| Background Gastric cancer is one of the common malignant tumors.Its incidence ranks fourth among the common malignant tumors,and its mortality rate is second only to lung cancer.According to the estimate of China National Cancer Registration Center,there were 4.29 million new cancer patients and 2.81 million cancer deaths in China in 2015,of which 679,000 new cancer patients and 498,000 cancer deaths[1].About 90%of patients in China are advanced gastric cancer.According to statistics,65%of patients with advanced gastric cancer have T stage of T3 or T4.As many as 85%of patients have lymph node involvement.Without surgical intervention,the median survival period of advanced gastric cancer is only 5.4 months[2].At present,the main treatment of gastric cancer is surgery-centered comprehensive treatment.Since professor Kitano was first reported in 1994 laparoscopic gastric cancer surgery,laparoscopic gastric cancer surgery is widely carried out,at present,the multi-center prospective randomized controlled study with large sample has confirmed that early gastric cancer safe laparoscopic radical prostatectomy,can achieve cancer effect a radical cure effect,medium and long term follow-up results show that the clinical curative effect and the traditional laparotomy,laparoscopic radical treatment of early gastric cancer has become the treatment guidelines recommend[3]at present,for locally advanced gastric cancer D2 radical gastrectomy has become the accepted standard operationExisting studies have shown that laparoscopic D2 radical gastrectomy is safe and feasible,and long-term curative effect of laparotomy is now in our country,locally advanced gastric cancer in laparoscopic D2 radical strength though the center of the large sample size to carry out open has the obvious advantage of minimally invasive laparoscopic,but for laparoscopic two-dimensional vision instrument line design lack of flexibilityHands shaking amplification inherent defects,such as the lymph node in D2 radical prostatectomy with the equipment the activities of the restricted area,the local regional lymph node cleaning the difficult,on the pancreas area cleaning on the pancreas oppression,causing a high incidence of postoperative pancreatic leakage,the existing literature reported incidence of pancreatic leak after laparoscopic gastric cancer by as much as 5.3%-11.8% Applied to clinical surgery robot started in 2000,since it has 3 d high-resolution imaging eliminate tremor and flexible operation etc.,make the surgery more minimally invasive,therefore,more detailed more accurate robot operation gradually become the frontier and hot research topic in the field of minimally invasive surgery,which opened a new era of minimally invasive surgery[4]professor Hashizume first reported in 2003 gastric cancer radical auxiliary robots,opened up a robot of stomach cancer surgery robot for 3 d high-resolution imaging eliminate tremor and flexible wrist instruments,in the narrow operation area can accurately the advantages of the anatomyIt is better in locally advanced gastric cancer of the lymph node cleaning the stomach and the reduction of pancreas injury pancreatic leakage and other complications.Many studies at home and abroad and meta-analysis can get confirmed that the robot assisted gastric cancer radical with the immediate and long-term clinical effect of laparoscopic same[5-6],robot has gradually become the frontier and hot research topic in the field of minimally invasive surgery.In our country,90%of patients see a doctor for advanced gastric cancer,now has become the standard operation for advanced gastric cancer D2 radical,but D2 surgery difficulty bigger,lymph node cleaning is wider in scope for local advanced robot D2 radical resection of gastric cancer clinical research more necessary,D2 with robot and laparoscopic in locally advanced gastric cancer radical gastrectomy all research reports is less.For this purpose,the center aims to explore the application of robot in lymph node dissection of locally advanced gastric cancer by comparing the recent clinical efficacy of these two surgical methods in D2 radical resection of locally advanced gastric cancer,so as to provide reference for clinical practice.Research Objective This study collected the clinical and pathological data of patients undergoing simultaneous robotic and laparoscopic D2 radical gastrectomy in Southwest Hospital of Military Medical University,and analyzed and compared the clinical efficacy of the two methods.To explore whether robots and laparoscopy have technical advantages in the complications of D2 radical gastrectomy for advanced gastric cancer,and to provide reliable and reasonable theoretical basis for the clinical