Objective: To compare short-term efficacy of robotic versus 3D laparoscopic-assisted D2 radical distal gastrectomy in gastric cancerpatients and those with different body mass index (BMI). Method: A retrospective cohort study was performed. Inclusion criteria:(1) gastric cancer proved by preoperative pathological results and tumor location was suitable for D2 radical distal gastrectomy; (2) no distal metastases such as in liver, kidney or abdominal cavity, and no direct invasion to the pancreas or colon on preoperative imaging; (3) postoperative pTNM stage ranged from I to III; (4) no conversion to open surgery or change of surgical procedure during operation; (5) complete clinicopathological data. Patients with severe chronic diseases, other malignant tumors, tumor invasion of other organs or distant metastases, benign gastric tumors, gastrointestinal stromal tumors and recurrent gastric cancer were excluded. According to the above criteria, 531 patients who underwent robotic or 3D laparoscopic-assisted distal gastrectomy at the General Surgery Department of Chinese PLA General Hospital from January 2016 to December 2019 were enrolled. Among them, 344 patients underwent 3D laparoscopic-assisted distal gastrectomy (3D-LADG group), including 250 males, 94 females, 66 cases (19.2%) with a BMI ≥ 25 kg/m(2), and 278 cases (80.8%) with a BMI < 25 kg/m(2), and 187 patients underwent robotic-assisted distal gastrectomy (RADG group), including 122 males, 65 females, 69 cases (36.9%) with a BMI≥25 kg/m(2) and 118 cases (63.1%) with a BMI < 25kg/m(2). There were no significant differences in baseline characteristics between the two groups (all P > 0.05). Operative indicators, postoperative recovery, pathological characteristics and complication rate were compared between the two groups. Subgroup analysis stratified BMI was also performed. Results: Compared with RADG group, 3D-LADG group presented more harvested lymph nodes (29.1±12.4 vs. 25.2±9.0, t=4.238, P<0.001), shorter postoperative hospital stay [8.0 (7.0 to 10.0) days vs. 10.0 (9.0 to 11.0) days, Z=-6.205, P<0.001], less operative cost [(3.6×10(4)±1.1×10(4)) yuan vs. (6.2×10(4)±3.5×10(4)) yuan, t=-9.727, P<0.001], less cost of hospitalization [8.6×10(4)(7.5×10(4) to 10.0×10(4)) yuan vs. 12.8×10(4)(11.7×10(4) to 14.1×10(4)) yuan, Z=-15.997, P<0.001] and longer first flatus time [(3.9±1.0) days vs. (3.4±1.2) days, t=4.271, P<0.001], whose differences were all statistically significant (all P<0.05). While there were no statistically significant differences in operation time, intraoperative blood loss, overall complication rate [10.8%(37/344) vs. 12.8%(24/187), χ(2)=0.515, P=0.473] and severe complications rate [2.0%(7/344) vs. 3.2%(6/187), χ(2)=0.294, P=0.588] between 3D-LADG group and RADG group (all P>0.05). In BMI<25 kg/m(2) group, propensity score matching (PSM) was used to reduce bias of baseline characteristics. After PSM, 3D-LADG group presented higher proportion of intraoperative blood loss <50 ml [26.7% (31/116) vs. 8.6% (10/116), χ(2)=13.065, P<0.001], more harvested lymph nodes [30.3±12.2 vs. 25.3±9.5, t=-3.192, P=0.002] and shorter postoperative hospital stay [9.0 (7.0 to 10.0) days vs. 10.0 (9.0 to 11.0) days, Z=-4.275, P<0.001] compared with RADG group, while other perioperative indicators showed no statistically significant differences between the two groups (all P>0.05). In BMI≥25 kg/m(2) group, 3D-LADG group presented higher proportion of intraoperative blood loss >200 ml [18.2% (12/66) vs. 1.4% (1/69), χ(2)=10.853, P=0.001] and shorter postoperative hospital stay [8.0 (6.0 to 10.0) days vs. 9.0 (8.0 to 10.5) days, Z=-3.039, P=0.002] compared with RADG group, while other perioperative indicators also showed no statistically significant differences between the two groups (all P>0.05). Conclusion: It is safe and feasible to perform 3D-LADG and RADG for patients with gastric cancer. The short-term efficacy of both is similar.
