【摘要】：研究背景： 胃癌是我國(guó)最常見的消化道惡性腫瘤之一，死亡率居惡性腫瘤首位，其治療手段主要以外科手術(shù)為主。傳統(tǒng)的手術(shù)方式為開腹胃癌手術(shù)，自1987腹腔鏡膽囊切除手術(shù)被成功應(yīng)用以來，腹腔鏡技術(shù)因其獨(dú)特的微創(chuàng)優(yōu)勢(shì)，在外科各個(gè)領(lǐng)域逐漸得到了廣泛的應(yīng)用。1994年Kitano等首次報(bào)道了腹腔鏡技術(shù)應(yīng)用于胃癌，經(jīng)過多年的發(fā)展，腹腔鏡胃癌根治術(shù)因其創(chuàng)傷小、恢復(fù)快逐漸成為外科治療胃癌的主要手段而被人們廣泛接受。如今，胃癌微創(chuàng)外科治療已成為目前研究的熱點(diǎn)之一。 隨著外科治療科技的發(fā)展，達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)逐漸被引入手術(shù)治療領(lǐng)域。2002年，Hashizume等首次報(bào)道了達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)輔助胃癌根治術(shù)。與傳統(tǒng)的腹腔鏡及開腹胃癌手術(shù)相比，達(dá)芬奇機(jī)器人作為一項(xiàng)新型的微創(chuàng)手術(shù)方式現(xiàn)今仍處于探索階段，目前國(guó)際國(guó)內(nèi)相關(guān)文獻(xiàn)報(bào)道有限，且多為單純病例報(bào)道，主要闡述達(dá)芬奇機(jī)器人手術(shù)是一種安全、可行的手術(shù)方式。但是，達(dá)芬奇機(jī)器人手術(shù)系統(tǒng)是否應(yīng)在外科治療胃癌中得到廣泛應(yīng)用，其臨床療效是否肯定,尚缺乏相應(yīng)的臨床對(duì)照研究；機(jī)器人胃癌手術(shù)對(duì)患者腹腔微轉(zhuǎn)移與傳統(tǒng)腹腔鏡及開腹手術(shù)相比是否具有不同影響，目前尚未見相關(guān)文獻(xiàn)報(bào)道。 研究目的： 因此，本實(shí)驗(yàn)通過收集我中心胃癌患者臨床資料，對(duì)比同期行達(dá)芬奇機(jī)器人遠(yuǎn)端胃癌根治術(shù)、腹腔鏡及開腹遠(yuǎn)端胃癌根治術(shù)患者臨床療效指標(biāo)，進(jìn)行對(duì)照分析，比較三種術(shù)式的臨床療效，并對(duì)患者進(jìn)行術(shù)后隨訪，評(píng)價(jià)達(dá)芬奇機(jī)器人胃癌手術(shù)的臨床療效及探討其在胃癌手術(shù)中的應(yīng)用價(jià)值。同時(shí)，收集機(jī)器人、腹腔鏡及開腹胃癌根治術(shù)三種手術(shù)方式患者手術(shù)前后腹腔沖洗液，分析三種不同手術(shù)方式患者腹腔沖洗液中癌胚抗原(carcino-embryonic antigen，CEA)及多巴脫羧酶(dopa decarboxylase,DDC)濃度的變化，對(duì)其進(jìn)行比較分析，初步探討機(jī)器人胃癌根治術(shù)對(duì)腹腔微轉(zhuǎn)移的影響，為機(jī)器人胃癌手術(shù)的進(jìn)一步推廣應(yīng)用提供理論和臨床依據(jù)。 研究方法： 選取我中心2010年3月至2013年7月成功行機(jī)器人遠(yuǎn)端胃癌根治術(shù)患者113例，與同期進(jìn)行的腹腔鏡遠(yuǎn)端胃癌根治術(shù)患者279例，開腹遠(yuǎn)端胃癌根治術(shù)患者87例作為研究對(duì)象。手術(shù)采用氣管插管，全身麻醉加硬膜外麻醉，根據(jù)腫瘤部位行根治性遠(yuǎn)端胃大部切除術(shù)。所有患者均按照日本第14版胃癌規(guī)約行遠(yuǎn)端胃癌根治及D2淋巴結(jié)清掃術(shù)。分別對(duì)機(jī)器人組和腹腔鏡組病人手術(shù)時(shí)間，術(shù)中出血量，淋巴結(jié)清掃數(shù)量，手術(shù)近、遠(yuǎn)端切緣長(zhǎng)度，首次排氣時(shí)間，首次進(jìn)食時(shí)間，術(shù)后住院時(shí)間，以及并發(fā)癥發(fā)生率等指標(biāo)進(jìn)行對(duì)照分析，并對(duì)三組患者進(jìn)行術(shù)后隨訪，做生存分析。