不同腹腔镜手术治疗胃底贲门部胃肠间质瘤疗效的多中心研究

Efficacy of different laparoscopic surgeries for gastrointestinal stromal tumors of gastriccardia and fundus: a multicenter study

目的:探讨不同腹腔镜手术治疗胃底贲门部胃肠间质瘤(GIST)的疗效。方法:采用回顾性队列研究方法,收集2007年12月至2021年12月我国广东省人民医院等14家医学中心收治的251例行腹腔镜根治性切除术胃底贲门部GIST患者的临床病理资料;男123例,女128例;年龄为58(24,87)岁。观察指标:(1)治疗情况。(2)不同腹腔镜手术患者的临床病理资料情况。(3)特殊腹腔镜技术亚组分析。正态分布的计量资料以x±s表示,组间比较采用t检验或方差分析;偏态分布的计量资料以M(Q1,Q3)表示,组间比较采用Mann-Whitney U检验或Kruskal-Wallis H检验。计数资料以绝对数或百分比表示,等级资料比较采用秩和检验。结果:(1)治疗情况。251例患者中,202例行胃楔形切除术,26例行特殊腹腔镜技术(10例浆膜剥离切除术、16例经胃腔内切除术),23例行胃结构性切除术(6例全胃切除术、17例近端胃部分切除术)。251例患者中,24例出现术后并发症。(2)不同腹腔镜手术患者的临床病理资料情况。行胃楔形切除术患者性别(男、女),年龄,肿瘤最大径,手术时间,术中出血量,切口长度,术后首次进食全流质食物时间,术后首次进食半流质食物时间,术后住院时间,围手术期并发症,核分裂数(≤5/50高倍视野、6~10/50高倍视野、>10/50高倍视野),危险度分级(极低危险度、低危险度、中危险度、高危险度),肿瘤部位(贲门部、胃底部)分别为93、109例,(59±11)岁,3.50(0.40,10.00)cm,88.00(25.00,290.00)min,20.00(25.00,290.00)mL,4.00(2.00,12.00)cm,3.00(1.00,9.00)d,4.00(1.00,16.00)d,5.00(1.00,18.00)d,14例,164、31、7例,47、83、50、22例,30、172例;行特殊腹腔镜技术患者上述指标分别为19、7例,(49±14)岁,2.55(0.20,5.00)cm,101.00(59.00,330.00)min,27.50(2.00,300.00)mL,4.50(0,6.00)cm,2.50(1.00,10.00)d,4.00(1.00,16.00)d,6.00(1.00,18.00)d,3例,20、5、1例,15、5、2、4例,24、2例;行胃结构性切除术患者上述指标分别为11、12例,(52±10)岁,5.00(0.80,10.00)cm,187.00(80.00,325.00)min,50.00(10.00,300.00)mL,6.00(4.00,12.00)cm,4.00(2.00,8.00)d,6.00(3.00,14.00)d,8.00(2.00,18.00)d,7例,11、5、7例,2、6、6、9例,13、10例;3者上述指标比较,差异均有统计学意义(χ^(2)=6.75,F=10.19,H=17.71、37.50、35.54、24.68、16.09、20.20、13.76,χ^(2)=13.32,Z=28.98、32.17,χ^(2)=82.14,P<0.05)。(3)特殊腹腔镜技术亚组分析。10例浆膜剥离切除术患者术后首次进食全流质食物时间,术后首次进食半流质食物时间,肿瘤位置分型(内生型、外生型、壁间型)分别为4.50(1.00,10.00)d,8.00(3.00,12.00)d,0、8、2例;16例经胃腔内切除术患者上述指标分别为2.00(1.00,4.00)d、3.00(1.00,6.00)d,16、0、0例;两者术后首次进食全流质食物时间、术后首次进食半流质食物时间比较,差异均有统计学意义(Z=-2.65,-3.16,P<0.05);两者肿瘤位置分型比较,差异有统计学意义(P<0.05)。结论:胃楔形切除术是治疗胃底贲门部GIST最常用的腹腔镜手术方式。特殊腹腔镜技术主要应用于贲门部GIST患者,手术重点为保留贲门功能。

