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腹腔镜胃癌根治术中血管损伤的危险因素分析

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  [摘要] 目的 探究在腹腔鏡胃癌根治术中血管损伤的危险因素及其对术后恢复的影响。 方法 回顾性分析2015年1月~2017年12月浙江省嘉兴市第一医院胃肠外科实施腹腔镜胃癌根治术的连续的136例的胃癌患者临床资料。根据术中血管损伤与否分为损伤组和非损伤组,分析血管损伤的危险因素及其对术后恢复的影响。 结果 在136例患者的手术中损伤组有84例,非损伤组有52例。在损伤组和非损伤组的对比研究中发现年龄>55岁(OR = 2.304,95%CI:1.072~4.950,P < 0.05)、肿瘤直径>3.5 cm(OR = 2.318,95%CI:1.027~5.232,P < 0.05)、出现淋巴结转移(OR = 5.015,95%CI:1.348~18.656,P < 0.05)均是术中血管损伤的独立危险因素。与非损伤组比较,损伤组患者术后住院天数显著延长(P < 0.05),术中失血量较多(P < 0.01)。当术中出血量≥200 mL时更易引起术后并发症的发生(P < 0.01)。 结论 患者高龄、肿瘤偏大、淋巴结侵犯是引起腹腔镜胃癌根治术中血管损伤的独立危险因素。当术中出现血管损伤时,术后住院时间显著延长,甚至影响并发症的发生。
  [关键词] 胃肿瘤;血管损伤;危险因素;腹腔镜
  [中图分类号] R735.2 [文献标识码] A [文章编号] 1673-7210(2019)04(b)-0093-04
  Risk factors analysis of intraoperative vascular injury during laparoscopic-assisted gastrectomy for gastric cancer
  WU Jiaming ZHU Yi DOU Guangjian ZHOU Yuan LU Bohao CHEN Zhiheng PENG Yuping
  Department of Gastrointestinal Surgery, the First Hospital of Jiaxing, Zhejiang Province, Jiaxing 314000, China
  [Abstract] Objective To explore the risk factors of vascular injury in laparoscopic radical gastrectomy and its influence on postoperative recovery. Methods The clinical data of 136 consecutive patients with gastric cancer who underwent laparoscopic radical gastrectomy in Department of Gastrointestinal Surgery, the First Hospital of Jiaxing Zhejiang Province, from January 2015 to December 2017 were retrospectively analyzed. The risk factors of vascular injury and its effect on postoperative recovery were analyzed. Results Among the 136 patients, 84 patients were in the injured group and 52 patients were in the non-injured group. In the comparison study between the injured group and the non-injured group, age > 55 years (OR = 2.304, 95%CI: 1.072-4.950, P < 0.05), diameter of tumor>3.5 cm (OR = 2.318, 95%CI: 1.027-5.232, P < 0.05), lymph node metastasis (OR = 5.015, 95%CI: 1.348-18.656, P < 0.05) were independent risk factors for intraoperative vascular injury. Compared with