RESUMO
Objective:To investigate the application value of Clavien-Dindo classification in evaluation of postoperative short-term complications of Da Vinci robotic-assisted or laparoscopic-assisted total gastrectomy with D 2 lymphadenectomy. Methods:The retrospective cohort study was conducted. The clinicopathological data of 262 patients with gastric cancer who were admitted to the 940th Hospital of Joint Logistic Support Force of Chinese People′s Liberation Army from January 2016 to January 2019 were collected. There were 214 males and 48 females, aged (58±11) years, with a range from 17 to 81 years. Of 262 patients, 120 cases undergoing Da Vinci robotic-assisted total gastrectomy + D 2 lymphadenectomy + Roux-en-Y anastomosis were divided into robotic group, and 142 cases undergoing laparoscopic-assisted total gastrectomy + D 2 lymphadenectomy + Roux-en-Y anastomosis were divided into laparoscopic group. Observation indicators: (1) intraoperative and postoperative situations; (2) postoperative pathological examination; (3)complications; (4) stratified analysis; (5) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect complications, tumor recurrence and survival of patients within postoperative 2 months. The follow-up was up to May 2019. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was analyzed using the t test. Measurement data with skewed distribution were represented as M (range), and comparison between groups was analyzed using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Comparison of ranked data between groups was analyzed using the rank sum test. Results:(1) Intraoperative and postoperative situations: cases undergoing conversion to open surgery, the operation time, volume of intraoperative blood loss, the number of lymph node dissected, time to first flatus, time to initial fluid diet intake, duration of postoperative hospital stay of the robotic group were 1, (243±42)minutes, 100 mL(range, 100-150 mL), 38±15, (2.8±1.0)days, 3 days(range, 3-4 days), 11 days(range, 9-13 days), respectively. The above indicators of the laparoscopic group were 2, (244±38)minutes, 100 mL(range, 100-150 mL), 34±14, (3.2±1.0)days, 4 days(range, 3-5 days), 10 days(range, 9-13 days), respectively. There were significant differences in the number of lymph node dissected, time to first flatus, time to initial fluid diet intake between the two groups ( t=2.068, -3.030, Z=-3.370, P<0.05), and there was no significant difference in cases undergoing conversion to open surgery, the operation time, volume of intraoperative blood loss, duration of postoperative hospital stay between the two groups ( χ2=0.000, t=-0.158, Z=-1.824, -0.088, P>0.05). (2) Postoperative pathological examination: cases with well differentiated tumor, moderately differentiated tumor, poorly differentiated tumor, signet ring cell carcinoma or other types of tumor, cases in stage T1b, T2, T3 or T4a (pT staging), cases in stage N0, N1, N2, N3a or N3b (pN staging), cases in stage ⅠB, ⅡA, ⅡB, ⅢA, ⅢB or ⅢC (pTNM staging) of the robotic group were 6, 50, 55, 9, 10, 22, 63, 25, 42, 19, 19, 24, 16, 17, 22, 23, 20, 23, 15, respectively. The above indicators of the laparoscopic group were 4, 42, 84, 12, 6, 18, 81, 37, 39, 27, 32, 19, 25, 13, 19, 28, 39, 16, 27, respectively. There was no significant difference in the above indicators between the two groups ( Z=-1.880, -1.827, -0.140, -1.460, P>0.05). (3) Complications: cases with complication classified as grade Ⅰ, grade Ⅱ, grade Ⅲa, grade Ⅲb, grade Ⅳa, grade Ⅳb of Clavien-Dindo classification, cases with death, cases with overall complications, cases with severe complications of the robotic group were 9, 6, 3, 2, 2, 0, 0, 22, 7, respectively. The above indicators of the laparoscopic group were 12, 15, 9, 6, 3, 1, 1, 47, 20, respectively. There were significant differences in cases with overall complications, cases with severe complications between the two groups ( χ2=7.309, 4.790, P<0.05), and there was no significant difference in cases with complication classified as grade Ⅰ, grade Ⅱ, grade Ⅲa, grade Ⅲb, grade Ⅳa, grade Ⅳb of Clavien-Dindo classification, cases with death