腹腔镜D2根治术联合胃背侧系膜近胃端完整系膜切除术在进展期胃癌中的应用

doi:10.3877/cma.j.issn.2095-2015.2025.05.007

目的

评估腹腔镜辅助D2淋巴清扫术联合胃背侧系膜近胃端完整系膜切除术（CME）在进展期胃癌治疗中的临床疗效，探讨该联合术式对围手术期临床结局、肿瘤生物学行为及远期生存预后的影响。

方法

本研究为单中心回顾性队列研究，样本为常州市中医医院普外科2022年1月至2023年12月收治的172例进展期胃癌患者，按照手术方法不同分为对照组和观察组。对照组行腹腔镜D2根治术，观察组行腹腔镜D2根治术联合CME。统计分析术中指标、术后恢复时间，并比较两组患者术前和术后5 d的肿瘤标志物水平、术后并发症。对所有患者随访1年，记录术后1年的复发率、转移率和生存率以及无进展生存期和总生存期。

结果

观察组患者的手术时间较对照组明显缩短，术中出血量明显少于对照组，近切缘距离明显短于对照组，淋巴结清扫数目明显多于对照组（P<0.05）。与对照组相比，观察组的首次排气时间、首次排便时间、下床活动时间明显提前，住院时间明显缩短（P<0.05）。两组患者在术后的癌胚抗原（CEA）、糖类抗原19-9（CA19-9）、神经元特异性烯醇化酶（NSE）水平较术前均出现明显下降，观察组患者术后的肿瘤标志物水平均明显低于同期对照组，观察组的降低幅度更大（P<0.05）。两组总体并发症发生率比较，差异无统计学意义（P>0.05）。观察组的复发率（19.77%）、转移率（8.14%）较对照组（36.05%、19.77%）明显降低（P<0.05）；观察组的生存率（73.26%）明显高于对照组（48.84%），无进展生存期和总生存期均明显高于对照组（P<0.05）。

结论

腹腔镜D2根治术联合CME通过遵循膜解剖理论完整切除肿瘤所在系膜单元，实现了解剖平面精准分离与淋巴引流系统的彻底清扫。该术式不仅显著优化围手术期指标，更通过阻断系膜内潜在转移途径和肿瘤微环境重塑，为进展期胃癌提供了兼顾根治性与功能保留的治疗策略。

关键词: 胃肿瘤, 腹腔镜, 胃癌D2根治术, 胃背侧系膜近胃端完整系膜切除术, 生存率

Objective

To evaluate the clinical efficacy of laparoscopic-assisted D2 lymphadenectomy combined with proximal complete mesocolic excision (CME) in the treatment of advanced gastric cancer, and to explore the influence of this combined operation on perioperative clinical outcome, tumor biological behavior and long-term survival and prognosis.

Methods

This study was a single-center retrospective cohort study. The samples were 172 patients with advanced gastric cancer admitted to Department of General Surgery, Changzhou Hospital of Traditional Chinese Medicine from January 2022 to December 2023. They were divided into the control group and the observation group based on different surgical methods. The control group underwent laparoscopic D2 radical gastrectomy, while the observation group received laparoscopic D2 radical gastrectomy combined with CME. Surgical-related indices and postoperative recovery were statistically analyzed, and the levels of tumor markers before surgery and 5 days after surgery, as well as postoperative complications were compared between the two groups of patients. All patients were followed up for one year, and the recurrence rate, metastasis rate and survival rate, progression-free survival and overall survival were recorded one year after operation.

Results

Compared with the control group, the operation time of the patients in the observation group was significantly shorter, the blood loss during operation was significantly less, the distance near the incision margin was significantly shorter, and the number of lymph node dissection was significantly more (P<0.05). Compared with the control group, the first exhaust time, the first defecation time and the time of getting out of bed in the observation group were significantly earlier, and the hospitalization time was significantly shorter (P<0.05). The levels of carcino-embryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9) and neuronspecific enolase (NSE) in the two groups decreased significantly after operation compared with those before operation. The levels of tumor markers in the observation group were significantly lower than those in the control group at the same period, and the decrease in the observation group was even greater (P<0.05). There was no statistical difference in the incidence of overall complications between the two groups (P>0.05). The recurrence rate (19.77%) and metastasis rate (8.14%) in the observation group were significantly lower than those in the control group (36.05% and 19.77%) (P<0.05). The survival rate of the observation group (73.26%) was significantly higher than that of the control group (48.84%), and the progression-free survival and overall survival were significantly longer than those of the control group (P<0.05).

