Clinical effect analysis of laparoscopic radical gastrectomy for gastric cancer: a report of 4 435 cases / 中华消化外科杂志

ABSTRACT

Objective To investigate the development trend,safety and clinical effects of laparoscopic radical gastrectomy (LRG) for gastric cancer.Methods The retrospective and descriptive study was conducted.The clinicopathological data of 4 435 patients with gastric cancer who underwent LRG in the Fujian Medical University Union Hospital between January 2008 and December 2017 were collected.There were 3 263 males and 1 172 females,aged (61±11)years,with a range of 12-93 years.According to the operation time,4 435 patients were divided into two periods,including 1 588 patients of the early period (2008-2012) and 2 847 patients of the later period (2013-2017).Observation indicators(1) the clinicopathological data of patients;(2) intraoperative and postoperative situations;(3) postoperative complications;(4) follow-up and survival situations.Follow-up using outpatient examination,visit to home,mail and telephone interview was performed to detect survival of patients once every 3 months within 2 years postoperatively and once every 6 months after 2 years postoperatively up to June 2018.Survival time was from operation time to the last follow-up,death or deadline of follow-up database such as loss to follow-up or death of other diseases.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed by the t test.Measurement data with skewed distribution were represented as M (range).Count data were described as frequency or percentage,comparison between groups was analyzed using the chi-square test.Linear analysis was done using the unitary linear regression.The survival rate and survival curve were respectively calculated and drawn by the Kaplan-Meier method,and Log-rank test was used for survival analysis.Results (1) The clinicopathological data of patientsthere were 3 263 males and 1 172 females of the 4 435 patients,accounting for 73.574％(3 263/4 435) and 26.426％ (1 172/4 435),respectively.TNM staging of the 4 435 patients1 133 cases were detected early gastric cancer (T1 stage) and 3 302 cases were detected advanced gastric cancer including 518,1 431,1 353 in T2,T3 and T4a stages respectively.Linear regression analysis showed a linear correlation between the cases of LRG and operation year (R2 =0.911,P＜0.05) and a gradually increasing in cases of LRG.The sex (male),cases with tumor at upper stomach,middle stomach,lower stomach,＞ 2 regions (tumor location),tumor diameter,cases with undifferentiated and differentiated tumor (pathological types),cases in pT1,pT2,pT3,pT4a stages (pT staging),in pN0,pN1,pN2,pN3a,pN3b stages (pN staging),in Ⅰ A,Ⅰ B,Ⅱ A,Ⅱ B,ⅢA,ⅢB,ⅢC stages (pTNM staging) were 1 204,383,302,714,189,(4.8±2.7)cm,361,1 227,382,193,418,595,588,212,255,318,215,325,137,150,172,253,267,284 in patients of the early period,and 2 059,807,530,1 128,382,(4.3±2.6) cm,976,1 871,751,325,1 013,758,1 138,444,505,486,274,616,258,378,322,528,443,302 in patients of the later period,with statistically significant differences between patients of the two periods (x2 =6.411,15.699,t =10.946,x2 =57.801,90.437,26.502,98.773,P＜0.05).(2) Intraoperative and postoperative situationsthe volume of intraoperative blood loss,cases with intraoperative blood transfusion,cases with Billroth Ⅰ,Billroth Ⅱ,residual stomach Roux-en-Y anastomosis,esophagogastric anastomosis,esophageal Roux-en-Y anastomosis of digestive tract reconstruction,number of lymph nodes dissected,time for initial fluid diet intake,time for initial semi-fluid diet intake,duration of postoperative hospital stay were (120±75)mL,38,599,122,0,32,835,32±13,(4.5±l.7)days,(8.6±2.5)days,(13.0± 7.3) days in patients of the early period,(104±68)mL,17,441,673,21,18,1 694,37±15,(4.1± 1.5)days,(7.9±2.8) days,(12.3±7.6) days in patients of the later period,showing statistically significant differences between patients of the two periods (t=2.169,x2 =26.843,397.185,t=-10.764,2.125,3.347,2.779,P＜0.05).Further linear regression analysis showed a linear correlation between the average number of lymph nodes dissected and operation year (R2=0.826,P＜0.05) and a gradually increasing in average number of lymph nodes dissected.(3) Postoperative complications690 of 4 435 patients had postoperative complications,with an incidence rate of 15.558％ (690/4 435),including 242 patients of the early period and 448 of the later period,showing no statistically significant difference (x2 =0.191,P ＞ 0.05).Eight patients died of severe postoperative complications,with a death rate of 0.180％ (8/4 435),including 5 of the early period and 3 of the later period,showing no statistically significant difference (x2 =2.485,P＞0.05).Of 4 435 patients,561 had stage Ⅰ-Ⅱ complications,with an incidence rate of 12.649％ (561/4 435),129 had stage Ⅲ-Ⅳ complications,with an incidence rate of 2.909％(129/4 435).There were 196 and 46 patients of the early period with stage Ⅰ-Ⅱ complications and stage Ⅲ-Ⅳ complications,365 and 83 of the later period with stage Ⅰ-Ⅱ complications and stage Ⅲ-Ⅳ complications,showing no statistically significant difference between patients of the two periods (x2 =0.211,0.001,P＞0.05).(4) Follow-up and survival situations4 250 of 4 435 patients including 1 465 of the early period and 2 785 of the later period were followed up for 1-123 months,with a median time of 37 months.The 5-year cumulative survival rate was 63.9％.The 5-year cumulative survival rate was 91.8％,80.2％ and 39.5％ in the stage Ⅰ,Ⅱ,Ⅲ patients,respectively,showing a statistically significant difference (x2 =810.146,P＜0.05).The 5-year cumulative survival rate was 60.8％ and 66.7％ in patients of the early and later period,respectively with a statistically significant difference (x2 =17.887,P＜0.05).Stratified analysis of TNM stagingthe 5-year cumulative survival rates of stage Ⅰ A,Ⅰ B,Ⅱ A,Ⅱ B,Ⅲ A,Ⅲ B,Ⅲ C patients in the early period were 92.7％,85.6％,79.4％,74.5％,58.1％,37.6％,18.9％ and 95.6％,90.4％,87.6％,79.5％,52.7％,41.2％,19.5％ in patients of the later period,with no statistically significant difference (x2 =0.414,2.575,2.872,2.119,0.632,0.972,2.212,P＞0.05).Conclusions Surgical volume of the LRG has shown an increasing trend year by year,and the number of lymph nodes dissected and postoperative recovery of patients are improving.LRG is a safe procedure with acceptable clinical efficacy for gastric cancer.