同時(shí)，收集我中心2013年1月至2014年3月收治行機(jī)器人胃癌根治術(shù)患者42例，以性別、年齡、BMI、腫瘤分期為協(xié)變量使用最鄰配比法分別配對(duì)腹腔鏡手術(shù)患者和開腹手術(shù)患者各42例，分別收集患者手術(shù)前后腹腔沖洗液，采用酶聯(lián)免疫吸附法，，檢測(cè)其腹腔沖洗液中CEA及DDC濃度變化。采用SPSS18.0統(tǒng)計(jì)軟件進(jìn)行統(tǒng)計(jì)分析，檢測(cè)結(jié)果以x s描述，計(jì)量資料采用t檢驗(yàn)、配對(duì)t檢驗(yàn)及方差分析，計(jì)數(shù)資料采用χ2檢驗(yàn)及非參數(shù)檢驗(yàn)，生存分析采用Kaplan-Meier法。P0．05為差異有統(tǒng)計(jì)學(xué)意義。 結(jié)果： 一、機(jī)器人與腹腔鏡及開腹胃癌根治術(shù)臨床療效對(duì)比 在本研究中發(fā)現(xiàn)，與腹腔鏡及開腹遠(yuǎn)端胃癌根治術(shù)相比較，機(jī)器人組手術(shù)時(shí)間更長(zhǎng)，淋巴結(jié)清掃數(shù)量更多、更徹底[(30.1±6.1) vs (27.8±7.3) vs(26.9±6.0)，P0.05]，術(shù)中出血更少[(113.8±68.4)mL vs(128.4±64.8)mL vs(278.6±178.4)mL，P0.05]。機(jī)器人組病人與腹腔鏡及開腹組在術(shù)后首次排氣時(shí)間[(3.0±0.9)d vs (3.1±0.9)d vs(4.1±1.1)d]，術(shù)后首次進(jìn)食時(shí)間[(3.7±0.9)d vs (3.9±0.8)d vs(4.6±0.8)d]，術(shù)后住院時(shí)間[(7.6±1.8)d vs (7.7±1.9)d vs(10.3±2.3)d]等方面比較，機(jī)器人組與腹腔鏡組差異無統(tǒng)計(jì)學(xué)意義(P0.05)，但明顯優(yōu)于開腹手術(shù)組(P0.05)。在圍手術(shù)期并發(fā)癥發(fā)面，三組病例并發(fā)癥發(fā)生率為機(jī)器人4.4%，腹腔鏡5.0%，開腹9.2%，機(jī)器人與腹腔鏡組差異無統(tǒng)計(jì)學(xué)意義(P0.05)，優(yōu)于開腹手術(shù)組(P＜0.05)。隨訪機(jī)器人組1、2、3年總體生存率分別為91．7％、77．4％和72．9％；腹腔鏡組1、2、3年總體生存率分別為91．2％、76．2％和70．4％，開腹組1、2、3年總體生存率分別為89.7%、71.9%、63.9%，三組比較差異無統(tǒng)計(jì)學(xué)意義(P＞0.05)。 二、機(jī)器人、腹腔鏡及開腹胃癌根治術(shù)對(duì)胃癌腹腔微轉(zhuǎn)移的影響 1、三組手術(shù)前后腹腔沖洗液中CEA濃度的變化 機(jī)器人組、腹腔鏡組及開腹組患者術(shù)前腹腔沖洗液中CEA的濃度分別為(241.68±188.6)μg/L、(221.32±173.6)μg/L及(257.39±134.9)μg/L，三者之間比較，差異無統(tǒng)計(jì)學(xué)意義(F=0.491,P0.05)；三組患者術(shù)后腹腔沖洗液中CEA的濃度分別為(1262.29±785.4)μg/L、(1171.80±699.1)μg/L及(2996.46±1946.9)μg/L，三組比較差異有統(tǒng)計(jì)學(xué)意義(P0.05)，兩兩比較機(jī)器人組患者術(shù)后腹腔沖洗液中CEA的濃度顯著低于開腹組(P0.05),腹腔鏡組患者術(shù)后腹腔沖洗液中CEA的濃度也同樣低于開腹組(P0.05)，機(jī)器人組與腹腔鏡組比較差異無統(tǒng)計(jì)學(xué)意義(P0.05)；且同種手術(shù)方式術(shù)后腹腔沖洗液中CEA的濃度均較術(shù)前顯著增高(t=-11.053,-11.700,-9.780,P0.05)。 