胃癌腹腔镜规范化手术治疗模式在上海部分区域医疗中心推广效能的初步分析

Preliminary analysis of the promotion effect of laparoscopic standardized surgical treatment for gastric cancer in regional medical centers in Shanghai

目的初步探讨胃癌腹腔镜规范化手术治疗模式在上海部分区域医疗中心培训推广的效能。方法采用回顾性队列研究的方法。自2020年1月开始,由上海交通大学医学院附属瑞金医院暨上海市微创外科临床医学中心牵头、对上海市11家区域医疗中心开展为期1年的胃癌腹腔镜规范化手术治疗先进技术培训推广,收集培训推广计划前后的手术患者病例资料。纳入标准为术中行腹腔镜下远端胃或全胃切除术、并经病理证实为胃癌、且肿瘤无远处转移或腹膜转移的患者;排除未施行腹腔镜D2根治切除、术前接受新辅助化疗和临床病例资料不完整者。2019年1—12月为规范化技术推广前,此期间接受腹腔镜手术的胃癌患者作为推广前组(46例);2021年1—12月期间接受腹腔镜手术的胃癌患者作为推广后组(102例);另外选取上海交通大学医学院附属瑞金医院2021年1—12月期间接受腹腔镜手术治疗的胃癌患者作为对照组(138例),分析3组患者的临床资料和手术相关指标以及术后并发症的发生情况。结果 3组患者的临床基线资料比较,差异均无统计学意义(均P>0.05)。与推广前组相比,推广后组的手术时长明显缩短[(207.3±36.0)min比(254.2±47.1)min,t=7.038,P<0.001],淋巴结清扫数目明显增多[(24.4±12.2)枚比(18.9±5.5)枚,t=2.900,P<0.001];而两组胃切除范围以及术后开放流质时间和住院时间方面,差异均无统计学意义(均P>0.05)。推广后组与对照组比较,手术时间较长[(207.3±36.0)min比(172.6±26.0)min,t=8.281,P<0.001],全胃切除术的比例较低[17.6%(18/102)比29.7%(41/138),χ^(2)=7.380,P=0.007],术后开放流质时间较长[(6.3±3.2)d比(5.5±3.0)d,t=2.029,P=0.044],住院时间也较长[(14.3±5.6)d比(10.1±4.8)d,t=6.036,P<0.001];而在淋巴结清扫数目方面,两组差异无统计学意义(P>0.05)。术后并发症发生率推广后组为9.8%(10/102),低于推广前组的23.9%(11/46),差异有统计学意义(χ^(2)=5.183,P=0.023),而推广后组与对照组[9.8%(10/102)比6.5%(9/138),χ^(2)=0.867,P=0.352]比较,差异无统计学意义。结论经过胃癌腹腔镜规范化治疗技术推广后,区域医疗中心腹腔镜胃癌手术的规范化程度有所提高,手术并发症发生率下降,接近大型综合性三甲医院水平,胃癌腹腔镜规范化治疗技术值得在区域医疗中心普及和推广。

Objective To explore the promotion effect of laparoscopic standardized surgery for gastric cancer observational in some regional medical centers in Shanghai.Methods A retrospective cohort study was carried out.Eleven regional medical centers in Shanghai received the promotion program of laparoscopic standardized surgery for gastric cancer,which was led by Ruijin Hospital,Shanghai Jiaotong University School of Medicine(Shanghai Minimally Invasive Surgery Center)from January to December 2020.Clinicopathological data of gastric cancer patients treated at these 11 regional medical centers before and after the promotion program were collected.Inclusion criteria were as follows:patients undergoing laparoscopic distal gastrectomy or total gastrectomy;gastric cancer confirmed by pathology;without distant metastasis or peritoneal metastasis.Patients who did not undergo laparoscopic D2 radical resection,or received neoadjuvant chemotherapy before surgery,or without complete clinical data were excluded.Patients undergoing laparoscopic surgery from January to December 2019 were included in the pre-promotion group(46 cases).Patients undergoing laparoscopic surgery from January to December 2021 were included in the post-promotion group(102 cases).In addition,patients undergoing laparoscopic surgery at Ruijin Hospital from January 2021 to December were included in the control group(138 cases).The baseline data,perioperative measurements postoperative complications,and pathological results of the three groups were analyzed and compared.Results There were no significant differences in baseline characteristics among the three groups(all P>0.05).Compared with the pre-promotion group,the operation time in post-promotion group was significantly shorter[(207.3±36.0)minutes vs.(254.2±47.1)minutes,t=7.038,P<0.001],and the number of harvested lymph node was significantly more(24.4±12.2 vs.18.9±5.5,t=2.900,P=0.004).However,there were no significant differences in the extent of resection,time to fluid intake,and postoperative hospital stay between the two groups(all P>0.05).Compared with the control group,the operation time[(207.3±36.0)minutes vs(172.6±26.0)minutes,t=8.281,P<0.001],time to fluid intake[(6.3±3.2)days than(5.5±3.0)days,t=2.029,P=0.044],and the postoperative hospital stay[(14.3±5.6)days vs.(10.1±4.8)days,t=6.036,P<0.001]in the post-promotion group were still longer.Total gastrectomy was less common in the post-promotion group compared with the control group[18 cases(17.6%)vs.41 cases(29.7%),χ^(2)=7.380,P=0.007].However,there was no significant difference in the number of harvested lymph node between the two groups(P>0.05).The morbidity of postoperative complication in the post-promotion group(9.8%,10/102)was significantly lower than that in the pre-promotion group(23.9%,11/46)(χ^(2)=5.183,P=0.023),while above morbidity was not significantly different between the post-promotion group and the control group[9.8%vs.6.5%(9/138),χ^(2)=0.867,P=0.352].Conclusion After the promotion of laparoscopic standardized surgery for gastric cancer in regional medical centers,the standardization degree of surgery has been improved,and the morbidity of postoperative complication decreases.Laparoscopic standardized surgery for gastric cancer can be promoted to more regional medical centers.