the non-injured group, the postoperative hospitalization days were significantly longer in the injured group (P < 0.05), and the amount of blood loss was higher (P < 0.01). Postoperative complications were more likely to occur when intraoperative blood loss was 200 mL or above (P < 0.01). Conclusion Advanced age, large tumor and lymph node invasion are independent risk factors for vascular injury in laparoscopic radical gastrectomy. When vascular injury occurs during the operation, the postoperative hospitalization time is significantly prolonged, even affecting the occurrence of complications.   [Key words] Gastric cancer; Intraoperative vascular injury; Risk factor; Laparoscope
  在我国胃癌位于癌症新发病率第二位,位于恶性肿瘤的死亡率第三位[1]。外科手术则是治疗胃癌的基本方法和主要手段,随着腹腔镜技术的发展及腔镜器械的更新换代,早期胃癌在腹腔镜手术中的安全性及有效性已得到公认[2]。近期亚洲多家研究中心已初步报道腹腔镜技术应用于进展期胃癌也是安全可行的[3]。然而,由于胃的血供丰富、解剖层次多及淋巴结清扫复杂,因此手术难度较大,技术要求仍较高[4-5]。特别是对新开展腹腔镜胃癌手术的外科医生来说,术中血管损伤出血是手术一大难关,故在术前评估时更需谨慎。对术中血管损伤的相关风险因素的了解则有助于进一步行术前风险的评估,降低术后短期的风险。本研究旨在探究腹腔镜胃癌根治术中发生血管损伤的相关危险因素及其对术后的影响。
  1 资料与方法
  1.1 一般资料
  收集浙江省嘉兴市第一医院(以下简称“我院”)胃肠外科2015年1月~2017年12月行腹腔镜胃癌根治术患者154例。纳入标准:①年龄>18岁;②术前病理活检诊断为胃恶性肿瘤;③术式为胃癌根治术(R0切除),T分期≤T4a,无远处转移;④有完整临床数据资料。排除标准:手术录像资料记录不完整者。排除18例,最终有136例连续的患者纳入本研究。
  1.2 方法
  通过回顾性分析纳入病例完整的临床资料,观看手术录像,根据术中是否出现血管损伤分为损伤组(84例)和非损伤组(52例)。通过临床数据资料的分析,研究术中出现血管损伤的危险因素及其對手术及术后恢复的影响。术中血管损伤:手术时对包括胃网膜左血管、胃网膜右血管、胃右血管、胰十二指肠上前静脉、胃十二指肠动脉、肝固有动脉、腹腔动脉干、胃左血管、肝总动脉、脾动静脉、门静脉等所有胃周主要血管造成损伤,且需要电凝、压迫或结扎离断等措施进行止血。手术经验:在本研究中默认术者的手术经验与手术例数的积累数量呈正相关,即手术经验以手术年限呈现。
  1.3 统计学方法
  应用SPSS 16.0软件对所得数据进行统计分析。符合正态分布的计量资料采用均数±标准差(x±s)表示,组间比较采用t检验,计数资料采用百分率表示,组间比较采用χ2检验。相关性分析采用单因素Logistic回归分析。以P < 0.05为差异有统计学意义。
  2 结果
  2.1 患者一般资料
  本研究纳入136例患者的临床资料及术后恢复指标,见表1。患者术后病理分期按第14版日本胃癌规约AJCC分期[6]:Ⅰ期13例(9.56%),Ⅱ期52例(38.24%),Ⅲ期71例(56.62%),伴有淋巴结转移89例(65.44%)。
  2.2 术中血管损伤出血的危险因素
  根据术中血管损伤情况将136例患者分为损伤组(84例)和非损伤组(52例),将性别、年龄、手术经验、体重指数(BMI)、肿瘤大小(以肿瘤最大直径表述)、肿瘤位置、T分期、N分期和术后病理分期进行Logistic回归的单因素分析,并以P < 0.2为筛选标准,将年龄、BMI、肿瘤大小、N分期和病理分期纳入Logistic回归的多因素分析,见表2。多因素分析显示当年龄>55岁(OR = 2.304,95%CI:1.072~4.950,P = 0.03)、肿瘤大小>3.5 cm(OR = 2.318,95%CI:1.027~5.232,P = 0.04)及出现淋巴结转移(OR = 5.015,95%CI:1.348~18.656,P = 0.01)时,更容易出现术中血管损伤,见表3。
