腹腔镜辅助下圆形吻合器与完全腹腔镜下直线切割闭合器行食管空肠吻合的短期疗效和生活质量比较研究

A comparative study on short⁃term outcomes and quality of life for gastric cancer patients between totally laparoscopic total gastrectomy using an endoscopic linear stapler and laparoscopic⁃assisted total gastrectomy using a circular stapler

目的:分析比较腹腔镜辅助下应用圆形吻合器与完全腹腔镜下应用直线切割闭合器行食管空肠吻合的短期疗效和生活质量。方法:采用回顾性队列研究方法,收集2017年1月至2020年1月期间,接受腹腔镜下全胃切除术的Ⅰ~Ⅲ期胃腺癌患者临床病理资料。排除年龄≥80岁、存在影响生活质量的严重合并症、合并其他脏器切除、行姑息性手术和因消化道穿孔、梗阻、出血等行急诊手术以及术后1年内死亡或失访者。共纳入130例患者,根据手术方式分为圆形吻合器组(77例)和直线切割闭合器组(53例);两组患者的年龄、性别、体质指数、合并症数量、腹部手术史、美国麻醉医师协会分级、肿瘤部位、分化程度、肿瘤长径、肿瘤T分期、肿瘤N分期、肿瘤病理分期和术前生活质量比较,差异均无统计学意义(均P>0.05),具有可比性。观察指标:(1)手术及术后情况;(2)术后并发症情况:术后需要保守治疗或手术干预的任何不良情况,其中术后30 d内发生并发定的定义为早期并发症,术后30 d至1年内发生并发症的定义为晚期并发症;(3)术后生活质量情况:通过生活质量核心量表(QLQ-C30)和胃癌特异性模块量表(QLQ-STO22)评估术后1年两组患者的生活质量,功能领域和总体健康状况项目得分越高,说明对应的生活质量越好,症状领域得分越高,表示对应的生活质量越差。结果:(1)手术及术后情况:相比圆形吻合器组,直线切割闭合器组术中出血量更少[50.0(50.0~100.0)ml比100.0(100.0~100.0)ml,Z=-3.111,P=0.002]、术后排气时间更早[(3.1±0.8)d比(3.5±1.1)d,t=-2.490,P=0.014];但两组患者在手术时间、清流进食时间、流食进食时间以及术后住院时间方面比较,差异均无统计学意义(均P>0.05)。(2)术后并发症情况:圆形吻合器组与直线切割闭合器组的早期并发症发生率分别为22.1%(17/77)和18.9%(10/53),晚期并发症发生率分别为18.2%(14/77)和15.1%(8/53),两组比较,差异均无统计学意义(均P>0.05)。(3)术后生活质量情况:术后随访1年,失访7例(5.4%),其中圆形吻合器组5例、直线切割闭合器组2例。术后1年QLQ-C30量表显示:直线切割闭合器组的经济困难程度较圆形吻合器组更重[33.3(0~33.3)分比0(0~33.3)分,Z=-1.972,P=0.049],差异具有统计学意义;两组其余功能领域及症状领域评分比较,差异均无统计学意义(均P>0.05)。术后1年QLQ-STO22量表显示:直线切割闭合器组的吞咽困难[0(0~5.6)分比0(0~11.1)分,Z=-2.094,P=0.036]和进食受限症状评分[0(0~4.2)分比0(0~8.3)分,Z=-2.011,P=0.044]低于圆形吻合器组,差异均有统计学意义;而两组间其他症状评分比较,差异均无统计学意义(均P>0.05)。结论:与圆形吻合器相比,胃癌全腔镜下应用直线切割闭合器行食管空肠吻合术中出血更少、排气更快,术后可减少吞咽困难、进食受限等症状,但一定程度增加患者经济负担。

Objective To explore the differences of short⁃term outcomes and quality of life(QoL)for gastric cancer patients between totally laparoscopic total gastrectomy using an endoscopic linear stapler and laparoscopic⁃assisted total gastrectomy using a circular stapler.Methods A retrospective cohort study was conducted.Clinicopathological data of patients with stage I to III gastric adenocarcinoma who underwent laparoscopic total gastrectomy from January 2017 to January 2020 were retrospectively collected.Those who were≥80 years old,had serious complications that could affect the quality of life,underwent multi⁃organ resections,palliative surgery,emergency surgery due to gastrointestinal perforation,obstruction,bleeding,died or lost to follow⁃up within 1 year after surgery were excluded.A total of 130 patients were enrolled and divided into circular stapler group(CS group,77 cases)and linear stapler group(LS group,53 cases)according to the surgical method.The differences of age,gender,body mass index,number of comorbidities,history of abdominal surgery,ASA,tumor location,degree of differentiation,tumor length,tumor T stage,tumor N stage,tumor pathological stage and preoperative quality of life between the two groups were not statistically significant(all P>0.05).The observation indicators:(1)Surgery and postoperative conditions.(2)Postoperative complications:Any adverse conditions that require conservative treatment or surgical intervention after surgery were defined as postoperative complications,of which,complications occurring within 30 days after surgery were defined as early complications;complications occurring within 30 days to 1 year after surgery were defined as late complications.(3)Postoperative quality of life was assessed by the quality of life core scale(QLQ⁃C30)and gastric cancer specific module scale(QLQ⁃STO22).The higher the scores of functional scales and global health status,the better the corresponding quality of life.The higher the scores of symptoms scales,the worse the corresponding quality of life.Results(1)Surgery and postoperative conditions:Compared with the CS group,the LS group presented less intraoperative blood loss[50.0(50.0⁃100.0)ml vs.100.0(100.0⁃100.0)ml,Z=-3.111,P=0.002]and earlier time to flatus[(3.1±0.8)days vs.(3.5±1.1)days,t=-2.490,P=0.014].However,there were no statistically significant differences between two groups of patients in terms of operation time,time to start a liquid diet and postoperative hospital stay(all P>0.05).(2)Postoperative complications:The early complication rates of the CS group and the LS group were 22.1%(17/77)and 18.9%(10/53),respectively,while the late complication rate were 18.2%(14/77)and 15.1%(8/53),respectively,whose differences were not statistically significant(all P>0.05).(3)Postoperative quality of life:After 1⁃year follow⁃up,7(5.4%)patients were lost,including 5 in CS group and 2 in LS group.One year after operation,the QLQ⁃C30 scale showed that the score of financial difficulty of the LS group was significantly higher than that of the CS group[33.3(0 to 33.3)vs.0(0 to 33.3),Z=–1.972,P=0.049]with statistically significant difference,and there were no statistically significant differences in the scores of other functional fields and symptom fields between the two groups(all P>0.05).The QLQ⁃STO22 scale showed that the scores of dysphagia[0(0 to 5.6)vs.0(0 to 11.1),Z=–2.094,P=0.036]and eating restriction were significantly lower[0(0 to 4.2)vs.0(0 to 8.3),Z=–2.011,P=0.044]in patients of the LS group than those of the CS group.There were no significant differences in scores of other symptoms between two groups(all P>0.05).Conclusions Compared with the circular stapler,the esophagojejunostomy with linear stapler for gastric cancer patients can reduce intraoperative blood loss,shorten the time to flatus after operation,alleviate the symptoms of dysphagia and eating restriction but increase the economic burden to a certain degree.