2、三組手術(shù)前后腹腔沖洗液中DDC濃度的變化 機(jī)器人組、腹腔鏡組及開腹組患者術(shù)前腹腔沖洗液中DDC的濃度分別為(7.74±4.8)μg/L、(7.19±4.2)μg/L及(7.71±5.8)μg/L，三者之間比較，差異無統(tǒng)計(jì)學(xué)意義(F=0.161,P0.05)；三組患者術(shù)后腹腔沖洗液中DDC的濃度分別為(87.34±55.0)μg/L、(81.00±52.2)μg/L及(146.35±134.5)μg/L，三組比較差異有統(tǒng)計(jì)學(xué)意義(P0.05)，兩兩比較機(jī)器人組患者術(shù)后腹腔沖洗液中DDC的濃度顯著低于開腹組(P0.05),腹腔鏡組患者術(shù)后腹腔沖洗液中DDC的濃度也同樣低于開腹組(P0.05)，機(jī)器人組與腹腔鏡組比較差異無統(tǒng)計(jì)學(xué)意義(P0.05)；且同種手術(shù)方式術(shù)后腹腔沖洗液中DDC的濃度均較術(shù)前顯著增高(t=-10.261,-9.955,-6.969,P0.05)。 結(jié)論： 1、達(dá)芬奇機(jī)器人胃癌根治術(shù)與腹腔鏡及開腹胃癌根治術(shù)相比具有淋巴結(jié)清掃數(shù)量更多更徹底、術(shù)中出血更少等優(yōu)點(diǎn)，且手術(shù)創(chuàng)傷小、術(shù)后并發(fā)癥少，術(shù)后恢復(fù)快，提示達(dá)芬奇機(jī)器人胃癌根治手術(shù)安全、可行，可以達(dá)到與腹腔鏡胃癌根治術(shù)及開腹胃癌根治術(shù)相同甚至更好的手術(shù)效果。 2、達(dá)芬奇機(jī)器人胃癌根治術(shù)與腹腔鏡胃癌根治術(shù)及開腹胃癌根治術(shù)相比，其術(shù)后隨訪1,2,3年總體生存率與腹腔鏡胃癌根治術(shù)及開腹胃癌根治術(shù)相比無顯著差異，提示機(jī)器人胃癌根治術(shù)可以達(dá)到與腹腔鏡及開腹胃癌根治術(shù)相當(dāng)?shù)呐R床療效。 3、達(dá)芬奇機(jī)器人、腹腔鏡及開腹胃癌根治術(shù)后腹腔沖洗液中CEA及DDC均高于術(shù)前，但機(jī)器人手術(shù)組及腹腔鏡手術(shù)組CEA及DDC濃度增高程度均顯著低于開腹手術(shù)組，提示機(jī)器人胃癌根治術(shù)與腹腔鏡胃癌根治術(shù)相比不增加胃癌腹腔微轉(zhuǎn)移的可能性，且明顯優(yōu)于開腹手術(shù)，值得進(jìn)一步推廣應(yīng)用。
[Abstract]:Research background:
Gastric cancer is one of the most common malignant tumors in the digestive tract in China. The mortality rate ranks first in the malignant tumor, and the main treatment means mainly by surgery. The traditional surgical method is laparotomy for gastric cancer. Since the 1987 laparoscopic cholecystectomy has been successfully applied, the laparoscope technology has been gradually in the various fields of surgery because of its unique minimally invasive advantages. It is the first time that.1994 Kitano has been widely used to report the application of laparoscopy to gastric cancer. After years of development, laparoscopic radical gastrectomy has been widely accepted by people for its small trauma and rapid recovery. Now, minimally invasive surgery for gastric cancer has become one of the hotspots of current research.