between the two groups ( χ2=0.080, 2.730, 1.042, 0.704, 0.000, 0.000, 0.000, P>0.05). (4) Stratified analysis: of the patients with overall complications in robotic group, cases of male or female, cases aged ≥65 years or <65 years, cases with body mass index (BMI) ≥24 kg/m 2 or <24 kg/m 2, cases with tumor diameter ≥5 cm or <5 cm, cases with or without abdominal surgery, cases with tumor located at upper stomach or middle stomach, cases in Ⅰ-Ⅱ grade or Ⅲ grade of American Society of Anesthesiologists (ASA) classification, cases with well differentiated tumor or undifferentiated tumor, cases in stage Ⅰ-Ⅱ or stage Ⅲ (pTNM staging), cases with operation time ≥250 minutes or <250 minutes, cases with volume of intraoperative blood loss ≥150 mL or <150 mL, cases with the number of lymph node dissected ≥25 or <25 were 15, 7, 14, 8, 11, 11, 16, 6, 4, 18, 19, 3, 15, 7, 7, 15, 8, 14, 12, 10, 12, 10, 14, 8, respectively. The above indicators of patients with overall complications in the laparoscopic group were 33, 14, 17, 30, 16, 31, 36, 11, 11, 36, 27, 20, 31, 16, 13, 34, 14, 33, 24, 23, respectively. Of the patients with overall complication, there were significant differences in cases of male, cases aged ≥65 years or <65 years, cases with BMI<24 kg/m 2, cases with tumor diameter≥5 cm, cases without abdominal surgery, cases with tumor located at middle stomach, cases in Ⅰ-Ⅱ grade or Ⅲ grade of ASA classification, cases with well differentiated tumor, cases in stage Ⅲ (pTNM staging), cases with operation time ≥250 minutes, cases with volume of intraoperative blood loss <150 mL, cases with the number of lymph node dissected ≥25 between the two groups ( χ2=6.683, 4.207, 6.761, 7.438, 4.297, 6.325, 9.433, 3.970, 4.850, 4.911, 3.952, 3.915, 6.865, 4.128, P<0.05) and there was no significant difference in cases of female, cases with BMI≥24 kg/m 2, cases with tumor diameter <5 cm, cases with abdominal surgery, cases with tumor located at upper stomach, cases with undifferentiated tumor, cases in stage Ⅰ-Ⅱ (pTNM staging), cases with operation time < 250 minutes, cases with volume of intraoperative blood loss ≥150 mL, cases with the number of lymph node dissected <25 between the two groups ( χ2=0.277, 1.052, 1.996, 1.552, 2.172, 2.594, 2.244, 3.771, 1.627, 3.223, P>0.05). (5) Follow-up: 262 patients were followed up postoperatively for 2 months. During the follow-up, no patient was diagnosed with tumor recurrence, and one patient in the laparoscopic group died of severe infection. Conclusions:The Clavien-Dindo classification can be used in evaluating postoperative short-term complications of Da Vinci robotic-assisted or laparoscopic-assisted total gastrectomy with D 2 lymphadenectomy. Compared with laparoscopic-assisted total gastrectomy with D 2 lymphadenectomy, Da Vinci robotic-assisted total gastrectomy with D 2 lymphadenectomy has the advantages of minimally invasiveness, low incidence of overall and severe complication.
RESUMO
Objective To explore the clinical efficacy of Da Vinci robot-assisted radical gastrectomy for gastric cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 472 patients who underwent radical gastrectomy for gastric cancer in the 940 Hospital of the People's Liberation Joint Service from June 2016 to June 2018 were collected.There were 372 males and 100 females,aged (57± 11) years,with a range from 17 to 85 years.Patients underwent gastrointestinal angiography,magnetic resonance imaging,computed tomography or gastrointestinal endoscopy before surgery,and were diagnosed with gastric cancer by biopsy.Of the 472 patients,241 underwent Da Vinci robot-assisted radical gastrectomy for gastric cancer were allocated into robotic group and 231 underwent laparoscopy-assisted radical gastrectomy were allocated into laparoscopic group.Observation indicators:(1) surgical situations;(2) postoperative situations;(3) follow-up and survival.Follow-up using outpatient examination and telephone interview was performed to detect the tumor recurrence and metastasis and survival of patients up to January 30,2019.Measurement data with normal distribution were expressed as Mean±SD,and comparison