,P>0.05).(6)Postoperative pathological examination results of patients with colorectal cancer:the tumor diameter,cases in stage T1,T2,T3,T4(tumor T staging),cases with vascular invasion,cases with nerve invasion,cases with tumor nodule,cases in stage N0,N1-N2(tumor N staging),the number of positive lymph node,the number of lymph node dissected,cases with qualified lymph node dissected,cases in stageⅠ,Ⅱ,Ⅲ,Ⅳ(TNM clinical staging)were 5.0 cm(3.0 cm,6.0 cm),3,2,7,7,3,2,1,8,11,0(0,4),17(14,23),18,2,3,12,2 in patients of the glasses⁃free 3D colorectal cancer group,and 4.0 cm(3.0 cm,5.0 cm),7,16,43,12,14,12,7,46,32,0(0,1),16(13,19),74,14,17,40,7 in patients of the polarized glasses 3D colorectal cancer group,with no significant difference between the two groups(Z=-0.768,-1.135,χ2=0.049,0.292,0.278,1.762,Z=-0.694,-1.349,χ2=0.001,Z=-1.011,P>0.05).(7)Follow⁃up:165 patients received follow⁃up,with out short⁃term reoperation or postoperative death in the postoperative 30 days.Conclusion There is no significant difference in the efficacy between glasses⁃free 3D laparoscopic surgery and polarized glasses 3D laparoscopic surgery for radical resection of gastrointestinal malignant tumors,of which the clinical value requires further study.