腹腔镜与开腹手术治疗胃来源且长径大于2cm的胃肠间质瘤多中心倾向评分匹配法疗效比较

Efficacy comparison between laparoscopy and open surgery in the treatment of gastric gastrointestinal stromal tumors larger than 2 cm using multicenter propensity score matching method

目的对比腹腔镜与开腹手术治疗胃来源的胃肠间质瘤(GIST)的临床疗效。方法采用多中心回顾性队列研究方法。病例纳入标准:直径>2 cm的原发性胃GIST;接受开腹或腹腔镜手术治疗;经术后病理确诊且无远处转移;未接受术前靶向药物治疗。收集2010年1月1日至2017年5月1日期间,解放军总医院(320例)、上海交通大学医学院附属仁济医院(284例)、华中科技大学同济医学院附属协和医院(175例)及天津医科大学肿瘤医院(78例)共计857例患者的临床病理资料,其中444例行开腹手术(开腹组),413例行腹腔镜手术(腔镜组)。应用倾向性评分匹配的最近邻匹配法对开腹组与腔镜组的肿瘤部位和肿瘤大小进行1∶1匹配,卡钳值为0.04;采用t检验、χ^2检验或Wilcoxon秩和检验比较两组患者短期疗效,采用Kaplan-Meier曲线和log rank检验比较长期预后。结果倾向评分匹配后,两组分别纳入293例患者,两组患者性别、年龄、肿瘤部位、肿瘤长径以及改良美国国立卫生研究院(NIH)分级等一般资料比较,差异均无统计学意义(均P>0.05)。与开腹组相比,腔镜组术中出血量少者比例高[<100 ml比例:52.9%(155/293)比36.2%(106/293),Z=-12.857,P<0.001],术后进食时间[(4.0±0.2)d比(5.3±0.9)d,t=1.505,P=0.003]和引流管拔除时间较早[(4.8±1.0)d比(6.5±1.0)d,t=1.847,P=0.008],术后住院时间较短[(8.6±0.3)d比(10.5±0.3)d,t=4.235,P<0.001]。按照解剖部位进行亚组分析:(1)胃贲门部及幽门部:两组围手术期指标差异均无统计学意义(均P>0.05)。(2)胃底部:腔镜组较开腹组术后进食时间早[(4.0±0.2)d比(4.5±0.2)d,t=0.512,P=0.038]、引流管拔除时间[(5.1±0.4)d比(6.4±0.6)d,t=0.517,P=0.044]和术后住院时间[(8.0±0.5)d比(11.1±0.9)d,t=0.500,P=0.002]明显缩短,而其他围手术期指标差异无统计学意义(均P>0.05)。(3)胃小弯侧:腔镜组的术中出血量[<100 ml比例:58.1%(43/74)比33.7%(25/74),Z=7.632,P=0.034]、胃管拔出时间[(2.7±0.2)d比(3.2±0.3)d,t=0.503,P=0.007]、术后排气时间[(2.8±0.1)d比(3.4±0.2)d,t=0.532,P=0.030]、术后进食时间[(3.6±0.2)d比(4.3±0.2)d,t=0.508,P=0.020]、引流管拔除时间[(4.2±0.4)d比(5.7±0.5)d,t=0.508,P=0.020]及术后住院时间[(8.3±0.6)d比(10.7±0.3)d,t=0.502,P=0.006]均优于开腹组。(4)胃大弯侧:腔镜组术中出血量[<100 ml比例:52.7%(39/74)比36.5%(27/74),Z=7.681,P=0.032]、胃管拔出时间[(2.6±0.2)d比(3.6±0.2)d,t=0.501,P=0.001]、术后排气时间[(2.7±0.2)d比(3.4±0.2)d,t=0.501,P=0.016]、术后进食时间[(3.6±0.2)d比(4.7±0.2)d,t=0.500,P=0.001]、引流管拔除时间[(4.0±0.5)d比(5.9±0.4)d,t=0.508,P=0.002]及术后住院时间[(7.5±0.3)d比(9.5±0.1)d,t=0.500,P=0.001]均优于开腹组。按肿瘤大小进行亚组分析:(1)肿瘤长径2.0~5.0 cm组:腔镜组的排气时间[(2.9±0.1)d比(3.5±0.1)d,t=0.500,P=0.001]、术后进食时间[(4.5±0.1)d比(5.0±0.2)d,t=0.501,P=0.013]、引流管拔除时间[(4.8±0.3)d比(6.0±0.3)d,t=0.511,P=0.008]及术后住院时间[(8.1±0.4)d比(10.1±0.3)d,t=0.513,P=0.001]均优于开腹组。(2)肿瘤长径5.1~10.0 cm组:腔镜组术后进食时间[(4.0±0.2)d比(4.7±0.2)d,t=0.506,P=0.015]、引流管拔除时间[(4.6±0.4)d比(6.4±0.5)d,t=0.501,P=0.004]、术后住院时间[(8.2±0.3)d比(10.9±0.6)d,t=0.500,P=0.001]均优于开腹组。两组均无术中及术后并发症。腔镜组和开腹组5年无复发生存率分别为95.4%和91.6%(P=0.734),5年总体生存率分别为93.8%和90.8%(P=0.691),差异均无统计学意义。结论在经验丰富的医疗中心,肿瘤>2 cm胃GIST腹腔镜手术安全、可行,疗效与开腹手术相当。对于非胃大弯侧及胃底体前壁、直径≤5 cm的GIST行腹腔镜手术可加快患者术后康复。

