| Research BackgroundGastric cancer is one of the most common gastrointestinal malignancy. it’s mortality isin the first place among malignancy and its treatment based mainly in surgery. Thetraditional surgical approach is open gastric surgery. Since Laparoscopic cholecystectomywas successfully applied in1987,laparoscopic techniques have been widely used in all areaof surgical gradually because of its unique minimally invasive advantages. In1994, Kitanoreported the laparoscopic technique was used in gastric cancer surgery in the first time.After years of development, laparoscopic gastrectomy become the main means of surgicaltreatment of gastric cancer and has been widely accepted gradually because of its lesstrauma and quicker recovery. Today, minimally invasive surgical treatment of gastric cancerhas become one of the hot research.With the development of surgical treatment technology, the da Vinci robotic surgicalsystem was introduced to surgery field gradually. In2002, Hashizume et. reported the daVinci robotic surgical system assisted radical gastrectomy. Compared with traditionallaparoscopic and open gastric surgery, da Vinci robot as a new minimally invasive surgicalapproach is still in the exploratory stage today. In the current international and domesticlimited literature reports, most of which is the simple case reports, mainly on the up daVinci robotic surgery is a safe and feasible surgical approach. However,should the da Vincirobotic surgical system has been widely used in the surgical treatment of gastric cancer? Isthe clinical term effect affirmative whether or not? It is still lacking appropriate controlledclinical studies. Compared with traditional laparoscopic and open surgery, whether roboticsurgery for gastric cancer has different influence on patients’ peritoneal micrometastaseshas yet to see in the relevant literature. Research PurposeIn our study, the clinical data was collected in the department of general surgery insouthwest hospital. We compared the clinical efficacy of the da Vinci robot distalgastrectomy, laparoscopic distal gastrectomy and open distal gastrectomy patient indicators.We also made a postoperative follow-up of these patients. What we did all the above was toevaluate the clinical efficacy of da Vinci robotic surgery for gastric cancer and to explore itsvalue in gastric surgery. Meanwhile, we collected patients’ peritoneal lavage fluid beforeand after da Vinci robotic, laparoscopic and open radical gastrectomy. Then, we comparedchanges of concentrations of carcino-embryonic antigen(CEA) and dopadecarboxylase(DDC) in the three different surgical methods in patients to explorepreliminarily the effect which the da Vinci robotic gastrectomy has made on peritonealmicrometastases. Thus we could provide theoretical and clinical basis for the furtherapplication of robotic surgery.Research MethodWe selected113successful cases of da Vinci robotic distal gastrectomy,279successfulcases of laparoscopic distal gastrectomy and87successful cases of open distal gastrectomyperformed with the same period in our department from March2010to July2013asresearch subjects. All patients’ radical distal gastrectomy operations were performedaccording to the tumor site with tracheal intubation, general anesthesia and epiduralanesthesia. All the patients were also treated with distal gastrectomy and D2lymph nodedissection in accordance with the gastric cancer Statute of Japan14th edition. We comparedrespectively patients’ operative time, blood loss, number of lymph node dissection,proximal and distal margin length, first exhaust time, first eating time, postoperativehospital stay time and the incidence of complications and so on among the robotic,laparoscopic and open group. The three groups of patients were follow-up to make asurvival analysis. Meanwhile,42gastric cancer cases were collected who had underwentrobotic gastrectomies in our department from January2013to March2014,42patients withlaparoscopic gastrectomy and42patients with open gastrectomy were matched with thenearest available scores such as age, sex, BMI and cancer stage. The peritoneal lavage fluidwas collected respectively before and after gastrectomy. Then changes in concentration ofCEA and DDC in the peritoneal lavage was detected by enzyme-linked immunosorbent assay. SPSS18.0statistical software were used for statistical analysis. The measurementdata was evaluated by t-test, paired t-test and analysis of variance, chi-square test and non-parametric tests was used to evaluate count data. Kaplan-Meier method was used insurvival analysis. P values of less than0.05were considered significant.ResultI. Contrast of the clinical efficacy of a robot laparoscopic and open gastric cancersurgeryCompared with laparoscopic and open distal gastrectomy, robotic operative time waslonger, the lymph node was cleaned more thoroughly, the number of lymph node dissectionwas