摘要目的 比较机器人与腹腔镜辅助手术对SiewertⅡ型食管胃结合部腺癌(AEG)患者行根治性胃切除术淋巴结清扫及近期结局的影响.方法 纳入标准:肿瘤中心位于食管胃结合部上下2 cm之间且经术前内镜下活检病理证实为腺癌.排除标准:肿瘤局部侵袭到肝、脾、胰腺等脏器,术中肿瘤腹腔播散或远处转移;姑息治疗的手术者或术前行新辅助化疗者;有严重心、肺、肝、肾等合并症者;同时性多原发癌患者;急诊手术患者.根据以上标准,2014年10月至2018年10月期间于青岛大学附属医院胃肠外科治疗的82例SiewertⅡ型AEG患者入组本研究,根据计算机生成的随机分配表随机分为机器人组和腹腔镜组,分别排除术中探查2例侵犯脾脏和2例侵犯脾脏病例,两组各41例患者纳入研究.两组患者均实施经腹腔食管裂孔入路的根治性胃切除术加D2淋巴结清扫术.比较两组患者术中及术后短期结局指标,包括手术时间、术中出血量、食管切除长度、术后并发症、术后胃肠道恢复时间、住院天数、术后非计划再手术率及再住院率等.对于符合正态分布的计量资料采用x±s表示,采用两独立样本t检验进行两组间比较;计数资料的比较采用χ2检验.结果 机器人组年龄(62.3±10.0)岁,男性35例(85.4%),体质指数(24.4±3.2)kg/m2;腹腔镜组年龄(62.5± 10.0)岁,男性37例(90.2%),体质指数(23.8±2.6)kg/m2.两组基线资料的比较,差异均无统计学意义(均P>0.05).两组均顺利完成手术,均无中转开腹者,均为R0切除,均无术后死亡的发生.与腹腔镜组比较,机器人组的术中出血量更少[(70.7±39.9)ml比(110.2±70.6)ml,t=3.118,P=0.003],食管切除长度更长[(3.0±0.7)cm比(1.9±0.5)cm,t=8.759,P<0.001],但装机时间更长[(56.5±7.4)min比(36.0±6.6)min,t=4.241,P<0.001],住院费用更高[(122 317.3±57 789.3)元比(99 401.6±39 349.5)元, t=2.099,P=0.039],差异均有统计学意义(均P<0.05).机器人组清扫淋巴结总数为(39.2±15.3)枚,明显高于腹腔镜组的(33.0±12.1)枚(t=0.733,P=0.047).机器人组和腹腔镜组下纵隔淋巴结No.110和No.111分别为(3.6±1.2)枚比(1.5±1.0)枚以及(3.7±2.0)枚比(1.8±1.1)枚,差异均有统计学意义(分别t=10.138,P<0.001;t=8.227,P<0.001);膈下淋巴结No.19和No.20分别为(2.3±1.2)枚比(1.1±0.9)枚以及(2.0±1.0)枚比(1.0±0.1)枚,差异均有统计学意义(分别t=7.082,P<0.001;t=8.672,P<0.001);而两组间腹腔淋巴结总数及各站腹腔淋巴结数目差异无统计学意义(均P>0.05).各站淋巴结转移率以No.1、No.2、No.3、No.7最高,均在20%左右,其次No.8a、No.9、No.11p、No.110淋巴结转移率接近5%,其他站淋巴结(No.4sa、No.4sb、No.4d、No.5、No.6、No.11d、No.12a、No.19、No.20及No.111)发生转移概率不足5%.两组术后并发症发生率、术后发热时间、术后排气排粪时间、进流质饮食时间以及术后住院时间的差异均无统计学意义(均P>0.05).腹腔镜组非计划再手术者有2例(4.9%),非计划再入院者1例(2.4%),机器人组分别为3例(7.3%)和2例(4.9%);两组比较,差异亦无统计学意义(分别χ2=0.240,P=0.675;χ2=0.346,P=1.000).结论 机器人辅助SiewertⅡ型AEG根治性全胃切除术安全、可行,相比腹腔镜手术更加精细,手术出血量更少,淋巴结清扫质量更高,尤其是对于膈下及下纵隔淋巴结清扫.

