RESUMO
Objective To investigate the risk factors of perioperative complications of laparoscopic radical distal gastrectomy and influence of body shape on the short-term therapeutic effects.Methods The retrospective case-control study was conducted.The clinicopathological data of 506 patients (328 males and 178 females,average age 60 years with the range of 24-85 years) who underwent laparoscopic radical distal gastrectomy+D2 lymph nodes dissection in the 8 clinical centers between March 2016 and November 2018 were collected,including 143 in the First Affiliated Hospital of Xiamen University,66 in the Affiliated Hospital of Qinghai University,66 in the Second Affiliated Hospital of Wenzhou Medical University,64 in the Zhongshan Hospital of Xiamen University,54 in the Affiliated Hangzhou First people's Hospital of Zhejiang University School of Medicine,48 in the Zhangzhou Affiliated Hospital of Fujian Medical University,35 in the Affiliated Quanzhou First Hospital of Fujian Medical University,30 in the Second Affiliated Hospital of Xiamen Medical College.The maximum thickness of subcutaneous fat at the level of umbilicus (USCF),the maximum vertical distance between the anterior abdominal skin and the back skin at the level of the umbilicus (UAPD),the maximum horizontal distance between the anterior abdominal skin and the back skin at the level of the umbilicus (UTD),the maximum verticaldistance between the anterior abdominal skin and the back skin at the level of the xiphoid bone (XAPD),the maximum horizontal distance between the.anterior abdominal skin and the back skin at the level of the xiphoid bone (XTD),the distance between the anterior abdominal skin and the root of celiac artery (CAD) and the maximum horizontal distance at a right angle to CAD (CATD) were measured using preoperative imaging examinations.Observation indicators:(1) intraoperative and postoperative situations;(2) follow-up situations;(3) risk factors analysis of perioperative complications;(4) influence of body shape related indexes on intraoperative situations and postoperative recovery:① Pearson univariate correlation analysis,② liner regression model analysis.Followup using outpatient examination and telephone interview was performed to detect the postoperative survival and tumor recurrence or metastasis up to December 2018.Measurement data with normal distribution were represented as Mean±SD.Measurement data with skewed distribution were described as M (range).Comparisons of count data were analyzed using the chi-square test.Comparisons of ordinal data were analyzed by Mann-Whitney U nonparametric test.Risk factors of perioperative complications of laparoscopic distal gastrectomy were analyzed by Logistic regression model.Influence of body shape related indexes on intraoperative situations and postoperative recovery was analyzed by Pearson univariate correlation analysis and liner regression model.Results (1) Intraoperative and postoperative situations:all the 506 patients underwent successful laparoscopic distal gastrectomy,including 103 with Billroth Ⅰ anastomosis,140 with Billroth Ⅱ anastomosis,201 with Billroth Ⅱ + Braun anastomosis,62 with Roux-en-Y anastomosis.The operation time,volume of intraoperative blood loss,number of lymph nodes dissected,time to postoperative anal exsufflation,time for initial fluid diet intake,time for initial semi-fluid diet intake and duration of postoperative hospital stay were (233±44)minutes,(102±86)mL,34±13,(3.6±1.5)days,(5.8±3.3)days,(8.3±3.8)days,(12.2±5.7)days respectively in the 506 patients.Of 506 patients,196 were defined as pathological stage Ⅰ,122 were defined as pathological stage Ⅱ and 188 were defined as pathological stage Ⅲ postoperatively.Of 506 patients,93 had 106 times of perioperative complications,including 33 times of pulmonary and upper respiratory infection,12 times of incisional infection,11 times of anastomotic leakage,11 times of abdominal infection,8 times of intestinal obstruction,8 times of gastroplegia,6 times of abdominal hemorrhage,5 times of bacteremia,3 times of anastomotic hemorrhage,3 times of lymph fluid leakage,2 times of pancreatic leakage,1 time of urinary infection,1 time of anatomotic stenosis,1 time of deep venous thrombosis and 1 time of pulmonary embolism;the same patient can merge multiple complications.Eleven patients were in the Clavien-Dindo classification ≥ Ⅲ.