  2.3 术中血管损伤对术后恢复的影响
  与非损伤组比较,损伤组中术中失血量(P < 0.01)和术后住院天数(P = 0.02)显著性增加,而术后首次排气、进食时间、淋巴结检出数和并发症在两组间比较差异无统计学意义(P > 0.05),见表4。损伤组的亚组分析提示,在84例损伤组患者中61例术中失血量<200 mL,其中有2例患者出现术后并发症(3.28%),而术中失血量≥200 mL有23例,其中出现术后并发症有7例患者(30.43%),两者间差异有高度统计学意义(P < 0.01)。
  3 讨论
  我国在全球范围内为胃癌高发病和高死亡率国家,手术切除是治疗胃癌的有效方式之一。然而腹腔镜胃癌根治术在技术层面的要求更高,特别是复杂的D2淋巴结清扫时出现的血管损伤及出血[7-9]。有相关研究[10-13]报道提示出血也是主要的术中并发症之一。而既往文献较少报道腹腔镜胃癌根治术中发生血管损伤的相关危险因素的研究。在本研究中,共纳入136例行腹腔镜胃癌根治术的患者,发现高龄、肿瘤偏大及淋巴结侵犯均是术中血管损伤的独立危险因素。当出现术中血管损伤后,可显著增加术中失血量,延长术后住院天数和手术的淋巴结清扫时间。
  本研究结果显示,术中发生血管损伤的危险因素为年龄>55岁、肿瘤大小>3.5 cm和有淋巴结转移。尽管在多个中心报道胃切除在高龄患者群体中安全性和可行性均得到初步证实[14-15],然而老年患者的重要器官功能常发生退行性变,代偿能力和免疫功能低下,生理储备能力不足,对手术的耐受性差。此外在高龄患者中,术前更常伴有其他疾病,例如高血压、糖尿病、心血管疾病、动脉粥样性硬化、呼吸系统疾病、肝脏疾病等,上述因素均可影响患者术后恢复甚至增加术后并发症的发生[16-17]。同时,绝大部分伴发的疾病会降低血管弹性,术中不同程度牵拉或裸化、分离时更易引起血管的损伤出血。而肿瘤偏大则影响胃体的病变范围,导致胃周组织融合、粘连,给手术分离、层面的解剖带来一定难度。Kim等[18]认为腹腔镜D2根治术的重点和难点在于胃系膜的游离和胃周淋巴结的清扫。根据日本胃癌规约(14版),远端胃切除术D2淋巴结清扫的范围应包括:No.7、8a、9、11p、12a组淋巴结。上述淋巴结位于胰腺上缘及胃胰皱襞间的狭小空间中,且均处于重要大血管(胃左动脉、肝总动脉、脾动脉和胃右动脉)周围,清扫空间局限、器械操作熟练程度要求高,如有不慎极易造成出血等术中并发症,严重时可直接导致中转开腹。而一旦No.7、8a、9、11p、12a组淋巴结存在转移或融合肿大,清扫难度进一步增加[19]。故术前评估时更需注意胃周淋巴结的转移情况,特别是肿大明显或孤立成团的淋巴结显像。   雖然本研究的分析中术者的手术经验不是术中血管损伤的独立性保护因素,但结合临床实践,术者的手术经验和熟练程度对于血管损伤的发生是不容忽视的一项因素。尤其是在相关腹腔镜胃癌手术的学习曲线研究显示,平均需30、40、50例手术后手术并发症的发生率显著性降低[20]。随着外科手术器械及技术的发展和微创理念的深入人心,腹腔镜手术自出现以来得到越来越多的应用。在胃肠外科方面,腹腔镜手术因其美容、微创、术后恢复快等一系列优势,已逐渐成为良性肿瘤、结直肠癌、早期胃癌的替代术式。我院于2015年开始全面将腹腔镜技术应用于胃癌手术治疗,根据此研究结果提示开展腹腔胃癌根治术前,术者在病例选择及术前相关风险因素评估时更需谨慎。
  同时损伤组及非损伤组的比较分析结果显示,术中血管损伤对术后恢复(首次排气和进食时间)和并发症的发生无显著影响,但是当出现血管损伤且出血量较大时(出血量≥200 mL)显著增加术后并发症的发生。
  因此在行术前评估时需注意患者高龄、肿瘤偏大及有淋巴结转移征象的患者,手术时更需警惕术中血管损伤的可能。当出现术中血管损伤且出血量较大时,术后需加强监护及治疗。
  在腹腔镜胃癌根治术中,高龄、肿瘤偏大、淋巴结侵犯均是引起术中血管损伤的独立危险因素。在术前评估时尤其需要关注,特别刚开展该技术时应尽量选择术中血管损伤风险较低的患者。当术中出现血管损伤时,显著延长术后住院时间,甚至影响术后并发症的发生。此外,本研究也存在一定局限性,样本量偏少导致未能对入组患者进一步分层,回顾性研究本身也降低了结论的可信度,仍需前瞻性的多中心随机对照研究以作进一步证实。
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  (收稿日期:2018-12-03 本文編辑:金 虹)
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