机器人与腹腔镜手术治疗肥胖中低位直肠癌患者短期疗效比较

李森; 薛勇敢; 柯沐; 黄埔; 邝衍绅; 孟庆禹; 宁伯彬; 王文琛; 刘唯正; 滕志鹏; 李鹏; 刘洪一; 贾宝庆

doi:10.3969/j.issn.2095-5227.2023.06.009

机器人与腹腔镜手术治疗肥胖中低位直肠癌患者短期疗效比较

doi: 10.3969/j.issn.2095-5227.2023.06.009

1.
解放军医学院，北京　100853
2.
解放军总医院第一医学中心普通外科医学部，北京　100853
3.
中国医学科学院肿瘤医院深圳医院乳腺外科，广东深圳　518172
4.
白求恩国际和平医院烧伤整形科，河北石家庄　050051

详细信息

作者简介:
李森，男，硕士，医师。研究方向：胃肠道肿瘤。Email: lisen9427@163.com

通讯作者:
贾宝庆，男，博士，主任医师，教授，博士生导师。Email: baoqingjia@126.com

中图分类号: R735.36
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出版历程
- 收稿日期: 2023-03-24
- 网络出版日期: 2023-05-05
- 刊出日期: 2023-06-28

Evaluation of short-term outcomes of robotic versus laparoscopic surgery in obese patients with mid-low rectal cancer

1.
Chinese PLA Medical School, Beijing 100853, China
2.
Department of General Surgery, the First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
3.
Department of Breast Surgery, the Cancer Hospital Chinese Academy of Medical Sciences, Shenzhen Center, Shenzhen 518172, Guangdong Province, China
4.
Department of Burn and Plastic Surgery, the Bethune International Peace Hospital, Shijiazhuang 050051, Hebei Province, China

More Information

Corresponding author: JIA Baoqing. Email: baoqingjia@126.com

摘要

摘要: 背景由于腹腔镜器械存在自由度低等固有缺点，其在肥胖中低位直肠癌患者中应用受限。而机器人手术相较于腹腔镜在此类人群中应用是否具有优势仍然未知。目的比较机器人与腹腔镜手术治疗肥胖中低位直肠癌患者的短期疗效。方法回顾性分析2017年2月 - 2022年8月解放军总医院第一医学中心普通外科五病区收治的肥胖中低位直肠癌患者的临床资料，根据手术治疗设备将患者分为机器人组和腹腔镜组，以倾向性评分匹配(propensity score matching，PSM)对两组患者基线资料进行1∶1匹配后比较两组结局指标，评价两种手术方式的短期疗效，应用单因素和多因素logistic回归分析并发症发生的影响因素。结果本研究共纳入207例患者，其中机器人组108例，腹腔镜组99例。PSM后两组患者各为66例。机器人组的环周切缘阳性率(4.5% vs 15.2%，P=0.041)及术后30 d内并发症发生率(7.6% vs 22.7%，P=0.015)均低于腹腔镜组，差异有统计学意义。多因素logistic回归分析提示使用机器人手术系统有助于降低术后30 d内并发症发生率(OR：0.269，95% CI：0.090 ~ 0.804，P=0.019)。结论与腹腔镜手术相比，机器人手术有助于降低肥胖中低位直肠癌患者术后环周切缘阳性率和术后30 d内并发症发生率，在改善短期疗效方面具有一定优势。
- 机器人手术 /
- 腹腔镜手术 /
- 直肠癌 /
- 肥胖
Abstract: Background Due to the inherent disadvantages of laparoscopic instruments such as the loss of several degrees of freedom, their applications in the treatment of mid-low rectal cancer in obese patients are limited. However, the definitive outperformance of the robotic system versus laparoscopic procedure when treating mid-low rectal cancer in the obese population remains to be determined. Objective To evaluate the short-term outcomes of robotic versus laparoscopic surgery in obese patients with mid-low rectal cancer. Methods Clinical data about obese patients with mid-low rectal cancer admitted to the Fifth Ward of the General Surgery Department in the First Medical Center of Chinese PLA General Hospital from February 2017 to August 2022 were retrospectively analyzed. According to the surgical procedure, the patients were divided into robotic group and laparoscopic group. After performing propensity score matching (PSM) of the baseline characteristics of the two groups, the indicators were compared to evaluate the short-term outcomes. Univariate and multivariate logistic regression were used to analyze the influencing factors of the occurrence of complications. Results A total of 207 cases were screened for this study, including 108 cases in the robotic group and 99 cases in the laparoscopic group. After PSM, there were 66 patients in each group. The positive rate of circumferential incision margin (4.5% vs 15.2%, P=0.041) and the incidence of complications within 30 days after surgery (7.6% vs 22.7%, P=0.015) reduced significantly in the robotic group when compared to the laparoscopic group. Multivariate logistic regression analysis suggested that robotic surgery could reduce the incidence of complications within 30 days after surgery (OR: 0.269, 95%CI: 0.090-0.804, P=0.019). Conclusion Compared with laparoscopic surgery, robotic surgery contributes to reducing the positive rate of circumferential resection margin and the incidence of complications within 30 days after surgery in obese patients with mid-low rectal cancer, and has certain advantages in improving short-term outcomes.
- robotic surgery /
- laparoscopy /
- rectal cancer /
- obesity