abstractsObjective To compare the effects of robotic and laparoscopic?assisted radical total gastrectomy on lymph node dissection and short?term outcomes in patients with Siewert type II adenocarcinoma of esophagogastric junction(AEG). Methods Inclusion criteria: the tumor center was located between 2 cm above and below the esophagogastric junction and was confirmed as adenocarcinoma by endoscopic biopsy. Exclusion criteria: tumor with local invasion of the liver,spleen, pancreas or other organs;intraoperative finding of tumor dissemination or distant metastasis; patients undergoing palliative surgical treatment or preoperative neoadjuvant chemotherapy; patients with serious heart diseases,lung diseases,liver diseases,kidney diseases and other comorbidities;patients with multiple primary cancers;patients receiving emergency surgery. According to the above criteria, 82 patients with Siewert type II AEG who underwent gastrointestinal surgery at the Affiliated Hospital of Qingdao University from October 2014 to October 2018 were enrolled in the study. They were randomly divided into robotic surgery groups (41 cases) and laparoscopic group (41 cases) according to a computer?generated randomized allocation table. Both groups underwent radical total gastrectomy plus D2 lymph node dissection through the transabdominal esophageal hiatus approach. The intraoperative conditions and postoperative short?term outcomes were compared between two groups, including surgery time, intraoperative blood loss, length of esophagectomy, postoperative complications, postoperative gastrointestinal recovery time, length of hospital stay, postoperative unplanned reoperation rate and rehospitalization rate. Mean ± SD is used for the measurement data that conforms to the normal distribution, and two independent sample t?tests are used to compare the two groups; the comparison of the count data is performed by the χ2 test. Results There were 35 males(85.4%)with age of(62.3± 10.0) years and body mass index of (24.4±3.2) kg/m2 in the robotic surgery group. There were 37 males(90.2%)with age of(62.5± 10.0)years and body mass index of(23.8± 2.6)kg/m2 in the laparoscopic group. No significant differences in the baseline data between two groups were found (all P>0.05). All the patients of both groups completed R0 resection successfully without conversion to laparotomy or perioperative death. Compared with the laparoscopic group,the robotic group had less intraoperative blood loss[(70.7±39.9)ml vs.(110.2±70.6)ml,t=3.118,P=0.003],longer resected esophagus[(3.0±0.7)cm vs.(1.9±0.5)cm,t=8.759,P<0.001],but longer setup time[(56.5±7.4) minutes vs.(36.0±6.6)minutes,t=4.241,P<0.001],and higher hospitalization costs[(122 317.31± 57 789.33) yuan vs. (99 401.56 ± 39 349.53) yuan,t=2.099,P=0.039],whose differences were statistically significant (all P<0.05). The total number of harvested lymph node in the robotic surgery group was 39.2±15.3,which was significantly higher than that in the laparoscopic group(33.0± 12.1)(t=0.733,P=0.047). In the robotic group and the laparoscopic group,the mediastinal lymph node No. 110 and No. 111 were 3.6 ± 1.2 vs. 1.5 ± 1.0 and 3.7 ± 2.0 vs. 1.8 ± 1.1, respectively, with significant difference(t=10.138,P<0.001,t=8.227,P<0.001);axillary lymph node No.19 and No.20 were 2.3±1.2 vs. 1.1±0.9 and 2.0±1.0 vs. 1.0±0.1, respectively, with significant difference(t=7.082, P<0.001,t=8.672,P<0.001). There were no significant differences in the total number of abdominal lymph node and the number of lymph node in abdominal stations between two group(all P>0.05). The highest lymph node metastasis rate was approximately 20% and observed in No. 1,No. 2,No. 3,and No.7,followed by No.8a,No.9,No.11p,and No.110 with around 5%. The lymph node metastasis rate in other stations(No.4sa, No.4sb, No.4d, No.5, No.6, No.11d, No.12a, No.19, No.20 and No.111)was less than 5%. There were no significant differences in postoperative complication rate,postoperative fever time,postoperative exhaust and defecation time,fluid diet time,and postoperative hospital stay (all P>0.05). There were 2 patients(4.9%) with unplanned reoperation and 1 patient (2.4%) with unplanned re?admission in the laparoscopic group,while 3 patients(7.3%)with unplanned reoperation and 2 patients (4.9%)with unplanned re?admission in the robotic surgery group,whose differences were also not statistically significant (χ2=0.240,P=0.675;χ2=0.346,P=1.000). Conclusion Robot?assisted radical total gastrectomy for Siewert II AEG is safe and feasible,which is characterized by more sophisticated operation,less blood loss and higher quality of lymph node dissection,especially for subphrenic and inferior mediastinal lymph nodes.