With the development of surgical technology, the Da Vinci robotic surgical system has been gradually introduced into the field of surgical treatment for.2002 years. Hashizume and other reports of the Da Vinci robotic surgical system assisted radical gastrectomy for the first time. Compared with the traditional laparoscopic and open gastric cancer surgery, the Da Vinci machine is a new type of minimally invasive surgery. It is still in the exploration stage. At present, the international and domestic related literature is limited, and most of the case reports are simple cases. It is mainly explained that Da Vinci robot operation is a safe and feasible operation mode. However, whether the Da Vinci robot operation system should be widely used in the surgical treatment of gastric cancer, its clinical efficacy is not appropriate, and it is still short of corresponding. Compared with traditional laparoscopy and laparotomy, there are no relevant literature reports on the effect of robotic gastric cancer surgery on patients with abdominal micrometastasis compared with traditional laparoscopy and laparotomy.
The purpose of the study is:
Therefore, by collecting the clinical data of the gastric cancer patients in my center, comparing the clinical curative effects of the distal gastrectomy of Da Vinci robot, laparoscopy and laparotomy for the radical gastrectomy of gastric cancer, the clinical curative effect of the three kinds of surgical methods was compared, and the patients were followed up to evaluate the hand of the Da Vinci robot. The clinical effect of the operation and its value in the operation of gastric cancer were discussed. At the same time, the peritoneal lavage fluid was collected before and after the operation of three surgical methods, which were operated by robot, laparoscope and open stomach radical gastrectomy, and analyzed the carcino-embryonic antigen (CEA) and dopa decarboxylase (DOPA decarb) in the abdominal irrigating fluid of the patients with different surgical methods. The changes of oxylase, DDC) concentration are compared and analyzed. The effect of radical gastrectomy on peritoneal micrometastasis is preliminarily discussed, which provides a theoretical and clinical basis for the further popularization and application of the operation of robot gastric cancer.
Research methods:
From March 2010 to July 2013, 113 cases of distal radical gastrectomy for gastric cancer were performed in our center. 279 patients with laparoscopic distal gastrectomy and 87 patients with radical resection of distal gastric cancer at the same time were selected as the subjects. The operation was performed by tracheal intubation, general anesthesia and epidural anesthesia. All patients underwent radical gastrectomy. All patients underwent radical resection of the distal gastric carcinoma and D2 lymph node dissection according to the fourteenth version of Japan's gastric cancer protocol. The operation time, the amount of bleeding, the number of lymph node dissection, the operation near, the length of the distal cutting edge, the first air exhausting time, the first feeding time, the time of postoperative hospitalization, and the operation time of the patients in the robot group and the laparoscope group were respectively carried out. The incidence of complications and other indexes were analyzed, and three groups of patients were followed up for survival analysis. At the same time, 42 patients with radical gastrectomy for robotic gastric cancer were collected from January 2013 to March 2014, with sex, age, BMI, and tumor staging as covariate. The abdominal irrigating fluid of the patients before and after operation was collected in 42 cases. The changes of CEA and DDC in the peritoneal lavage fluid were detected by enzyme linked immunosorbent assay. The statistical analysis was carried out by SPSS18.0 statistical software. The results were described with x s, the measurement data were tested with T, t test and variance analysis, and the count data were tested by x 2 test and Non parametric test, survival analysis using Kaplan-Meier method.P0.05, the difference was statistically significant.
Result:
1. Comparison of clinical efficacy between robot assisted laparoscopic surgery and open radical gastrectomy for gastric cancer
In this study, compared with laparoscopy and laparotomy, the robot group had longer operation time, more lymph node dissection, more thorough [(30.1 + 6.1) vs (27.8 + 7.3) vs (26.9 + 6)), P0.05], less bleeding in the operation [113.8 + 68.4) mL vs (128.4 + 64.8) mL vs (278.6 + 178.4) mL, P0.05]. robot group patients and abdominal cavity The first time exhaust time was [(3 + 0.9) d vs (3.1 + 0.9) d vs (4.1 + 1.1) d] after operation, and the first time after the operation [(3.7 + 0.9) d vs (3.9 + 0.8) d vs (4.6 + 0.8) d], and the postoperative hospital stay [(7.6 +]) d vs It was better than the open operation group (P0.05). In the perioperative complications, the incidence of complications in the three groups was robot 4.4%, laparoscopy 5%, laparotomy 9.2%, and there was no significant difference between the robot and the laparoscopy group (P0.05), superior to the laparotomy group (P < 0.05). The overall survival rate of the follow-up machine group was 91.7%, 77.4% and 72.9, respectively. The total survival rate of 1,2,3 years in the laparoscopic group was 91.2%, 76.2% and 70.4% respectively. The overall survival rate of the open group was 89.7%, 71.9%, and 63.9%, respectively, and there was no statistical difference between the three groups (P > 0.05).