between groups was done using the t test.Measurement data with skewed distribution were described as M (range).Count data were described as absolute number or percentage,and the chi-square test was used for comparison between groups.Comparison of ordinal data was done using the rank-sum test.The accumulative survival rate,tumor-bearing survival rate and mortality of tumor recurrence were calculated by the Kaplan-Meier method,and Log-rank test was used for survival analysis.Results (1) Surgical situations:472 patients underwent successful operation,with R0 margin.Cases with total gastrectomy + D2 lymph node dissection + Roux-en-Y anastomosis,cases with distal subtotal gastrectomy + D2 lymph node dissection + Billroth Ⅱ anastomosis,operation time,upper margin distance,lower margin distance,tumor diameter,cases with shallow muscular invasion,deep muscular invasion,subserosal invasion and serosal invasion (depth of tumor invasion)were 107,134,(234±44)minutes,(4±3)cm,(6±4)cm,(5 ±3)cm,8,17,32,184 in the robotic group,and 94,137,(239±46)minutes,(4±3)cm,(6±4) cm,(5±3)cm,7,19,30,175 in the laparoscopic group,respectively;there was no significant difference in above indicators between the two groups (x2 =0.200,2.459,t =-1.212,-1.074,-0.420,-1.236,Z =0.171,P＞ 0.05).The volume of i ntraoperative blood loss,number of lymph nodes dissected in total gastrectomy,number of lymph nodes dissected in distal subtotal gastrectomy were (126±113)mL,45±14,and 36±18 in the robotic group,and (149±132) mL,39±14,30± 16 in the laparoscopic group,showing statistically significant differences between the two groups (t=-2.093,3.275,2.195,P＜0.05).(2) Postoperative situations:the time to recovery of gastrointestinal function,time of postoperative abdominal drainage tube removal,and hospitalization cost in the robotic group were (2.6 ± 0.6)days,(5.7± 1.2) days,and (100 157±44 888) yuan,respectively.The above indices of the laparoscopic group were (3.1±0.7)days,(7.0±3.0)days,and (82 220± 18 941)yuan,respectively.There were statistically significant differences between the two groups (t =-5.371,-3.212,5.603,P ＜ 0.05).The duration of postoperative hospital stay was (12±6)days in the robotic group and (12±6)days in the laparoscopic group,with no significant difference between the two groups (t =0.755,P＞ 0.05).Eighteen out of 472 patients had complications.There were 3 cases of anastomotic leakage in the robotic group,2 cases of gastroplegia,1 case of duodenal stump,and 1 case of pulmonary infection,with a incidence of postoperative complication as 2.90％ (7/241).There were 4 cases of anastomotic leakage in the laparoscopic group,1 case of gastroplegia,1 case of duodenal stump,and 3 cases of pulmonary infection,with a incidence of postoperative complication as 3.90％ (9/231).There was no statistically significant difference in the incidence of postoperative complication between the two groups (x2 =1.503,P ＞ 0.05).Patients with digestive tract fistula were re-explored and performed continuous flushing-negative pressure aspiration and nutritional support treatment,and then discharged after improvement.Patients with gastroplegia and lung infection were discharged after corresponding conservative treatment.(3) Follow-up and survival:404 out of 472 patients were followed up for 7-31 months,with a median follow-up time of 19 months,including 212 in the robotic group and 192 in the laparoscopic group.The 3-year survival rates were 96.70％ and 91.67％ in the robotic group and laparoscopic group,with no statistically significant difference between the two groups (x2=1.037,P＞0.05).During the follow-up,the tumor-beating survival rate and mortality of tumor recurrence of the robotic group were 0.47％ and 2.36％,respectively,versus 1.04％ and 6.77％ of the laparoscopic group,with statistically significant differences between the two groups (x2 =3.198,4.208,P＜0.05).Conclusion The Da Vinci robot-assisted radical gastrectomy for gastric cancer is safe and effective,which can reduce volume of intraoperative blood loss,shorten the postoperative recovery time,increase the number of lymph node dissection,however,it will increase the treatment expense.