application of robots in D2 radical gastrectomy for advanced gastric cancer.Research Method This study is a retrospective case-control study.From September 1,2016 to September 1,2017,162 consecutive cases of locally advanced gastric cancer were treated by the General Surgery and Minimally Invasive Gastrointestinal Surgery Center of Xi nan Hospital Affiliated.The clinical and pathological data of patients with locally advanced gastric cancer who underwent Da Vinci robotic radical gastrectomy or traditional laparoscopic radical gastrectomy（D2 lymph node dissection）were collected and Analysis.Among them,65patients underwent Da Vinci robotic radical gastrectomy（hereinafter referred to as"robotic group"）and 97 patients underwent traditional laparoscopic radical gastrectomy（hereinafter referred to as"laparoscopic group"）.Observation Indicators:（1）The consistency of preoperative age,sex,TNM stage,body mass index and ASA stage was compared between the two groups.（2）The comparison of short-term results and clinicopathological data between the two groups included:operative blood loss,operation time,resection method,reconstruction method,classification of complications,types of complications,ventilation time,hospital stay,extubation time of abdominal drainage tube,number of lymph nodes resected,radical distal gastric enlargement.Detection of lymph nodes at various points,stations and regions by robots and laparoscopy in partial resection and radical total gastrectomy.The blood amylase level and abdominal drainage fluid amylase level were monitored for three consecutive days after operation.（3）Follow-up:Survival,recurrence and/or metastasis after operation.Follow-up was carried out through outpatient and/or regular telephone contact.The deadline for follow-up was up to the end of November 2017.Statistical analysis:The data collected in this study were analyzed by SPSS Statistics Version 17.0 statistical software,and the measurement data of normal distribution were expressed by （?）±s,while the comparison between groups was analyzed by t-test.Comparing the counting data,χ2 test or Fisher’s exact probability method were used,while P<0.05 was considered to have statistical difference.Result （1）General condition of patients:There was no significant difference in age,ASA stage,sex,BMI robot group and laparoscopic group（P=0.763,0.283,0.553,1.045）.（2）Surgical treatment:The two groups of patients successfully completed the operation,no conversion to laparoscopy patients,no conversion to laparoscopy patients.The pathological margins of all cases were negative（R0 excision）.Surgical conditions:There was no significant difference in operative time（distal subtotal gastrectomy+D2 resection and total gastrectomy+D2 resection）,proximal and distal margins between robotic and laparoscopic groups.（P=1.272,0.960,1.883,0.361）.There were no significant differences in surgical resection（distal subtotal gastrectomy+D2 resection and total gastrectomy+D2resection）,surgical reconstruction（Roux-en-Y or Billroth II）,pathological stage（II-A,II-B,III-A,III-B,III-C）between robotic group and laparoscopic group（P=0.326,0.71,0.681）.Compared with laparoscopic group,the blood loss of robotic group was（123+39 VS 142+40）mL,and the difference was statistically significant（P=0.015）.In lymphadenectomy:In the distal subtotal gastrectomy plus D2 lymphadenectomy,the number of lymphadenectomies in the robotic group and laparoscopic group at the second station was（6.04（+3.98）VS 4.45（+3.12）.The number of lymphadenectomies in the robotic group was higher than that in the robotic group,and the difference was statistically significant（P=0.018）.The number of perigastric lymph nodes resected by robotic group and laparoscopic group was（13.51+6.53 VS 11.40+5.30）.There was significant difference between robotic group and laparoscopic group（P=0.044）.In the robotic group and laparoscopic group,the first group（NO.1）,the third group（NO.3）,the fourth group（NO.4）,the fifth group（NO.5）,the sixth group（NO.6）,the seventh group（NO.7）,the eighth group（NO.8a）,the ninth group（NO.9）,the 11th group（NO.11p）,the 12a group（NO.12a）and the first station,the spleen region,the inferior pyloric region of gastric antrum,the gastric small curve region,and the gastric small curve region were observed.There was no significant difference in lymphadenectomy in the foot of cardiac diaphragm（P=0.539,0.072,0.318,0.932,0.311,0.3,0.096,0.076,0.313,0.269,0.615,0.318,0.311,0.063）.The total number of lymph nodes detected in the robotic group and the laparoscopic group were（36.25+14.12 VS 35.73+11.62）respectively.There was a significant difference between the two groups（P=0.862）.In total gastrectomy plus D2 lymphadenectomy,the number of lymph nodes dissected by