Objective To investigate the efficacy of different laparoscopic surgeries for gastrointestinal stromal tumors(GIST)of gastric cardia and fundus.Methods The retrospective cohort study was conducted.The clinicopathological data of 251 patients with GIST of gastric cardia and fundus who underwent laparoscopic radical resection in 14 medical centers,including Guangdong Provincial People′s Hospital et al,from December 2007 to December 2021 were collected.There were 123 males and 128 females,aged 58(24,87)years.Observation indicators:(1)treatment;(2)clinicopathological data of patients undergoing different laparoscopic surgeries;(3)subgroup analysis for special laparoscopic techniques.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was conducted using the t test or ANOVA.Measurement data with skewed distribution were represented as M(Q1,Q3),and comparison between groups was conducted using the Mann-Whitney U test or Kruskal-Wallis H test.Count data were described as absolute numbers or percentages.Comparison of ordinal data was conducted using the rank sum test.Results(1)Treatment.Of the 251 patients,202 cases underwent gastric wedge resection,26 cases underwent special laparoscopic techniques including 10 cases with serotomy and dissection and 16 cases with transluminal gastrectomy,23 cases underwent structural gastrectomy including 6 cases with total gastrectomy and 17 cases with proximal partial gastrectomy.There were 24 patients had postoperative complications after surgery.(2)Clinicopathological data of patients undergoing different laparoscopic surgeries.The gender(male,female),age,tumor diameter,operation time,volume of intraoperative blood loss,length of incision,time to postoperative initial whole liquid food intake,time to postoperative initial semi-liquid food intake,duration of postoperative hospital stay,cases with perioperative complications,cases with mitotic count as≤5/50 high power field,6‒10/50 high power field,>10/50 high power field,cases be classified as very low risk,low risk,medium risk,high risk according to the National Institutes of Health risk classification, cases with tumor located at fundusand gastric cardia were 93, 109, (59±11)years, 3.50(0.40,10.00)cm, 88.00(25.00,290.00)minutes,20.00(25.00,290.00)mL, 4.00(2.00,12.00)cm, 3.00(1.00,9.00)days, 4.00(1.00,16.00)days, 5.00(1.00,18.00)days,14, 164, 31, 7, 47, 83, 50, 22, 30, 172 in patients undergoing gastric wedge resection, respectively.The above indicators were 19, 7, (49±14)years, 2.55(0.20,5.00)cm, 101.00(59.00,330.00)minutes, 27.50(2.00,300.00)mL, 4.50(0,6.00)cm, 2.50(1.00,10.00)days, 4.00(1.00,16.00)days, 6.00(1.00,18.00)days,3, 20, 5, 1, 15, 5, 2, 4, 24, 2 in patients undergoing special laparos-copic techniques, and 11, 12, (52±10)years, 5.00(0.80,10.00)cm, 187.00(80.00,325.00)minutes, 50.00(10.00,300.00)mL, 6.00(4.00,12.00)cm,4.00(2.00,8.00)days, 6.00(3.00,14.00)days, 8.00(2.00,18.00)days, 7, 11, 5, 7, 2, 6, 6, 9, 13, 10 inpatients undergoing structural gastrectomy. There were significant differences in the above indicatorsamong the three groups of patients (χ² =6.75, F=10.19, H=17.71, 37.50, 35.54, 24.68, 16.09, 20.20,13.76, χ²=13.32, Z=28.98, 32.17, χ²=82.14, P<0.05). (3) Subgroup analysis for special laparoscopictechniques. The time to postoperative initial whole liquid food intake, time to postoperative initialsemi-liquid food intake, classification of tumor location (endophytic type, exophytic type, parietaltype) were 4.50(1.00,10.00)days, 8.00(3.00,12.00)days, 0, 8, 2 in patients undergoing serotomy anddissection, versus 2.00(1.00,4.00)days, 3.00(1.00,6.00)days, 16, 0, 0 in patients undergoing transluminalgastrectomy. There were significant differences in time to postoperative initial whole liquid foodintake, time to postoperative initial semi-liquid food intake between them (Z=−2.65, −3.16, P<0.05);and there was a significant difference in classification of tumor location between them (P<0.05).Conclusions Gastric wedge resection is the most commonly used laparoscopic technique for GISTof gastric cardia and fundus. The application of special laparoscopic techniques is focused on theGIST of cardia to preserve the function of the cardia.