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Objective@#To explore the application value of early postoperative enteral eco-immune nutrition in the nutritional support treatment for intra-abdominal infection.@*Methods@#The prospective study was conducted. The clinicopathological data of 62 patients with intra-abdominal infection who were admitted to the 940 Hospital of the People′s Liberation Army Joint Service Support Force from February 2018 to December 2018 were collected. All patients were randomly divided into two groups by the envelope method with double-blind technique, including patients who began being given enteral eco-immune nutrition preparation at postoperative 24-48 hours in eco-immune group and patients who began being given simple enteral nutrition preparation at 24-48 hours in control group. Observation indicators: (1) analysis of immune function indices before treatment and after 7 days of treatment in the two groups; (2) postoperative conditions in the two groups; (3) follow-up. Follow-up using telephone interview was performed to detect complications and recurrence of infection up to May 2019. Measurement data with normal distribution were represented as Mean±SD, and intra-group comparison and comparison between groups were analyzed using the t test. Count data were represented as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test.@*Results@#Sixty-two patients were screened for eligibility, including 38 males and 24 females, aged (54±14)years, with the range of 22-81 years. There were 30 in the eco-immune group and 32 in the control group. (1) Analysis of immune function indices before treatment and after 7 days of treatment in the two groups: before treatment, the percentages of CD3+, CD4+, CD8+, ratio of CD4+ /CD8+, count of natural killer (NK) cells, levels of blood endotoxin and immunoglobulin A (IgA) for the eco-immune group were 61%±12%, 34%±5%, 28%±5%, 1.25±0.34, 17.26%±2.74%, (2.4±0.3)ng/L, and (1.7±0.5)g/L, versus 59%±11%, 33%±5%, 27%±4%, 1.27±0.36, 16.96%±2.99%, (2.5±0.5)ng/L, (1.8±0.5)g/L for the control group, respectively, there were no significant differences between the two groups (t=-0.563, -0.354, -0.987, 0.327, -0.462, 0.887, 0.991, P>0.05). After 7 days of treatment, the above indices for the eco-immune group were 62%±8%, 37%±6%, 27%±8%, 1.45±0.32, 22.63%±7.25%, (2.2±0.4)ng/L, and (2.3±0.4)g/L, versus 58%±8%, 32%±4%, 27%±6%, 1.26±0.22, 16.26%±2.10%, (2.7±0.6)ng/L, and (2.0±0.4)g/L for the control group, respectively, there were significant differences in the percentages of CD3+, CD4+, ratio of CD4+ /CD8+, count of NK cells, levels of blood endotoxin and IgA (t=-2.393, -4.336, -3.074, -5.338, 4.010, -3.155, P<0.05), but no significant difference in the percentage of CD8+ between the two groups (t=0.077, P>0.05). In the eco-immune group, the percentage of CD4+, ratio of CD4+ /CD8+, count of NK cells, levels of blood endotoxin and IgA showed significant differences after 7 days of treatment (t=-2.899, -2.739, -4.385, 2.157, -5.788, P<0.05), but the percentages of CD3+ and CD8+ showed no significant differences after 7 days of treatment (t=-0.490, 1.193, P>0.05). In the control group, the percentage of CD8+ and level of IgA showed significant differences after 7 days of treatment (t=3.659, -2.258, P<0.05), but the percentage of CD4+, ratio of CD4+ /CD8+, count of NK cells, and level of blood endotoxin showed no significant differences after 7 days of treatment (t=0.157, 0.759, 1.132, 1.212, -0.532, P>0.05). (2) Postoperative conditions in the two groups: the time to first flatus and duration of postoperative hospital stay of the eco-immune group were (2.4±0.5)days and (8±4)days, respectively, versus (2.9±0.7)days and (11±7)days of the control group; there were significant differences in the above indices between the two groups (t=-3.017, -2.764, P<0.05). In the eco-immune group, the incidence of complication was 6.7%(2/30), including 1 case of wound infection, 1 case of pulmonary infection. In the control group, the incidence of complication was 31.2%(10/32), including 6 cases of wound infection, 2 cases of pulmonary infection, 1 case of intra-abdominal infection, and 1 case of systemic inflammatory response syndrome. There was a significant difference in the incidence of complication between the two groups (χ2=4.122, P<0.05). The patients with infection were recovered after corresponding systematic conservative treatments. (3) Follow-up: of the 62 patients, 46 were followed up for 3-9 months, with a median follow-up time of 6 months, including 26 in the eco-immune group and 20 in the control group. During the follow-up, no complication or infection recurred in the two groups.@*Conclusion@#Compared with simple enteral nutrition, early postoperative enteral eco-immune nutrition in the nutritional support treatment is safe and effective for patients with intra-abdominal infection, which can enhance the immune function of patients, shorten the recovery time of patients, and reduce the incidence of infection complications.