Objective To compare the efficacy between laparoscopy and open surgery for gastric gastrointestinal stromal tumor(GIST)larger than 2 cm.Methods A multicenter retrospective cohort study was performed.Inclusion criteria:long diameter of primary gastric GIST>2 cm;undergoing laparoscopy or open surgery;diagnosis confirmed by postoperative pathology without distant metastasis;without preoperative targeted therapy.Clinicopathological data of 857 gastric GIST patients,including 320 in PLA General Hospital,284 in Shanghai Renji Hospital,175 in Wuhan Union Hospital and 78 in Tianjin Cancer Hospital,from January 2010 to May 2017 were retrospectively collected.There were 418 males and 439 females,mainly aged between 50 and 70 years old.Among 857 patients,413 were in the laparoscopy group and 444 in the open group.The nearest neighbor matching of propensity score matching method was conducted with 1:1 matching based on tumor location and size between laparoscopy and open group to obtain samples of covariate equilibrium,and the caliper value was 0.04.The t test,χ^2 test and Wilcoxon rank test were used to compare short-term efficacy,and the Kaplan-Meier curve and log rank test were applied to compare long-term outcomes between the two groups.Results After propensity score matching,laparoscopy group and open group both enrolled 293 cases.The baseline data,including age,gender,tumor location,tumor long diameter,NIH classification,etc.were not significantly different between the two groups(all P>0.05).Compared with the open group,the laparoscopy group had less intraoperative blood loss[<100 ml:2.9%(155/293)vs.36.2%(106/293),Z=-12.857,P<0.001],shorter time to postoperative feeding[(4.0±0.2)days vs.(5.3±0.9)days,t=1.505,P=0.003]and to the removal of drainage tube[(4.8±1.0)days vs.(6.5±1.0)days,t=1.847,P=0.008],and shorter postoperative hospital stay[(8.6±0.3)days vs.(10.5±0.3)days,t=4.235,P<0.001].Subgroups analysis according to anatomical location:(1)Gastric cardia and pylorus:there were no statistically significant differences in perioperative parameters between the two groups(all P>0.05).(2)Stomach base:feeding time after surgery[(4.0±0.2)days vs.(4.5±0.2)days,t=0.512,P=0.038],drainage tube removal time[(5.1±0.4)days vs.(6.4±0.6)days,t=0.517,P=0.044],postoperative hospital stay[(8.0±0.5)days vs.(11.1±0.9)days,t=0.500,P=0.002]were all significantly shorter in the laparoscopy group as compared to the open group,while the differences in other perioperative parameters were not statistically significant(all P>0.05).(3)Lesser curvature of the stomach:the laparoscopy group had less intraoperative blood loss[<100 ml ratio:58.1%(43/74)vs.33.7%(25/74),Z=7.632,P=0.034],shorter gastric tube removal time[(2.7±0.2)days vs.(3.2±0.3)days,t=0.503,P=0.007],earlier postoperative passage of gas[(2.8±0.1)days vs.(3.4±0.2)days,t=0.532,P=0.030],earlier postoperative feeding[(3.6±0.2)days vs.(4.3±0.2)days,t=0.508,P=0.020],shorter drainage tube removal time[(4.2±0.4)days vs.(5.7±0.5)days,t=0.508,P=0.020]and postoperative hospital stay[(8.3±0.6)days vs.(10.7±0.3)days,t=0.502,P=0.006]as compared to the open group.(4)Great curvature of the stomach:the laparoscopy group presented less intraoperative blood loss[<100 ml ratio:52.7%(39/74)vs.36.5%(27/74),Z=7.681,P=0.032],earlier gastric tube removal[(2.6±0.2)days vs.(3.6±0.2)days,t=0.501,P=0.001],earlier postoperative passage of gas[(2.7±0.2)days vs.(3.4±0.2)days,t=0.501,P=0.016],earlier postoperative feeding[(3.6±0.2)days vs.(4.7±0.2)days,t=0.500,P=0.001],shorter drainage tube removal time[(4.0±0.5)days to(5.9±0.4)days,t=0.508,P=0.002]and postoperative hospital stay[(7.5±0.3)days to(9.5±0.1)days,t=0.500,P=0.001]than the open group.Subgroup analysis according to tumor size:(1)Tumor long diameter 2.0-5.0 cm:the laparoscopy group had earlier passage of gas[(2.9±0.1)days vs.(3.5±0.1)days,t=0.500,P=0.001],earlier postoperative feeding[(4.5±0.1)days vs.(5.0±0.2)days,t=0.501,P=0.013],shorter drainage tube removal time[(4.8±0.3)days vs.(6.0±0.3)days,t=0.511,P=0.008]and postoperative hospital stay[(8.1±0.4)days to(10.1±0.3)days,t=0.513,P=0.001]than the open group.(2)Tumor long diameter 5.1-10.0 cm:in the laparoscopic group,postoperative feeding time[(4.0±0.2)days vs.(4.7±0.2)days,t=0.506,P=0.015],drainage tube removal time[(4.6±0.4)days vs.(6.4±0.5)days,t=0.501,P=0.004],postoperative hospital stay[(8.2±0.3)days vs.(10.9±0.6)days,t=0.500,P=0.001]were all shorter than those in the open group.No intraoperative and postoperative complications were observed in each group.The 5-year recurrence-free survival rates of the laparoscopy group and the open group were 95.4% and 91.6%,respectively(P=0.734),and the 5-year overall survival rates were 93.8% and 90.8%(P=0.691),respectively,and the differences were not statistically significant.Conclusions In experienced medical centers,laparoscopic surgery for gastric GIST larger than 2 cm is safe and feasible,and can achieve comparable efficacy with open surgery.For gastric GISTs which do not locate in the greater curvature and the anterior wall of the stomach,and whose long diameter is≤5 cm,laparoscopic surgery does not increase the risk of recurrence and metastasis,and can accelerate postoperative recovery.