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表 1 倾向性评分匹配前后两组患者基线资料比较

Table 1. Comparison of baseline characteristics of the two groups before and after PSM

指标	倾向性评分匹配前				倾向性评分匹配后
指标	机器人组(n=108)	腹腔镜组(n=99)	t/Z/χ²值	P值	机器人组(n=66)	腹腔镜组(n=66)	t/Z/χ²值	P值
年龄/岁	58.4 ± 11.2	60.6 ± 9.6	1.523	0.129	60.8 ± 10.5	60.4 ± 9.1	-0.239	0.811
＜65岁/(例，%)	75(69.4)	61(61.6)			42(63.6)	41(62.1)
≥65岁/(例，%)	33(30.6)	38(38.4)			24(36.4)	25(37.9)
性别/(例，%)			0.562	0.454			0.811	0.368
男	73(67.6)	62(62.6)			39(59.1)	44(66.7)
女	35(32.4)	37(37.4)			27(40.9)	22(33.3)
BMI/[kg·m^-2，Md(IQR)]	26.7(25.7，28.2)	26.3(25.6，27.7)	-1.339	0.181	26.7(25.7，28.1)	26.4(25.6，28.2)	-0.043	0.965
ASA/(例，%)			1.315	0.252			0.000	1.000
≤Ⅱ	100(92.6)	87(87.9)			59(89.4)	59(89.4)
＞Ⅱ	8(7.4)	12(12.1)			7(10.6)	7(10.6)
合并症/(例，%)	50(46.3)	53(53.5)	1.083	0.298	38(57.6)	31(47.0)	1.488	0.223
既往腹部手术史/(例，%)	17(15.7)	15(15.2)	0.014	0.907	12(18.2)	7(10.6)	1.537	0.215
病理分期/(例，%)			0.595	0.743			0.044	0.978
Ⅰ	37(34.3)	29(29.3)			20(30.3)	20(30.3)
Ⅱ	32(29.6)	31(31.3)			20(30.3)	21(31.8)
Ⅲ	39(36.1)	39(39.4)			26(39.4)	25(37.9)
新辅助治疗史/(例，%)	34(31.5)	8(8.1)	17.196	＜0.001	8(12.1)	8(12.1)	0.000	1.000
肿瘤位置/[cm，Md(IQR)]	5.0(4.0，8.0)	5.0(4.0，8.0)	-0.453	0.651	5.0(4.0，8.0)	5.0(4.0，8.0)	-0.324	0.746
0 ~ 5 cm/(例，%)	59(54.6)	50(50.5)			35(53.0)	34(51.5)
＞5 ~ 10 cm/(例，%)	49(45.4)	49(49.5)			31(47.0)	32(48.5)

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表 2 两组患者围术期指标比较

Table 2. Comparison of perioperative indicators between the two groups

指标	机器人组 (n=66)	腹腔镜组 (n=66)	t/Z/χ²值	P值
手术方式/(例，%)			0.044	0.833
直肠前切除术	51(77.3)	52(78.8)
经腹会阴联合切除术	15(22.7)	14(21.2)
造口/(例，%)	36(54.5)	34(51.5)	0.122	0.727
手术时间/[min，Md(IQR)]	165(145，196)	155(130，185)	-1.509	0.131
中转开腹/(例，%)	0(0)	0(0)	-	-
失血量/[mL，Md(IQR)]	100(50，100)	50(50，100)	-1.097	0.273
输血/(例，%)	3(4.5)	4(6.1)	-	＞0.999
首次进流食时间/[d，Md(IQR)]	4(3，4)	3(2，3)	-1.251	0.211
引流管拔除时间/[d，Md(IQR)]	6(5，8)	6(5，8)	-0.302	0.763
导尿管拔除时间/[d，Md(IQR)]	2(1，3)	2(1，3)	-0.412	0.680
术后住院时间/[d，Md(IQR)]	8(7，10)	7(6，10)	-0.812	0.417