(2) Follow-up situations:465 of 506 patients were followed up for 1-32 months with a median time of 12 months.During the follow-up,451 had postoperative survival and 38 had tumor recurrence or metastasis.(3) Risk factors analysis of perioperative complications.① Results of univariate analysis showed that age,body mass index (BMI),preoperative hemoglobin,preoperative serum albumin and XAPD were related factors affecting perioperative complications of laparoscopic distal gastrectomy (x2 =10.289,7.427,5.269,5.481,4.285,P＜ 0.05).② Results of multivariate analysis showed that age,BMI,preoperative serum albumin were independent related factors affecting perioperative complications of laparoscopic distal gastrectomy (odds ratio =1.033,1.118,0.937,95％ interval confidence:1.011-1.057,1.025-1.219,0.887-0.990,P＜0.05).(4) Influence of body shape related indexes on intraoperative situations and postoperative recovery.① Results of Pearson univariate correlation analysis showed correlations between UAPD,XAPD,CAD,CATD and volume of intraoperative blood loss (r=0.107,0.169,0.179,0.106,P＜0.05),between UAPD,XAPD,CAD and the number of lymph nodes dissected (r=-0.137,-0.143,-0.173,P＜0.05),between USCF,XAPD and time to postoperative anal exsufflation (r =0.122,0.109,P＜0.05),between USCF,XAPD,CAD and time for initial fluid diet intake (r=0.132,0.108,0.132,P＜0.05),between USCF,XAPD and duration of postoperative hospital stay (r=0.116,0.100,P＜0.05).② Results of liner regression model analysis showed a positive correlation between CAD and volume of intraoperative blood loss (r =6.776),a negative correlation between CAD and the number of lymph nodes dissected (r =-0.841),with statistically significant differences (t =2.410,-1.992,P＜ 0.05);a positive correlation between USCF and time to postoperative anal exsufflation (r=0.170),between USCF and time for initial fluid diet intake (r=0.365),between USCF and duration of postoperative hospital stay (r=0.636) respectively,with statisticallysignificant differences (t =2.188,1.981,2.107,P＜ 0.05).Conclusions Abdominal shape can influence intraoperative situations and postoperative recovery of laparoscopic distal gastrectomy,but cannot increase risks ofperioperative complications.Age,BMI and preoperative serum albumin are independent related factors affecting perioperative complications of laparoscopic distal gastrectomy.
RESUMO
Objective To investigate the short-term clinical effects of selecting duodenal transection timing on laparoscopic-assisted distal gastrectomy (LADG).Methods The retrospective cohort study was conducted.The clinicopathological data of 239 gastric cancer (GC) patients undergoing LADG in the 5 medical centers between March 2016 and March 2018 were collected,including 104 in the First Affiliated Hospital of Xiamen University,45 in Zhangzhou Affiliated Hospital of Fujian Medical University,35 in Quanzhou Affiliated Hospital of Fujian Medical University,30 in the Second Affiliated Hospital of Xiamen Medical College,25 in Zhongshan Hospital of Xiamen University.Of 239 patients undergoing LADG + D2 lymph node dissection,107 receiving duodenal transection and then lymph node dissection in the upper region of pancreas after lymph node dissection in the lower region of pylorus and 132 receiving lymph node dissection in the upper region of pancreas and then duodenal transection were respectively divided into anterior approach group and posterior approach group.Sixty-four,8,16,14 and 5 patients in the anterior approach group and 40,37,19,16 and 20 patients in the posterior group respectively came from the First Affiliated Hospital of Xiamen University,Zhangzhou Affiliated Hospital of Fujian