Two, the influence of robot, laparoscopic and open radical gastrectomy on peritoneal micrometastasis in gastric cancer.
The changes of CEA concentration in peritoneal lavage fluid before and after operation in 1 and three groups.
The concentration of CEA in the peritoneal lavage fluid of the patients in the robot group, the laparoscopic group and the laparotomy group were (241.68 + 188.6) mu g/L, (221.32 + 173.6) g/L and (257.39 + 134.9) g/L, and the difference was not statistically significant (F=0.491, P0.05), and the concentration of CEA in the three groups was (1262.29 + 785.4) mu g/L (1171.), respectively. 80 + 699.1) mu g/L and (2996.46 + 1946.9) mu g/L, the three groups were statistically significant (P0.05). 22 compared with the robot group, the concentration of CEA in the peritoneal lavage fluid was significantly lower than that in the open group (P0.05). The concentration of CEA in the peritoneal lavage fluid in the laparoscopic group was also lower than that in the laparotomy group (P0.05), and the robot group was compared with the laparoscope group. There was no significant difference between the two groups (P 0.05), and the concentration of CEA in peritoneal lavage fluid increased significantly after operation (t = - 11.053, - 11.700, - 9.780, P 0.05).
The changes of DDC concentration in peritoneal lavage fluid before and after operation in 2 and three groups.
The concentration of DDC in the peritoneal lavage fluid of the patients in the robot group, the laparoscopy group and the laparotomy group were (7.74 + 4.8) mu g/L, (7.19 + 4.2) g/L and (7.71 + 5.8) g/L, and the difference was not statistically significant (F=0.161, P0.05). The concentration of DDC in the three groups of postoperative peritoneal lavage was (87.34 + 55) mu g/L, respectively, (81 + 52.2) g/L and (146.35 + 134.5) mu g/L, the difference between the three groups was statistically significant (P0.05). 22 compared with the robot group, the concentration of DDC in the peritoneal lavage fluid was significantly lower than that of the open group (P0.05). The concentration of DDC in the peritoneal lavage fluid in the laparoscopic group was also lower than that in the open group (P0.05). There was no statistical difference between the robot group and the laparoscope group. Significance (P 0.05), and the concentration of DDC in peritoneal lavage fluid after the same operation was significantly higher than that before operation (t=-10.261, -9.955, -6.969, P 0.05).
Conclusion:
1, Da Vinci robot radical gastrectomy with laparoscopic radical gastrectomy and laparotomy with radical resection of gastric cancer has the advantages of more lymph node dissection, less bleeding, less surgical trauma, less postoperative complications and quick recovery after operation, which suggests that the radical resection of gastric cancer by Da Vinci robot is safe and feasible, and can be achieved with laparoscopic radical gastrectomy for gastric cancer. And open radical gastrectomy is the same or even better.
2, compared with laparoscopic radical gastrectomy, laparoscopic radical gastrectomy and radical gastrectomy for gastric cancer, the overall survival rate of 1,2,3 years after surgery is not significantly different from that of laparoscopic radical gastrectomy and radical gastrectomy for gastric cancer. It suggests that the radical operation of the robot for gastric cancer is comparable to that of laparoscopy and radical gastrectomy for gastric cancer. Curative effect.
3, the CEA and DDC in the peritoneal lavage fluid of the Da Vinci robot, laparoscopy and laparotomy were higher than those before the operation, but the level of CEA and DDC in the robotic operation group and the laparoscopic operation group were significantly lower than those in the laparotomy group. It is superior to open surgery and is worthy of further application.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R735.2;TP242

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