Abstract: Objective:To investigate the development trend, safety and clinical effects of laparoscopic radical gastrectomy (LRG) for gastric cancer.
Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 4 435 patients with gastric cancer who underwent LRG in the Fujian Medical University Union Hospital between January 2008 and December 2017 were collected. There were 3 263 males and 1 172 females, aged (61±11)years, with a range of 12-93 years. According to the operation time, 4 435 patients were divided into two periods, including 1 588 patients of the early period (2008-2012) and 2 847 patients of the later period (2013-2017). Observation indicators: (1) the clinicopathological data of patients; (2) intraoperative and postoperative situations; (3) postoperative complications; (4) followup and survival situations. Followup using outpatient examination, visit to home, mail and telephone interview was performed to detect survival of patients once every 3 months within 2 years postoperatively and once every 6 months after 2 years postoperatively up to June 2018. Survival time was from operation time to the last followup, death or deadline of followup database such as loss to followup or death of other diseases. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed by the t test. Measurement data with skewed distribution were represented as M (range). Count data were described as frequency or percentage, comparison between groups was analyzed using the chi-square test. Linear analysis was done using the unitary linear regression. The survival rate and survival curve were respectively calculated and drawn by the Kaplan-Meier method, and Logrank test was used for survival analysis.
Results:(1) The clinicopathological data of patients: there were 3 263 males and 1 172 females of the 4 435 patients, accounting for 73.574%(3 263/4 435) and 26.426%(1 172/4 435), respectively. TNM staging of the 4 435 patients: 1 133 cases were detected early gastric cancer (T1 stage) and 3 302 cases were detected advanced gastric cancer including 518, 1 431, 1 353 in T2, T3 and T4a stages respectively. Linear regression analysis showed a linear correlation between the cases of LRG and operation year (R²=0.911, P<0.05) and a gradually increasing in cases of LRG. The sex (male), cases with tumor at upper stomach, middle stomach, lower stomach, >2 regions (tumor location), tumor diameter, cases with undifferentiated and differentiated tumor (pathological types), cases in pT1, pT2, pT3, pT4a stages (pT staging), in pN0, pN1, pN2, pN3a, pN3b stages (pN staging), in ⅠA, ⅠB, ⅡA, ⅡB, ⅢA, ⅢB, ⅢC stages (pTNM staging ) were 1 204, 383, 302, 714, 189, (4.8±2.7)cm, 361, 1 227, 382, 193, 418, 595, 588, 212, 255, 318, 215, 325, 137, 150, 172, 253, 267, 284 in patients of the early period, and 2 059, 807, 530, 1 128, 382, (4.3±2.6) cm, 976, 1 871, 751, 325, 1 013, 758, 1 138, 444, 505, 486, 274, 616, 258, 378, 322, 528, 443, 302 in patients of the later period, with statistically significant differences between patients of the two periods (x²=6.411, 15.699, t=10.946, x²=57.801, 90.437, 26.502, 98.773, P<0.05). (2) Intraoperative and postoperative situations: the volume of intraoperative blood loss, cases with intraoperative blood transfusion, cases with BillrothⅠ, BillrothⅡ, residual stomach Roux-en-Y anastomosis, esophagogastric anastomosis, esophageal Roux-en-Y anastomosis of digestive tract reconstruction, number of lymph nodes dissected, time for initial fluid diet intake, time for initial semifluid diet intake, duration of postoperative hospital stay were (120±75)mL, 38, 599, 122, 0, 32, 835, 32±13, (4.5±1.7)days, (8.6±2.5)days, (13.0± 7.3)days in patients of the early period, (104±68)mL, 17, 441, 673, 21, 18, 1 694, 37±15, (4.1± 1.5)days, (7.9±2.8)days, (12.3±7.6)days in patients of the later period, showing statistically significant differences between patients of the two periods (t=2.169, x²=26.843, 397.185, t=-10.764, 2.125, 3.347, 2.779, P<0.05). Further linear regression analysis showed a linear correlation between the average number of lymph nodes dissected and operation year (R²=0.826, P<0.05) and a gradually increasing in average number of lymph nodes dissected. (3) Postoperative complications: 690 of 4 435 patients had postoperative complications, with an incidence rate of 15.558%(690/4 435), including 242 patients of the early period and 448 of the later period, showing no statistically significant difference (x²=0.191, P>0.05). Eight patients died of severe postoperative complications, with a death rate of 0.180%(8/4 435), including 5 of the early period and 3 of the later period, showing no statistically significant difference (x²=2.485, P>0.05). Of 4 435 patients, 561 had stage Ⅰ-Ⅱ complications, with an incidence rate of 12.649%(561/4 435), 129 had stage Ⅲ-Ⅳ complications, with an incidence rate of 2.909%(129/4 435). There were 196 and 46 patients of the early period with stage Ⅰ-Ⅱ complications and stage Ⅲ-Ⅳ complications, 365 and 83 of the later period with stage Ⅰ-Ⅱ complications and stage Ⅲ-Ⅳ complications, showing no statistically significant difference between patients of the two periods (x²=0.211, 0.001, P>0.05). (4) Followup and survival situations: 4 250 of 4 435 patients including 1 465 of the early period and 2 785 of the later period were followed up for 1-123 months, with a median time of 37 months. The 5year cumulative survival rate was 63.9%. The 5year cumulative survival rate was 91.8%, 80.2% and 39.5% in the stage Ⅰ, Ⅱ, Ⅲ patients, respectively, showing a statistically significant difference (x²=810.146, P<0.05). The 5year cumulative survival rate was 60.8% and 66.7% in patients of the early and later period, respectively with a statistically significant difference (x²=17.887, P<0.05). Stratified analysis of TNM staging: the 5year cumulative survival rates of stage ⅠA, ⅠB, ⅡA, ⅡB, ⅢA, ⅢB, ⅢC patients in the early period were 92.7%, 85.6%, 79.4%, 74.5%, 58.1%, 37.6%, 18.9% and 95.6%, 90.4%, 87.6%, 79.5%, 52.7%, 41.2%, 19.5% in patients of the later period, with no statistically significant difference (x²=0.414, 2.575, 2.872, 2.119, 0.632, 0.972, 2.212, P>0.05).
Conclusions:Surgical volume of the LRG has shown an increasing trend year by year, and the number of lymph nodes dissected and postoperative recovery of patients are improving. LRG is a safe procedure with acceptable clinical efficacy for gastric cancer.