Conclusion

Laparoscopic D2 radical resection combined with CME can completely remove the mesangial unit where the tumor is located by following the theory of membrane anatomy, and realize accurate separation of anatomical plane and thorough cleaning of lymphatic drainage system. This operation not only significantly optimizes the perioperative indicators, but also provides a new treatment strategy for advanced gastric cancer with both radical and functional preservation by blocking the potential metastasis pathway in mesangium and remodeling the tumor microenvironment.

Key words: Gastric neoplasms, laparoscope, Laparoscopic D2 radical gastrectomy, Complete mesocolic excision of the gastric dorsal mesentery, Survival rate

表1 两组进展期胃癌患者基线资料比较

临床资料	对照组(n=86)	观察组(n=86)	t/χ²值	P值
性别[例(%)]			0.374	0.541
男	48(55.81)	44(51.46)
女	38(44.19)	42(48.84)
年龄(岁,±s)	51.39±6.26	51.24±6.12	0.159	0.874
体重指数(kg/m²,±s)	23.47±3.40	23.51±3.58	0.075	0.940
肿瘤平均直径(cm,±s)	5.24±0.62	5.26±0.69	0.200	0.842
TNM分期[例(%)]			1.695	0.428
Ⅱ b	28(32.56)	32(37.21)
Ⅲ a	32(37.21)	24(27.91)
Ⅲ b	26(30.23)	30(34.88)
肿瘤部位[例(%)]			0.379	0.827
胃窦	38(44.19)	42(48.84)
胃体	28(32.56)	26(30.23)
胃底	20(23.26)	18(20.93)
组织学类型[例(%)]			0.358	0.836
管状腺癌	70(81.40)	72(83.72)
乳头状腺癌	10(11.63)	8(9.30)
其他类型	6(6.98)	6(6.98)
分化程度[例(%)]			0.427	0.808
高分化	12(13.95)	10(11.63)
中分化	45(52.33)	48(55.81)
低分化	29(33.72)	28(32.56)
脉管癌栓[例(%)]			0.135	0.713
有	24(27.91)	22(25.58)
无	62(72.09)	64(74.42)
神经侵犯[例(%)]			0.105	0.746
有	30(34.88)	28(32.56)
无	56(65.12)	58(67.44)

表1 两组进展期胃癌患者基线资料比较

临床资料	对照组(n=86)	观察组(n=86)	t/χ²值	P值
性别[例(%)]			0.374	0.541
男	48(55.81)	44(51.46)
女	38(44.19)	42(48.84)
年龄(岁,±s)	51.39±6.26	51.24±6.12	0.159	0.874
体重指数(kg/m²,±s)	23.47±3.40	23.51±3.58	0.075	0.940
肿瘤平均直径(cm,±s)	5.24±0.62	5.26±0.69	0.200	0.842
TNM分期[例(%)]			1.695	0.428
Ⅱ b	28(32.56)	32(37.21)
Ⅲ a	32(37.21)	24(27.91)
Ⅲ b	26(30.23)	30(34.88)
肿瘤部位[例(%)]			0.379	0.827
胃窦	38(44.19)	42(48.84)
胃体	28(32.56)	26(30.23)
胃底	20(23.26)	18(20.93)
组织学类型[例(%)]			0.358	0.836
管状腺癌	70(81.40)	72(83.72)
乳头状腺癌	10(11.63)	8(9.30)
其他类型	6(6.98)	6(6.98)
分化程度[例(%)]			0.427	0.808
高分化	12(13.95)	10(11.63)
中分化	45(52.33)	48(55.81)
低分化	29(33.72)	28(32.56)
脉管癌栓[例(%)]			0.135	0.713
有	24(27.91)	22(25.58)
无	62(72.09)	64(74.42)
神经侵犯[例(%)]			0.105	0.746
有	30(34.88)	28(32.56)
无	56(65.12)	58(67.44)

表2 两组进展期胃癌患者手术相关指标比较（

±s）

组别	例数	手术时间(min)	术中出血量(mL)	近切缘距离(cm)	淋巴结清扫数目(个)
对照组	86	172.47±36.43	125.03±16.49	8.02±0.63	19.42±3.73
观察组	86	149.36±29.75	80.68±9.17	6.14±0.49	28.61±4.05
t值		4.557	21.798	21.844	15.479
P值		0.000	0.000	0.000	0.000

表2 两组进展期胃癌患者手术相关指标比较（

±s）

组别	例数	手术时间(min)	术中出血量(mL)	近切缘距离(cm)	淋巴结清扫数目(个)
对照组	86	172.47±36.43	125.03±16.49	8.02±0.63	19.42±3.73
观察组	86	149.36±29.75	80.68±9.17	6.14±0.49	28.61±4.05
t值		4.557	21.798	21.844	15.479
P值		0.000	0.000	0.000	0.000

