Evaluation of short-term outcomes of robotic versus laparoscopic surgery in obese patients with mid-low rectal cancer
-
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。 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. -
Key words:
- robotic surgery /
- laparoscopy /
- rectal cancer /
- obesity
-
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 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) 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 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 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 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 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 -
[1] 国家卫生健康委员会. 中国居民营养与慢性病状况报告(2020年)[J]. 营养学报,2020,42(6): 521. [2] Bardou M,Rouland A,Martel M,et al. Review article:obesity and colorectal cancer[J]. Aliment Pharmacol Ther,2022,56(3): 407-418. doi: 10.1111/apt.17045 [3] Sung H,Ferlay J,Siegel RL,et al. Global cancer statistics 2020:GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin,2021,71(3): 209-249. doi: 10.3322/caac.21660 [4] Keller DS,Berho M,Perez RO,et al. The multidisciplinary management of rectal cancer[J]. Nat Rev Gastroenterol Hepatol,2020,17(7): 414-429. doi: 10.1038/s41575-020-0275-y [5] Bell S,Kong JC,Wale R,et al. The effect of increasing body mass index on laparoscopic surgery for colon and rectal cancer[J]. Colorectal Dis,2018,20(9): 778-788. doi: 10.1111/codi.14107 [6] WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies[J]. Lancet,2004,363(9403): 157-163. doi: 10.1016/S0140-6736(03)15268-3 [7] Chien SC,Chandramouli C,Lo CI,et al. Associations of obesity and malnutrition with cardiac remodeling and cardiovascular outcomes in Asian adults:a cohort study[J]. PLoS Med,2021,18(6): e1003661. doi: 10.1371/journal.pmed.1003661 [8] Glynne-Jones R,Wyrwicz L,Tiret E,et al. Rectal cancer:ESMO Clinical Practice Guidelines for diagnosis,treatment and follow-up[J]. Ann Oncol,2017,28(Suppl_4): iv22-iv40. [9] 中国医师协会外科医师分会结直肠外科医师委员会,中国研究型医院学会机器人与腹腔镜外科专业委员会. 机器人结直肠癌手术专家共识(2015版)[J]. 中华消化外科杂志,2015,14(11): 51 [10] 中华医学会外科学分会腹腔镜与内镜外科学组, 中国抗癌协会大肠癌专业委员会腹腔镜外科学组. 腹腔镜结直肠癌根治手术操作指南(2008版)[J/OL]. http://dx.chinadoi.cn/10.3760/cma.j.issn.1671-0274.2009.03.030. [11] Jiang WZ,Xu JM,Xing JD,et al. Short-term outcomes of laparoscopy-assisted vs open surgery for patients with low rectal cancer:the LASRE randomized clinical trial[J]. JAMA Oncol,2022,8(11): 1607-1615. doi: 10.1001/jamaoncol.2022.4079 [12] Fleshman J,Branda M,Sargent DJ,et al. Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes:the ACOSOG Z6051 randomized clinical trial[J]. JAMA,2015,314(13): 1346-1355. doi: 10.1001/jama.2015.10529 [13] Lee KC,Chung KC,Chen HH,et al. The impact of obesity on postoperative outcomes in colorectal cancer patients:a retrospective database study[J]. Support Care Cancer,2022,30(3): 2151-2161. doi: 10.1007/s00520-021-06626-7 [14] Bayraktar O,Aytaç E,Özben V,et al. Does robot overcome obesity-related limitations of minimally invasive rectal surgery for cancer?[J]. Surg Laparosc Endosc Percutan Tech,2018,28(1): e8-e11. doi: 10.1097/SLE.0000000000000500 [15] 柯沐,徐茂林,刘新,等. 机器人与腹腔镜根治术治疗SiewertⅡ/Ⅲ型食管胃结合部腺癌的疗效比较及预后影响因素分析[J]. 解放军医学院学报,2021,42(4): 372-377. doi: 10.3969/j.issn.2095-5227.2021.04.003 [16] Crippa J,Grass F,Achilli P,et al. Risk factors for conversion in laparoscopic and robotic rectal cancer surgery[J]. Br J Surg,2020,107(5): 560-566. doi: 10.1002/bjs.11435 [17] Chen Z, Yu H, Wu H, et al. Comparison of Operative Time Between Robotic and Laparoscopic Low Anterior Resection for Rectal Cancer:A Systematic Review and Meta-Analysis[J/OL]. https://doi.org/10.1177/15533506221148237. [18] Shiomi A,Kinugasa Y,Yamaguchi T,et al. Robot-assisted versus laparoscopic surgery for lower rectal cancer:the impact of visceral obesity on surgical outcomes[J]. Int J Colorectal Dis,2016,31(10): 1701-1710. doi: 10.1007/s00384-016-2653-z [19] Panteleimonitis S,Pickering O,Abbas H,et al. Robotic rectal cancer surgery in obese patients may lead to better short-term outcomes when compared to laparoscopy:a comparative propensity scored match study[J]. Int J Colorectal Dis,2018,33(8): 1079-1086. doi: 10.1007/s00384-018-3030-x [20] 于秀芝. 腹腔镜结直肠癌根治术与开腹结直肠癌根治术对结直肠癌患者术后炎症反应及免疫功能的影响比较[J]. 新乡医学院学报,2019,36(5): 471-474. [21] Oikonomakis I,Jansson D,Hörer TM,et al. Results of postoperative microdialysis intraperitoneal and at the anastomosis in patients developing anastomotic leakage after rectal cancer surgery[J]. Scand J Gastroenterol,2019,54(10): 1261-1268. doi: 10.1080/00365521.2019.1673476 [22] Sueda T,Tei M,Nishida K,et al. Short-term outcomes of robotic-assisted versus conventional laparoscopic-assisted surgery for rectal cancer:a propensity score-matched analysis[J]. J Robot Surg,2022,16(2): 323-331. doi: 10.1007/s11701-021-01243-2 [23] Feeney G,Sehgal R,Sheehan M,et al. Neoadjuvant radiotherapy for rectal cancer management[J]. World J Gastroenterol,2019,25(33): 4850-4869. doi: 10.3748/wjg.v25.i33.4850 -

计量
- 文章访问数: 86
- HTML全文浏览量: 52
- PDF下载量: 6
- 被引次数: 0