more[(30.1±6.1) vs (27.8±7.3) vs(26.9±6.0), P<0.05], and blood loss was lessduring the operation[(113.8±68.4)mL vs(128.4±64.8)mL vs(278.6±178.4)mL, P<0.05].Compared the data of3groups on the first exhaust time[(3.0±0.9)d vs (3.1±0.9)d vs(4.1±1.1)d], first eating time[(3.7±0.9)d vs (3.9±0.8)d vs(4.6±0.8)d], postoperative hospitalstay time[(7.6±1.8)d vs (7.7±1.9)d vs(10.3±2.3)d], there were no significantly differentbetween the robotic group and laparoscopy group(P>0.05), while there were significantlydifferent with open group(P<0.05). The perioperative complications rate of3groups wererespectively robotic group (4.4%), laparoscopy group(5.0%), open group(9.2%), and therewere no significantly different between the robotic group and laparoscopy group(P>0.05),while there were significantly different with open group(P<0.05). The1,2,3-year survivalrates of the robotic group were91.7%,77.4%,72.9%, the laparoscopy group were91.2%,76.2%,70.4%, the open group were89.7%,71.9%,63.9%, and the difference were notsignificant among the3groups(p>0.05).II. Effects of three groups(robot, laparoscopic, and open radical gastrectomy group) ongastric cancer peritoneal micrometastases1.the changes of peritoneal lavage fluid concentration of CEA before and after surgeryof the three groupsThe concentration of CEA before surgery of the robot, laparoscopic, and open radicalgastrectomy group was respectively (241.68±188.6)μg/L,(221.32±173.6) μg/L and(257.39±134.9) μg/L. The difference among the three groups was not significant(F=0.491, P>0.05). The concentration of CEA after surgery of the robot, laparoscopic, andopen radical gastrectomy group was respectively (1262.29±785.4) μg/L,(1171.80± 699.1) μg/L and (2996.46±1946.9) μg/L. The difference among the three groups wassignificant(P <0.05). In pairwise comparison, the concentration of CEA after surgery of therobot group was significantly lower than that of the open gastrectomy group (p<0.05); Theconcentration of CEA after surgery of the laparoscopy group was also significantly lowerthan that of the open gastrectomy group(p<0.05); But there is no significantly differencebetween the robot and the laparoscopy group(p>0.05). The concentration of CEA aftersurgery was significantly higher than that before surgery in the samegroup(t=-11.053,-11.700,-9.780,P<0.05).2.the changes of peritoneal lavage fluid concentration of DDC before and after surgeryof the three groupsThe concentration of DDC before surgery of the robot, laparoscopic, and open radicalgastrectomy group was respectively (7.74±4.8)μg/L,(7.19±4.2) μg/L and (7.71±5.8)μg/L. The difference among the three groups was not significant(F=0.161, P>0.05). Theconcentration of DDC after surgery of the robot, laparoscopic, and open radicalgastrectomy group was respectively (87.34±55.0) μg/L,(81.00±52.2) μg/L and (146.35±134.5) μg/L. The difference among the three groups was significant(P <0.05). Inpairwise comparison, the concentration of DDC after surgery of the robot group wassignificantly lower than that of the open gastrectomy group (p<0.05); The concentration ofDDC after surgery of the laparoscopy group was also significantly lower than that of theopen gastrectomy group(p<0.05); But there is no significantly difference between the robotand the laparoscopy group(p>0.05). The concentration of DDC after surgery wassignificantly higher than that before surgery in the samegroup(t=-10.261,-9.955,-6.969,P<0.05).Conclusion1.Compared with laparoscopic and open gastrectomy, Da Vinci robotic gastrectomyhad some advantages, the lymph node was cleaned more thoroughly, and the number oflymph node dissection was more; In addition, da Vinci robotic gastrectomy brought lessblood loss, smaller surgery trauma, lower incidence of postoperative complications andfaster recovery. All the above indicated that Da Vinci gastric cancer surgery is safe, feasibleand could even achieve better operation outcome than laparoscopic and open gastric cancersurgery. 2.Compared with laparoscopic and open gastrectomy, the postoperative1,2,3-yearsurvival rates of Da Vinci robotic gastrectomy had no significant different withlaparoscopic and open gastrectomy. It indicated that Da Vinci robotic gastrectomy couldachieve the considerable clinical efficacy with laparoscopic and open gastrectomy.3.The peritoneal lavage fluid concentration of CEA and DDC after robotic,laparoscopic and open gastric cancer surgery were higher than those before surgery. But theincreased degree of the concentration of CEA and DDC in the robotic and laparoscopicsurgery group was significantly lower than that in the open group. It indicated that da Vincirobotic gastrectomy did not increase the peritoneal micrometastases compared withlaparoscopic gastrectomy, and were significantly better than open gastrectomy. Thus, DaVinci robotic gastrectomy was worthy of further application. |
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