目的： 比较机器人与3D腹腔镜辅助远端胃癌D(2)根治术的近期疗效，以及在不同体质指数患者中的应用效果。 方法： 采用回顾性队列研究方法。病例纳入标准：（1）术前均经胃镜活检证实胃癌，肿瘤位置适合行远端胃癌D(2)根治术；（2）经影像检查无肝、肺、腹腔等远处转移，无肿瘤直接侵犯胰腺和结肠；（3）术后病理分期Ⅰ~Ⅲ期；（4）手术期间无中转开腹或更换术式；（5）临床病理资料完整。排除合并严重慢性基础疾病或其他恶性肿瘤者、肿瘤侵犯其他器官及远处转移者、以及胃良性肿瘤或胃肠间质瘤及复发性胃癌的患者。根据以上标准，收集2016年1月至2019年12月期间，于解放军总医院普通外科学部接受3D腹腔镜或机器人辅助下远端胃癌D(2)根治术的531例患者的临床及病理资料，其中采用3D腹腔镜者344例（3D腹腔镜手术组），男性250例，女性94例，体质指数≥25.0 kg/m(2)者66例（19.2%），体质指数<25.0 kg/m(2)者278例（80.8%）；采用机器人者187例（机器人手术组），其中男性122例，女性65例，体质指数≥25.0 kg/m(2) 69例（36.9%），体质指数<25.0 kg/m(2)者118例（63.1%）。两组基线资料及肿瘤病理学特征的比较，差异均无统计学意义（均P>0.05），具有可比性。比较两组以及不同体质指数亚组间的手术情况、术后恢复情况、病理特征以及术后并发症率等指标。 结果： 与机器人手术组比较，3D腹腔镜手术组患者淋巴结清扫数目更多[（29.1±12.4）枚比（25.2±9.0）枚，t=4.238，P<0.001]，术后住院时间更短[M（范围）：8.0（7.0~10.0） d比10.0（9.0~11.0） d，Z=-6.205，P<0.001]，手术费用[（3.6±1.1）万元比（6.2±3.5）万元，t=-9.727，P<0.001]和住院总费用[M（范围）：8.6（7.5~10.0）万元比12.8（11.7~14.1）万元，Z=-15.997，P<0.001]均较少，但首次排气时间偏晚[（3.9±1.0） d比（3.4±1.2） d，t=4.271，P<0.001]，差异均有统计学意义（均P<0.05）。3D腹腔镜手术组与机器人手术组手术时间、术中失血量、术后并发症率[10.8%（37/344）比12.8%（24/187），χ(2)=0.515, P=0.473]以及严重并发症发生率[2.0%（7/344）比3.2%（6/187），χ(2)=0.294, P=0.588]差异无统计学意义（均P>0.05）。在体质指数<25.0 kg/m(2)组中应用倾向性评分匹配方法减少基线偏倚；相比机器人手术组，3D腹腔镜手术组术中低于50 ml出血量的比例更高[26.7%（31/116）比8.6%（10/116），χ(2)=13.065，P<0.001]，淋巴结清扫数目更多[（30.3±12.2）枚比（25.3±9.5）枚，t=-3.192，P=0.002]，术后住院时间更短[M（范围）：9.0（7.0~10.0） d比10.0（9.0~11.0） d，Z=-4.275，P<0.001]，差异均有统计学意义（均P<0.05），其他围手术期指标差异均无统计学意义（均P>0.05）。在体质指数≥25.0 kg/m(2)组中，相比机器人手术组，3D腹腔镜手术组术中超过200 ml出血量的患者比例更高[18.2%（12/66）比1.4%（1/69），χ(2)=10.853，P=0.001]，但术后住院时间偏短[M（范围）：8.0（6.0~10.0） d比9.0（8.0~10.5） d，Z=-3.039，P=0.002]，差异有统计学意义（P<0.05），而其他围手术期指标差异均无统计学意义（均P>0.05）。 结论： 在3D腹腔镜和机器人下行远端胃癌D(2)根治术均安全可行，近期疗效相当。.
Keywords: Curative effect, short-term; D2 radical gastrectomy; Gastric neoplasms, distal; Laparoscope, three-dimensional imaging system; Robotic surgery.