Medical University,Quanzhou Affiliated Hospital of Fujian Medical University,Second Affiliated Hospital of Xiamen Medical College and Zhongshan Hospital of Xiamen University.Observation indicators:(1) surgical and postoperative situations;(2) postoperative complications;(3) stratified analyses of surgical and postoperative situations in patients with different TNM staging,body mass index (BMI) and maximum tumor dimension;(4) follow-up and survival.Follow-up using outpatient examination and telephone interview was performed to detect postoperative overall survival and tumor recurrence or metastasis up to April 2018.Measurement data with normal distribution were represented as (-x)±s,and comparison between groups was analyzed using the independent-samples t test.Measurement data with skewed distribution were described as M (Q),and comparison between groups was analyzed using the nonparametric test.Comparisons of count data were analyzed using chi-square test or Fisher exact probability.Comparison of ordinal data was done by the rank-sum test.Results (1) Surgical and postoperative situations:all the patients underwent successful operation,without perioperative death.Number of lymph node dissection in the upper region of pylorus in the anterior and posterior approach groups were respectively 3.9±2.6 and 3.0±2.5,with a statistically significant difference between groups (t=2.778,P＜0.05).Cases with Billroth Ⅰ,Billroth Ⅱ,Billroth Ⅱ +Bruan and Roux-en-Y of digestive tract reconstruction,operation time,dissected times of lymph nodes in greater curvature of stomach,lower region of pylorus,upper region of pancreas and lesser curvature of stomach,cases with visible port vein,volume of intraoperative blood loss,number of overall lymph node dissection,numbers of lymph node dissection in greater curvature of stomach,lower region of pylorus,upper region of pancreas and lesser curvature of stomach,time to postoperative anal exsufflation,time for postoperative fluid diet intake,time for postoperative semi-fluid diet intake,intraperitoneal drainage-tube removal time and duration of postoperative hospital stay were respectively 16,32,47,12,(233.0±41.0)minutes,(14.6±5.4)tninutes,(21.9±6.3)nminutes,(32.7±6.8) minutes,(7.4±2.9)minutes,74,(87±73)mL,35.0±10.0,8.5±4.1,4.8±4.2,13.3±5.2,4.3± 3.3,(4.1±2.6)days,(5.4±2.8) days,(7.9± 3.5) days,(8.9± 2.9) days,(11.7± 4.5) days in the anterior approach group and 17,47,61,7,(243.0±44.0) minutes,(15.7±5.2) minutes,(23.1±8.0) minutes,(34.2±7.1) minutes,(7.9±2.8)minutes,79,(93±57)mL,33.0±10.0,8.1±4.8,5.3±4.9,12.5±5.6,3.8±2.4,(3.8±3.3)days,(5.0±3.6)days,(7.5±4.0) days,(8.5±3.8)days,(11.3±5.7) days in the posterior approach group,with no statistically significant difference between groups (x2 =3.431,t =-1.836,-1.546,-1.324,-1.634,-1.228,x2=2.552,t=-0.684,1.630,0.797,-0.871,1.148,1.314,0.954,0.951,0.884,1.065,0.694,P＞0.05).(2) Postoperative complications:cases with overall complications,anastomotic leakage,anastomotic stenosis,anastomotic bleeding,pancreatic fistula,postoperative gastroparesis,intra-abdominal hemorrhage,incision infection,pneumonia,intra-abdominal infection,bacteremia,intestinal obstruction,endolymphatic leakage,Clavien-Dindo grade Ⅰ,Ⅱ,Ⅲa,Ⅲb and Ⅳa of postoperative complications were respectively 15,1,1,1,0,3,1,2,3,0,1,3,0,3,9,1,2,0 in the anterior approach group and 25,3,0,1,2,2,2,5,7,3,2,3,1,6,14,1,2,2 in the posterior approach group,with no statistically significant difference between groups (x2=1.027,0.643,0.022,0.479,0.161,0.765,0.921,0.161,0.063,Z=-1.055,P＞0.05).Patients in 2 groups with complications were cured by symptomatic treatment.