早期胃上部癌腹腔镜近端胃切除双通道吻合与腹腔镜全胃切除Roux-en-Y吻合两种消化道重建术式的疗效比较

Efficacy of laparoscopic proximal gastrectomy with double-tract reconstruction versus laparoscopic total gastrectomy with Roux-en-Y reconstruction for early upper gastric cancer

目的比较腹腔镜根治性近端胃切除双通道吻合与腹腔镜辅助根治性全胃切除Roux-en-Y吻合(R-Y吻合)这两种消化道重建术式对早期胃上部癌患者的临床疗效,为早期胃上部癌手术方式的选择提供参考。方法采用回顾性队列研究方法,分析2018年1月至2021年1月期间,西安交通大学第一附属医院普通外科同一手术治疗团队行腹腔镜近端胃切除双通道吻合或全胃切除Roux-en-Y吻合的80例早期胃上部癌患者的临床资料,按手术方式及消化道重建方式不同,分为双通道吻合组(32例)和R-Y吻合组(48例)。比较两组手术情况、术后并发症发生情况(包括术后30 d内的早期并发症和术后30 d后出现的远期并发症)以及随访情况(包括生存情况及营养状态)。生存情况用肿瘤相关生存率表示;营养状态的评估包括术后1年及2年血清总蛋白、白蛋白、总胆固醇、血红蛋白和维生素B_(12)水平以及体质量的变化,采用降低率表示,降低率=(术前值-术后观测时间点值)/术前值×100%。非正态分布的计量资料以M(IQR)表示,组间比较采用Mann-Whitney U检验,非等级计数资料组间比较采用χ^(2)检验或校正的χ^(2)检验或Fisher精确概率法;等级计数资料组间比较采用Mann-Whitney U检验。采用Kaplan-Meier法计算生存率并绘制生存曲线,采用log-rank检验进行组间生存率的比较。结果两组患者基线资料比较,除年龄和肿瘤大小差异有统计学意义(均P<0.01),其他差异均无统计学意义(均P>0.05)。两组均顺利完成手术,无中转开腹、联合脏器切除或早期死亡病例。两组患者在近切缘距肿瘤上缘、术后住院时间、排气时间、进食时间、住院花费、术后早期并发症发生和远期并发症发生方面比较,差异均无统计学意义(均P>0.05),与R-Y吻合组相比,双通道吻合组远端切缘更短[(3.2±0.5)cm比(11.7±2.0)cm,t=-23.033,P<0.001]、手术时间更长[232.5(63.7)min比185.0(63.0)min,Z=-3.238,P=0.001]、吻合时间更长[62.5(17.5)min比40.0(10.0)min,Z=-6.321,P<0.001]、术中出血更少[(138.1±51.6)ml比(184.3±62.1)ml,t=-3.477,P=0.001],差异均有统计学意义(均P<0.05)。全组患者术后中位随访18个月,2年癌症特异性生存率为97.5%,双通道吻合组为100%,R-Y吻合组为95.8%,两组术后2年癌症特异性生存率比较,差异无统计学意义(P=0.373)。术后1年时,与R-Y吻合组患者相比,双通道吻合组患者的体质量、血红蛋白及维生素B_(12)降低率更少,差异具有统计学意义(均P<0.05)。术后2年时,与R-Y吻合组患者相比,双通道吻合组患者的维生素B_(12)降低率仍更少(P<0.001);两组总蛋白、白蛋白、总胆固醇、体质量及血红蛋白的降低率相近(均P>0.05)。结论腹腔镜近端胃切除双通道吻合用于早期胃上部癌的治疗安全可行。术后短期营养状况及长期维生素B_(12)水平优于全胃切除Roux-en-Y吻合。

Objective To compare clinical efficacy between laparoscopic radical proximal gastrectomy with double-tract reconstruction(LPG-DTR)and laparoscopic radical total gastrectomy with Roux-en-Y reconstruction(LTG-RY)in patients with early upper gastric cancer,and to provide a reference for the selection of surgical methods in early upper gastric cancer.Methods A retrospective cohort study method was carried out.Clinical data of 80 patients with early upper gastric cancer who underwent LPG-DTR or LTG-RY by the same surgical team at the Department of General Surgery,the First Affiliated Hospital of Xi'an Jiaotong University from January 2018 to January 2021 were retrospectively analyzed.Patients were divided into the DTR group(32 cases)and R-Y group(48 cases)according to surgical procedures and digestive tract reconstruction methods.Surgical and pathological characteristics,postoperative complications(short-term complications within 30 days after surgery and long-term complications after postoperative 30 days),survival time and nutritinal status were compared between the two groups.For nutritional status,reduction rate was used to represent the changes in total protein,albumin,total cholesterol,body mass,hemoglobin and vitamin B_(12) levels at postoperative 1-year and 2-year.Non-normally distributed continuous data were presented as median(interquartile range),and the Mann-Whitney U test was used for comparison between groups.Theχ^(2) test or Fisher's exact test was used for comparison of data between groups.The Mann-Whitney U test was used to compare the ranked data between groups.The survival rate was calculated by Kaplan-Meier method categorical,and compared by using the log-rank test.Results There were no statistically significant differences in baseline data betweeen the two groups,except that patients in the R-Y group were oldere and had larger tumor.Patients of both groups successfully completed the operation without conversion to laparotomy,combined organ resection,or perioperative death.There were no significant differences in the distance from proximal resection margin to superior margin of tumor,postoperative hospital stay,time to flatus and food-taking,hospitalization cost,short-and long-term complications between the two groups(all P>0.05).Compared with the R-Y group,the DTR group had shorter distal margins[(3.2±0.5)cm vs.(11.7±2.0)cm,t=-23.033,P<0.001],longer surgery time[232.5(63.7)minutes vs.185.0(63.0)minutes,Z=-3.238,P=0.001],longer anastomosis time[62.5(17.5)minutes vs.40.0(10.0)minutes,Z=-6.321,P<0.001],less intraoperative blood loss[(138.1±51.6)ml vs.(184.3±62.1)ml,t=-3.477,P=0.001],with significant differences(all P<0.05).The median follow-up of the whole group was 18 months,and the 2-year cancer-specific survival rate was 97.5%,with 100%in the DTR group and 95.8%in the R-Y group(P=0.373).Compared with R-Y group at postoperative 1 year,the reduction rate of weight,hemoglobin and vitamin B_(12) were lower in DTR group with significant differences(all P<0.05);at postoperative 2-year,the reduction rate of vitamin B_(12) was still lower with significant differences(P<0.001),but the reduction rates of total protein,albumin,total cholesterol,body weight and hemoglobin were similar between the two groups(all P>0.05).Conclusions LPG-DTR is safe and feasible in the treatment of early upper gastric cancer.The short-term postoperative nutritional status and long-term vitamin B_(12) levels of patients undergoing LPG-DTR are superior to those undergoing LTG-RY.