机器人对比腹腔镜胃癌根治术后的复发结局:一项多中心倾向性评分匹配研究

Recurrence outcomes of robotic-versus laparoscopic-assisted gastrectomy for gastric cancer: a multi-center propensity score-matched cohort study

目的:分析与比较机器人辅助胃癌切除术(RAG)与传统腹腔镜辅助胃癌切除术(LAG)后患者的复发结局。方法:采用回顾性队列研究方法。纳入2015年1月1日至2019年6月30日期间,国内四家大型胃癌诊治中心接受微创胃癌根治术、并经术后组织学证实为T1~4aN0~3M0期的2915例胃腺癌患者的临床资料。其中福建医科大学附属协和医院1426例,南昌大学第一附属医院1108例,天津医科大学肿瘤医院196例,西安交通大学第一附属医院185例。其中930例接受RAG(机器人手术组),1985例接受LAG(腹腔镜手术组)。基于年龄、性别、体质指数、美国麻醉医师协会(ASA)评分、合并症、肿瘤大小、手术范围、淋巴结清扫范围、pT、pN、手术年份和辅助化疗等特征,使用1∶1倾向性评分匹配法,将机器人手术组与腹腔镜手术组患者进行配比。配比后每组各纳入837例进行最终分析。两组的临床基线资料差异无统计学意义(均P>0.05)。对两组的3年无复发生存率(RFS)、复发模式和条件复发生存(cRFS)结局进行比较。结果:术后3年随访中,机器人手术组和腹腔镜手术组分别有128例(15.3%)和141例(16.8%)患者出现复发(P=0.387),首次复发时间分别为(15.7±8.1)个月和(16.4±8.4)个月(P=0.449),差异均无统计学意义;两组患者中腹膜复发占比最高,分别为55例(6.6%)和69例(8.2%),两组比较差异无统计学意义(P=0.524)。机器人手术组与腹腔镜手术组的3年RFS差异没有统计学意义(83.2%比82.5%,P=0.781)。年龄>60岁、全胃切除术,pT分期较晚和pN分期较晚是胃癌患者复发的独立危险因素(均P<0.05);而采用机器人手术还是腹腔镜手术,并不是影响胃癌患者RFS的独立风险因素(P=0.242)。机器人手术组与腹腔镜手术组患者在术后各生存时间截点的3年cRFS具有可比性(术后1年:84.6%比84.7%,P=0.793;术后3年:91.5%比94.9%,P=0.647)。结论:由大型胃癌诊治中心外科医师施行RAG治疗局部可切除胃癌患者的3年复发率和复发模式均不劣于LAG。

Objective:To compare and evaluate recurrence patterns after robotic-assisted gastrectomy(RAG)versus laparoscopic-assisted gastrectomy(LAG).Methods:This was a retrospective cohort study of 2915 consecutive patients with gastric adenocarcinoma confirmed by postoperative histology as T1-4aN0-3M0,who had undergone minimally invasive radical gastrectomy at four large gastric cancer treatment centers(Fujian Medical University Union Hospital:1426 patients;the First Affiliated Hospital,Nanchang University:1108;Tianjin Medical University Cancer Institute and Hospital:196;and First Affiliated Hospital of Xi'an Jiaotong University:185 cases)between 1 January 2015 and 30 June 2019.930 patients had undergone RAG(RAG group)and 1985 had undergone LAG(LAG group).We assessed the following characteristics:age,sex,body mass index,American Society of Anesthesiologists score,comorbidities,tumor size,extent of surgery,extent of lymph node dissection,pT,pN,year of surgery,and adjuvant chemotherapy,after propensity score matching(1:1).There were no significant differences in baseline clinical characteristics between the two groups formed by propensity score matching(837 in each group)(all P>0.05).The 3-year recurrence-free survival(RFS),recurrence pattern,and conditional RFS were compared.Results:We detected no significant differences in the overall recurrence rate at 3 years(128/837[15.3%]vs.141/837[16.8%],P=0.387)or time to recurrence(15.7±8.1 months vs.16.4±8.4 months,P=0.449)between the RAG and LAG groups.Peritoneal recurrence was the most common type of recurrence in both groups(55[6.6%]vs.69[8.2%],P=0.524).The difference in 3-year RFS between the RAG and LAG groups was not statistically significant(83.2%vs.82.5%,P=0.781).We found that age>60 years,total gastrectomy,and worse pT stage and pN stage were independent risk factors for recurrence in the study patients(all P<0.05),whereas the surgical procedure(RAG or LAG)was not an independent risk factor for RFS(P=0.242).The 3-year conditional RFS at various time points was comparable between the two groups(1 year postoperatively:84.6%vs.84.7%,P=0.793;3 years postoperatively:91.5%vs.94.9%,P=0.647).Conclusions:In this multicenter study of patients with locally resectable gastric cancer,we demonstrated that RAG performed by surgeons at large gastric cancer centers is not inferior to LAG in 3-year recurrence rate or recurrence patterns.