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表 3 两组患者病理结果比较

Table 3. Comparison of pathological outcomes between the two groups

指标	机器人组 (n=66)	腹腔镜组 (n=66)	t/Z/χ²值	P值
肿瘤大小/cm	3.5 ± 1.3	3.7 ± 1.2	0.491	0.624
收获淋巴结数目/[例，Md(IQR)]	14(12，16)	15(13，17)	-1.489	0.136
组织分化程度/(例，%)			2.717	0.487
完全缓解	2(3.0)	1(1.5)
高	1(1.5)	0(0)
中	56(84.8)	53(80.3)
低	7(10.6)	12(18.2)
脉管侵犯/(例，%)	6(9.1)	8(12.1)	0.320	0.572
神经侵犯/(例，%)	4(6.1)	6(9.1)	0.433	0.511
CRM阳性/(例，%)	3(4.5)	10(15.2)	4.181	0.041

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表 4 两组患者并发症比较(例，%)

Table 4. Comparison of complications between the two groups (n, %)

指标	机器人组 (n=66)	腹腔镜组 (n=66)	Z/χ²值	P值
术中并发症	1(1.5)	1(1.5)	-	1.000
输尿管损伤	0(0)	1(1.5)	-	＞0.999
急性心血管疾病	1(1.5)	0(0)	-	＞0.999
术后并发症	5(7.6)	15(22.7)	5.893	0.015
吻合口瘘	0(0)	2(3.0)	-	0.496
明显失血	1(1.5)	2(3.0)	-	＞0.999
肠梗阻	0(0)	4(6.1)	-	0.119
腹腔感染	0(0)	1(1.5)	-	＞0.999
肺炎	1(1.5)	3(4.5)	-	0.619
急性脑梗死	0(0)	1(1.5)	-	＞0.999
尿潴留	1(1.5)	0(0)	-	＞0.999
急性心血管疾病	1(1.5)	0(0)	-	＞0.999
急性呼吸衰竭	0(0)	1(1.5)	-	＞0.999
输尿管瘘	0(0)	1(1.5)	-	＞0.999
乳糜瘘	1(1.5)	0(0)	-	＞0.999
Clavien-Dindo分级			-	0.337
Ⅱ	4(6.1)	11(16.7)	3.685	0.055
Ⅲ	0(0)	2(3.0)	-	0.496
Ⅳ	0(0)	2(3.0)	-	0.496
Ⅴ	1(1.5)	0(0)	-	＞0.999

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表 5 术后30 d内并发症发生的单因素和多因素logistic回归分析

Table 5. Univariate and multivariate logistic regression analysis of factors associated with occurrence of complications within 30 days

因素	单因素分析			多因素分析
因素	OR	95% CI	P值	OR	95% CI	P值
年龄			0.831
≥65岁 vs ＜65岁	0.897	0.332 ~ 2.428
性别			0.476
男 vs 女	0.688	0.246 ~ 1.925
BMI			0.441
≥30 kg·m^-2 vs 25 ~ ＜30 kg·m^-2	0.439	0.054 ~ 3.575
合并症			0.481
有 vs 无	0.709	0.273 ~ 1.845
既往腹部手术史			0.547
有 vs 无	0.621	0.132 ~ 2.924
病理分期			0.841
Ⅱ期 vs Ⅰ期	1.441	0.417 ~ 4.985	0.564
Ⅲ期 vs Ⅰ期	1.302	0.391 ~ 4.338	0.667
新辅助治疗			0.998
有 vs 无	0.000	0.000
肿瘤位置			0.454
＞5 ~ 10 cm vs ≤5 cm	0.691	0.262 ~ 1.819
手术路径			0.020			0.019
机器人手术 vs 腹腔镜手术	0.279	0.095 ~ 0.819		0.269	0.090 ~ 0.804
手术方式			0.817
经腹会阴联合切除术 vs 直肠前切除术	0.870	0.267 ~ 2.838
造口			0.436
有 vs 无	0.684	0.263 ~ 1.780
手术时间			0.732
≥180 min vs ＜180 min	0.835	0.297 ~ 2.345
失血量			0.078			0.072
≥200 mL vs ＜200 mL	3.250	0.876 ~ 12.052		3.525	0.893 ~ 13.904
肿瘤大小			0.144
≥5 cm vs ＜5 cm	0.447	0.152 ~ 1.317

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