(3) Stratified analyses of surgical and postoperative situations in patients with different TNM staging,BMI and maximum tumor dimension:operation time,dissected times of lymph nodes in upper region of pancreas,cases with visible port vein,number of overall lymph node dissection,numbers of lymph node dissection in upper region of pylorus and upper region of pancreas were respectively (236.0±41.0)minutes,(33.9±6.2) minutes,32,36.0±12.0,3.8±3.0,13.4±5.5 in patients of the anterior approach group with Ⅲ stage of TNM staging and (253.0± 45.0) minutes,(36.5 ±7.0) minutes,29,31.0±t9.0,2.5±2.0,11.4±4.6 in patients of the posterior approach group with Ⅲ stage of TNM staging,with statistically significant differences between groups (t =-1.988,-2.066,x2 =4.686,t =2.472,2.757,2.016,P＜0.05).Numbers of overall lymph node dissection and number of lymph node dissection in upper region of pylorus were respectively 37.0± 12.0,3.6±3.1 in patients of the anterior approach group with BMI ≥ 25 kg/m2 and 30.0±7.0,2.0± 1.3 in patients of the posterior approach group with BMI ≥ 25 kg/m2,with statistically significant differences between groups (t =2.211,2.205,P＜0.05).Volume of intraoperative blood loss and number of lymph node dissection in upper region of pylorus were respectively (80±45) mL,4.0±2.6 in patients of the anterior approach group with maximum tumor dimension ≥ 3.3 cm and (110±67)mL,2.8± 1.8 in patients of the posterior approach group with maximum tumor dimension ≥ 3.3 cm,with statistically significant differences between groups (t =-2.320,2.589,P ＜ 0.05).(4) Follow-up and survival:of 239 patients,202 were followed up for 2-24 months,with a median time of 12 months,including 89 in the anterior approach group and 113 in the posterior approach group.During the follow-up,cases with overall survival,tumor recurrence and metastasis were respectively 85,3,8 in the anterior approach group and 109,3,11 in the posterior approach group,with no statistically significant difference between groups (x2=0.032,0.089,0.119,P＞0.05).Conclusions Both of anterior approach and posterior approach are safe and feasible in LADG,with equivalent short-term efficacies.The anterior approach in LADG has an advantage of the lymph node dissection in the upper region of pylorus compared with posterior approach,and it also is better for patients with later tumor staging,higher BMI and bigger tumor.
RESUMO
<p><b>OBJECTIVE</b>To explore the technical feasibility, safety, and short-term clinical efficacy of right-to-lateral approach in laparoscopic-assisted radical gastrectomy.</p><p><b>METHODS</b>Clinicopathological data of 178 gastric cancer patients undergoing laparoscopic-assisted radical gastrectomy, including 92 patients with right-to-lateral approach(R-LG group) and 86 cases with left-to-lateral approach (L-LG group), in our department from October 2010 to September 2013 were analyzed retrospectively. Short-term efficacy and complication morbidity were compared between R-LG group and L-LG group according to body mass index (BMI).</p><p><b>RESULTS</b>For those patients with BMI ≥ 24 kg/m², the R-LG group (35 cases) had shorter mean operation time, less intraoperative blood loss, shorter painkiller used time than L-LG group (31 cases)[(227 ± 17) min vs. (262 ± 23) min, (73 ± 9) ml vs. (84 ± 8) ml and (2.1 ± 0.1) d vs. (2.6 ± 0.4) d, all P<0.05]. The average time to ambulation and recovery time of peristalsis in the R-LG group were faster than those in L-LG group [(2.2 ± 0.2) d vs. (2.8 ± 0.6) d and (3.6 ± 0.3) d vs. (4.2 ± 0.5) d, all P<0.05]. The R-LG group had more dissected lymph nodes per patient (35 ± 4) than the L-LG group (30 ± 5) with significant difference (P<0.05). There were no significances in postoperative hospital stay, postoperative complication morbidity and hospitalization expenses between R-LG and L-LG group (all P>0.05). For those patients with BMI<24 kg/m², there were no significant differences in all above parameters between R-LG group (57 cases) and L-LG group (55 cases). No mortality and recurrence was observed during follow-up of 3 to 24 months.</p><p><b>CONCLUSION</b>Right-to-lateral approach in laparoscopic-assisted radical gastrectomy is a safe and feasible procedure, especially for the obesity patients, which can shorten the operation time, decrease intraoperative blood loss, lead to a faster postoperative recovery and harvest more lymph nodes as compared to L-LG procedure.</p>