表3 两组进展期胃癌患者术后恢复情况比较（d，

±s）

组别	例数	首次排气时间	首次排便时间	下床活动时间	住院时间
对照组	86	2.71±0.68	4.33±0.84	3.40±0.71	10.02±1.89
观察组	86	2.03±0.51	2.92±0.58	1.93±0.44	6.95±1.13
t值		7.419	12.810	16.321	12.929
P值		0.000	0.000	0.000	0.000

表3 两组进展期胃癌患者术后恢复情况比较（d，

±s）

组别	例数	首次排气时间	首次排便时间	下床活动时间	住院时间
对照组	86	2.71±0.68	4.33±0.84	3.40±0.71	10.02±1.89
观察组	86	2.03±0.51	2.92±0.58	1.93±0.44	6.95±1.13
t值		7.419	12.810	16.321	12.929
P值		0.000	0.000	0.000	0.000

表4 两组进展期胃癌患者手术前后肿瘤标志物水平比较（

±s）

组别	例数	癌胚抗原(ng/mL)		糖类抗原19-9(U/mL)		神经元特异性烯醇化酶(μg/L)
组别	例数	术前	术后	术前	术后	术前	术后
对照组	86	9.65±1.36	4.14±0.73^*	40.37±5.88	16.48±2.84^*	16.01±2.75	6.42±1.02^*
观察组	86	9.71±1.44	2.86±0.41^*	40.21±5.67	11.35±2.19^*	16.34±2.90	4.51±0.73^*
t值		0.281	14.178	0.182	13.265	0.766	14.121
P值		0.779	0.000	0.856	0.000	0.445	0.000

表4 两组进展期胃癌患者手术前后肿瘤标志物水平比较（

±s）

组别	例数	癌胚抗原(ng/mL)		糖类抗原19-9(U/mL)		神经元特异性烯醇化酶(μg/L)
组别	例数	术前	术后	术前	术后	术前	术后
对照组	86	9.65±1.36	4.14±0.73^*	40.37±5.88	16.48±2.84^*	16.01±2.75	6.42±1.02^*
观察组	86	9.71±1.44	2.86±0.41^*	40.21±5.67	11.35±2.19^*	16.34±2.90	4.51±0.73^*
t值		0.281	14.178	0.182	13.265	0.766	14.121
P值		0.779	0.000	0.856	0.000	0.445	0.000

表5 两组进展期胃癌患者术后并发症发生率比较[例（%）]

组别	例数	腹腔感染	胃出血	吻合口瘘	肠梗阻	总发生率
对照组	86	2(2.33)	3(3.49)	2(2.33)	2(2.33)	9(10.47)
观察组	86	1(1.16)	2(2.33)	1(1.16)	2(2.33)	6(6.98)^*

表5 两组进展期胃癌患者术后并发症发生率比较[例（%）]

组别	例数	腹腔感染	胃出血	吻合口瘘	肠梗阻	总发生率
对照组	86	2(2.33)	3(3.49)	2(2.33)	2(2.33)	9(10.47)
观察组	86	1(1.16)	2(2.33)	1(1.16)	2(2.33)	6(6.98)^*

图1 两组胃癌患者无进展生存期的生存曲线

图2 两组胃癌患者总生存期的生存曲线

表6 两组进展期胃癌患者预后情况比较[例（%）]

组别	例数	术后1年复发率[例(%)]	术后1年转移率[例(%)]	术后1年生存率[例(%)]	无进展生存期(月)	总生存期(月)
对照组	86	31(36.05)	17(19.77)	42(48.84)	7.04±0.89	9.47±0.62
观察组	86	17(19.77)	7(8.14)	63(73.26)	9.56±1.18	11.53±0.84
χ²值		5.664	4.482	10.782	15.812	18.298
P值		0.017	0.028	0.001	0.000	0.000

表6 两组进展期胃癌患者预后情况比较[例（%）]

组别	例数	术后1年复发率[例(%)]	术后1年转移率[例(%)]	术后1年生存率[例(%)]	无进展生存期(月)	总生存期(月)
对照组	86	31(36.05)	17(19.77)	42(48.84)	7.04±0.89	9.47±0.62
观察组	86	17(19.77)	7(8.14)	63(73.26)	9.56±1.18	11.53±0.84
χ²值		5.664	4.482	10.782	15.812	18.298
P值		0.017	0.028	0.001	0.000	0.000

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Application of laparoscopic D2 radical gastrectomy combined with complete mesocolic excision of the gastric dorsal mesentery in advanced gastric cancer

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Application of laparoscopic D2 radical gastrectomy combined with complete mesocolic excision of the gastric dorsal mesentery in advanced gastric cancer