基于膜解剖的腹腔镜脾门淋巴结环周清扫术与前方清扫术的对比研究

目的:探讨基于膜解剖的局部进展期胃上部癌腹腔镜原位保脾脾门淋巴结环周清扫术的安全性、可行性及近期疗效。方法:回顾分析2016年12月至2019年12月为105例局部进展期胃上部癌患者施行基于膜解剖的腹腔镜原位保脾脾门淋巴结清扫术的临床资料,按脾门淋巴结清扫方式分为环周组(n=49,清扫脾叶血管前侧方及后方淋巴结)与前方组(n=56,仅清扫脾叶血管前侧方淋巴结),对比分析两组脾门淋巴结清扫总数、脾门阳性淋巴结清扫数量、脾门淋巴结阳性患者数及阳性率、术中术后并发症、术后恢复情况等,并分析脾门淋巴结阳性的相关因素。结果:两组患者的临床资料具有可比性,两组总手术时间、术中出血量、首次排气时间、左腹腔引流管拔除时间、进食流质时间、术后住院时间差异无统计学意义(P>0.05);环周组脾门淋巴结清扫时间长于前方组(P<0.05);两组术中并发症发生率、术后并发症发生率差异无统计学意义(P>0.05)。环周组胃周淋巴结清扫总数、脾门淋巴结清扫总数多于前方组(P<0.05);两组胃周阳性淋巴结数量、脾门阳性淋巴结数量差异无统计学意义(P>0.05)。脾门淋巴结阳性率为16.19%(17/105),χ²检验显示,肿瘤大小、第2站淋巴结阳性与否、pTNM分期与脾门淋巴结阳性有关(P<0.05)。环周组脾门淋巴结阳性患者例数多于前方组(12 vs.5,P=0.031)。环周组脾门前方淋巴结阳性患者12例,其中3例同时伴有脾门后方淋巴结阳性,3例均为T₄期、Ⅲ期患者。结论:基于膜解剖的腹腔镜原位保脾脾门淋巴结环周清扫术安全、可行,近期疗效可靠,与前方清扫术相比,可彻底完全清扫脾叶血管前侧方及后方淋巴结,获得更多的脾门淋巴结及脾门阳性淋巴结,有助于避免脾门后方阳性淋巴结遗漏,增强胃癌手术清扫效果,尤其适于T₄期、Ⅲ期胃上部癌患者,值得临床推广与应用。

Comparative study of membrane anatomy-guided laparoscopic splenic hilar lymph node circumferential dissection and anterior dissection

Objective:To study the safety,feasibility and short-term effectiveness of membrane anatomy-guided laparoscopic spleen-preserving splenic hilar lymph node circumferential dissection for locally advanced proximal gastric cancer.Methods:Clinical data of 105 patients with locally advanced proximal gastric cancer who underwent membrane anatomy-guided laparoscopic spleen-preserving splenic hilar lymph node dissection from Dec.2016 to Dec.2019 were retrospectively analyzed.According to the methods of splenic hilar lymph node dissection,patients were divided into two groups:circumferential group(n=49,the anterior and posterior lymph nodes of splenic lobe vessels were dissected)and anterior group(n=56,only the anterior lymph nodes of splenic lobe vessels were dissected).A comparative analysis was conducted between the two groups in regard to the total number of splenic hilar lymph nodes,the number of positive splenic hilar lymph nodes,the number of patients with positive splenic hilar lymph nodes,positive rate of splenic hilar lymph nodes,the incidence of intraoperative and postoperative complications,postoperative recovery and so on.The factors associated with positive splenic hilar lymph node were analyzed as well.Results:The clinical baseline data of patients in the two groups were comparable.There was no significant difference between the two groups in the total operative time,intraoperative blood loss,the time of first anal exhaust,the removal time of left abdominal cavity drainage tube,the time of starting fluid diet,the postoperative hospital stay(P>0.05);the time for splenic hilar lymph node dissection was longer in the circumferential group than that in the anterior group(P<0.05).There was no significant difference in the incidence of intraoperative complications and postoperative complications between the two groups(P>0.05).The number of perigastric lymph nodes and splenic hilar lymph nodes was more in the circumferential group than that in the anterior group(P<0.05);there was no significant difference between the two groups in the number of positive perigastric lymph nodes and positive splenic hilar lymph nodes(P>0.05).The positive rate of splenic hilar lymph nodes in 105 patients was 16.19%(17/105).The chi-square test showed that tumor size,positive or negative lymph nodes at the second station,and pTNM stage were related to positive splenic hilar lymph node(P<0.05).The number of patients with positive splenic hilar lymph node was significantly more in the circumferential group than that in the anterior group(12 cases vs.5 cases,P=0.031).In the circumferential group,there were 12 patients with positive anterior splenic hilar lymph nodes,3 of whom were accompanied by positive posterior splenic hilar lymph nodes,and all 3 patients were in stage T₄ and stageⅢ.Conclusions:Membrane anatomy-guided laparoscopic spleen-preserving splenic hilar lymph node circumferential dissection is feasible,safe and has reliable short-term efficiency.Compared with splenic hilar lymph node anterior dissection,it completely cleans the anterior and posterior lymph nodes of splenic lobe vessels.Therefore,the larger access to the number of splenic hilar lymph nodes and positive splenic hilar lymph nodes can help to avoid the omission of positive lymph nodes behind the splenic hilum,and enhance the effect of gastric cancer surgery,is especially suitable for patients with upper gastric cancer in T₄ stage andⅢstage.This method is worthy of clinical popularization and application.