robotic group and laparoscopic group in group 7（NO.7）was（5.44+2.63 VS 3.11+1.82）.There was significant difference between the two groups（P=0.003）.The number of lymph nodes dissected by robotic group and laparoscopic group in group 8A（NO.8a）was（2.92+1.87 VS1.62+1.33）.）There were significant differences between the two groups（P=0.015）.The number of lymph nodes resected in the upper pancreatic region in the robotic group and the laparoscopic group was（10.81+4.78 VS 7.76+3.34）respectively.There was a significant difference between the two groups（P=0.022）.The robotic group and laparoscopic group were divided into group 1（NO.1）,group 2（NO.2）,group 3（NO.3）,group 4（NO.4）,group 5（NO.5）,group 6（NO.6）,group 9（NO.9）,group 10（NO.10）,group 11p（NO.11p）,group 12a（NO.12a）and group 1,station 2,spleen area,subpyloric area of gastric antrum,small gastric curve area,and so on.There was no significant difference in lymphadenectomy in the foot of cardiac diaphragm（P=0.408,0.987,0.511,0.468,0.707,0.514,0.055,0.226,0.443,0.847,0.404,0.446,0.468,0.514,0.33,0.778）.The total number of lymph nodes detected in the robotic group and the laparoscopic group were（38.13（+11.67）VS 34.91（+12.74）respectively.There was a significant difference between the two groups（P=0.862）.（3）Postoperative condition:There was no significant difference in the classification of complications（grade II,III,IV,V）,types of complications（wound infection or liquefaction,gastric emptying disorder,pulmonary infection,anastomotic leakage,etc.）between the robotic group and the laparoscopic group（P=1.34）.2,2.501）.One patient in the robotic group had anastomotic leakage of jejunum and esophagus after radical total gastrectomy+Roux-en-y reconstruction anastomosis,and one patient in the laparoscopic group had anastomotic leakage of jejunum and esophagus after radical total gastrectomy+Roux-en-y reconstruction anastomosis.Both patients were operated under gastroscope.In the laparoscopic group,another patient had gastrojejunal anastomotic leakage after radical distal subtotal gastrectomy and Billroth II anastomosis reconstruction.The patient was reconstructed and jejunal nutrition tube was inserted during the operation.After conservative treatment,both groups of patients with surgical infection and/or liquefaction,pulmonary infection and gastric emptying disorder were cured and discharged.Postoperative ventilation time in the robotic group and laparoscopic group was（3.5+0.9VS 3.8+1.1）days,respectively.There was no significant difference between the two groups（P=0.513）.The feeding time of the robot group and the laparoscopic group was（3.7+1.4 VS4.0+0.8）days,respectively.There was no significant difference between the two groups（P=0.142）.The time of getting out of bed after operation in the robotic group and the laparoscopic group was（3.1+1 VS 3.4+0.7）days,respectively.There was no significant difference between the two groups（P=0.721）.The hospitalization time after operation in the robotic group and laparoscopic group was（10.0+4.0 VS 10.0+5.0）days,respectively.There was no significant difference between the two groups（P=0.115）.The hospitalization expenses of patients in the robotic group and laparoscopic group were(8.9041（+1.0299 VS）6.9521（+2.0928）million yuan,respectively.There was no significant difference between the robotic group and the laparoscopic group（P=0.001）.The serum amylase levels of robotic group and laparoscopic group on the 1st day,2nd day and 3rd day after operation were（181+47 VS 218+45）,（123+29 VS 162+37）,（85+22 VS 120+31）U/L,respectively.The difference between robotic group and laparoscopic group was significantly lower than that of laparoscopic group（P=0.024,0.002,0.001）.Amylase values of peritoneal drainage fluid in robotic group and laparoscopic group were（557+181 VS 793+284）,（357+127 VS 497+199）,（183+86 VS 219+77）U/L on the 1st,2nd and 3rd day after operation,which were significantly lower than those in laparoscopic group（P=0.005,0.024,0.041）.The levels of serum amylase and abdominal drainage fluid amylase in robotic group and laparoscopic group on the 3rd day after operation were lower than the high limit of 3 times normal value,and no special treatment intervention such as somatostatin was given.Conclusion Compared with laparoscopic gastrectomy,robot-assisted gastrectomy is a feasible and safe surgical method.Da Vinci robot has a high-definition and stable field of vision,which is helpful to local anatomy.It has less blood loss during operation than laparoscopic gastrectomy.It also has more lymphadenectomy in the upper pancreas and fewer complications related to pancreas after operation.It has advantages in deep narrow space and around large vessels. |
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