RESUMO
Objective To explore the application value of early postoperative enteral eco-immune nutrition in the nutritional support treatment for intra-abdominal infection.Methods The prospective study was conducted.The clinicopathological data of 62 patients with intra-abdominal infection who were admitted to the 940 Hospital of the People's Liberation Army Joint Service Support Force from February 2018 to December 2018 were collected.All patients were randomly divided into two groups by the envelope method with double-blind technique,including patients who began being given enteral eco-immune nutrition preparation at postoperative 24-48 hours in eco-immune group and patients who began being given simple enteral nutrition preparation at 24-48 hours in control group.Observation indicators:(1) analysis of immune function indices before treatment and after 7 days of treatment in the two groups;(2) postoperative conditions in the two groups;(3) follow-up.Follow-up using telephone interview was performed to detect complications and recurrence of infection up to May 2019.Measurement data with normal distribution were represented as Mean ± SD,and intra-group comparison and comparison between groups were analyzed using the t test.Count data were represented as absolute numbers or percentages,and comparison between groups was analyzed using the chi-square test.Results Sixty-two patients were screened for eligibility,including 38 males and 24 females,aged (54± 14)years,with the range of 22-81 years.There were 30 in the eco-immune group and 32 in the control group.(1) Analysis of immune function indices before treatment and after 7 days of treatment in the two groups:before treatment,the percentages of CD3+,CD4+,CD8+,ratio of CD4+/CD8+,count of natural killer (NK) cells,levels of blood endotoxin and immunoglobulin A (IgA) for the eco-immune group were 61％ ± 12％,34％ ± 5％,28％ ± 5％,1.25 ± 0.34,17.26％±2.74％,(2.4±0.3)ng/L,and (1.7±0.5)g/L,versus 59％±11％,33％±5％,27％±4％,1.27± 0.36,16.96％ ±2.99％,(2.5± 0.5) ng/L,(1.8± 0.5) g/L for the control group,respectively,there were no significant differences between the two groups (t =-0.563,-0.354,-0.987,0.327,-0.462,0.887,0.991,P＞ 0.05).After 7 days of treatment,the above indices for the eco-immune group were 62％±8％,37％±6％,27％± 8％,1.45±0.32,22.63％±7.25％,(2.2±0.4) ng/L,and (2.3±0.4) g/L,versus 58％±8％,32％±4％,27％ ±6％,1.26±0.22,16.26％±2.10％,(2.7±0.6)ng/L,and (2.0±0.4)g/L for the control group,respectively,there were significant differences in the percentages of CD3+,CD4+,ratio of CD4+/CD8+,count of NK cells,levels of blood endotoxin and IgA (t =-2.393,-4.336,-3.074,-5.338,4.010,-3.155,P＜0.05),but no significant difference in the percentage of CD8+ between the two groups (t =0.077,P＞0.05).In the coo-immune group,the percentage of CD4+,ratio of CD4+/CD8+,count of NK cells,levels of blood endotoxin and IgA showed significant differences after 7 days of treatment (t =-2.899,-2.739,-4.385,2.157,-5.788,P＜0.05),but the percentages of CD3+ and CD8+ showed no significant differences after 7 days of treatment (t =-0.490,1.193,P＞ 0.05).In the control group,the percentage of CD8+ and level of IgA showed significant differences after 7 days of treatment (t=3.659,-2.258,P＜0.05),but the percentage of CD4+,ratio of CD4+/CD8+,count of NK cells,and level of blood endotoxin showed no significant differences after 7 days of treatment (t =0.157,0.759,1.132,1.212,-0.532,P＞0.05).(2) Postoperative conditions in the two groups:the time to first flatus and duration of postoperative hospital stay of the eco-immune group were (2.4± 0.5) days and (8± 4) days,respectively,versus (2.9±0.7)days and (11±7)days of the control group;there were significant differences in the above indices between the two groups (t =-3.017,-2.764,P＜0.05).In the eco-immune group,the incidence of complication was 6.7％(2/30),including 1 case of wound infection,1 case of pulmonary infection.In the control group,the incidence of complication was 31.2％ (10/32),including 6 cases of wound infection,2 cases of pulmonary infection,1 case of intra-abdominal infection,and 1 case of systemic inflammatory response syndrome.There was a significant difference in the incidence of complication between the two groups (x2=4.122,P＜ 0.05).The patients with infection were recovered after corresponding systematic conservative treatments.(3) Follow-up:of the 62 patients,46 were followed up for 3-9 months,with a median follow-up time of 6 months,including 26 in the eco-immune group and 20 in the control group.During the follow-up,no complication or infection recurred in the two groups.Conclusion Compared with simple enteral nutrition,early postoperative enteral eco-immune nutrition in the nutritional support treatment is safe and effective for patients with intra-abdominal infection,which can enhance the immune function of patients,shorten the recovery time of patients,and reduce the incidence of infection complications.