[Early postoperative complications and risk factors in laparoscopic D2 radical gastrectomy for gastric cancer].

Objective: To investigate the morbidity and treatment of early postoperative complications after laparoscopic D2 radical gastrectomy for gastric cancer, and to explore the risk factors. Methods: A case-control study was performed to retrospectively collect clinicopathological data of 764 patients undergoing laparoscopic D2 radical gastrectomy for gastric cancer at our department between January 2015 and December 2017. Patient inclusion criteria: (1) gastric cancer diagnosed by preoperative electronic gastroscopy and biopsy, and confirmed by postoperative pathology; (2) without invasion into adjacent organs by preoperative evaluation of tumors; (3) tumors without definite liver and distant metastasis; (4) R0 resection of gastric cancer and standard D2 lymph node dissection; (5) patients with informed consent. Exclusion criteria: (1) unperformed laparoscopic D2 radical resection; (2) other types of gastric tumor confirmed by pathology; (3) cases with incomplete clinical data. Complication occurring within two weeks after laparoscopic D2 gastrectomy was defined as early postoperative complication. Patients were divided into two groups: non-complication group (693 cases) and complication group (71 cases) according to the occurrence of complications after operation. The clinicopathological data of two groups were analyzed and compared with t test and χ(2) test, and the factors of P < 0.2 were included in the multivariate logistic regression model to analyze the risk factors of postoperative complications. Results: Of 764 patients, 71 (9.3%) developed early postoperative complications, with median onset time of 3 (1 to 11) days. Surgical complications accounted for 7.9% (60/764), including 13 cases (1.7%) of abdominal hemorrhage, 12 cases (1.6%) of anastomotic leakage, 10 cases (1.3%) of incision infection, 8 cases (1.0%) of anastomotic bleeding, 7 cases (0.9%) of gastric stump weakness, 4 cases (0.5%) of abdominal infection, 4 cases (0.5%) of duodenal stump leakage and 2 cases (0.3%) of small intestinal obstruction. Non-surgical complications accounted for 1.4% (11/764), including 6 cases (0.8%) of pulmonary infection and 5 cases (0.7%) of cardiovascular disease. Two cases (0.3%) died of sepsis caused by severe abdominal infection; 9 cases (1.2%) recovered after receiving the second operation, among whom 5 cases were abdominal hemorrhage, 2 cases were anastomotic leakage and 2 cases were duodenal stump leakage; the remaining patients were healed with conservative treatment. Compared with patients without complications, patients with complications had higher proportions of BMI ≥24 kg/m(2) [42.3% (30/71) vs. 24.2%(168/693), χ(2)=10.881, P=0.001], comorbity [64.8% (46/71) vs. 33.5% (232/693), χ(2)=27.277, P<0.001], combined organ resection [70.4% (50/71) vs. 20.5% (142/693), χ(2)=85.338, P<0.001], and pTNM stage of III [70.4% (50/71) vs. 40.1% (278/693), χ(2)=24.196, P<0.001], meanwhile had longer time to postoperative flatus [(4.2±2.1) days vs. (2.9±1.2) days, t=4.621, P=0.023], longer hospital stay [(34.6±12.6) days vs. (14.2±6.2) days, t=9.862, P<0.001] and higher hospitalization cost [(126.8±64.5) thousand yuan vs. (85.2±35.8) thousand yuan, t=11.235, P<0.001]. Multivariate analysis showed that BMI ≥24 kg/m(2) (OR=3.762, 95% CI: 1.960-8.783, P=0.035), accompanying disease (OR=8.620, 95% CI: 1.862-29.752, P<0.001), combined organ resection (OR=6.210, 95% CI: 1.357-21.568, P=0.026), and pTNM stage (OR=4.752, 95% CI: 1.214-12.658, P<0.001) were the independent risk factors of postoperative complications. Conclusions: Laparoscopic D2 radical gastrectomy is a safe and effective approach for gastric cancer. Most early postoperative complications can obtain satisfactory efficacy after conservative treatment. Perioperative management should be strengthened for those patients with high BMI, accompanying diseases, combined organ resection, and advanced pTNM stage.目的： 分析腹腔镜胃癌D(2)根治术后早期并发症发生和治疗情况，并探讨术后早期并发症影响因素。 方法： 采用病例对照研究方法，回顾性收集华中科技大学同济医学院附属协和医院2015年1月至2017年12月间接受腹腔镜胃癌D(2)根治术的764例患者临床病理资料。病例入选标准：（1）术前均经电子胃镜及活检确诊为胃癌，术后均经病理证实胃癌诊断；（2）术前肿瘤评估未侵犯邻近器官；（3）肿瘤明确无肝脏及远处转移；（4）行胃癌R(0)切除并规范行D(2)淋巴结清扫；（5）签署知情同意书。排除标准：（1）未施行腹腔镜D(2)根治切除者；（2）病理检查确诊为其他类型胃肿瘤者；（3）临床病例资料不完整者。腹腔镜D(2)胃癌根治术后早期并发症是指胃癌患者行腹腔镜D(2)根治术后两周内发生的并发症。根据术后是否发生并发症，将患者分为术后有并发症组和术后无并发症组，应用t检验和χ(2)检验对两组临床资料进行分析比较，将P<0.2的临床病理因素纳入多元logistic回归模型，分析出现术后并发症的危险因素。 结果： 本组764例患者中，693例术后未出现早期并发症（无并发症组），71例（9.3%）术后早期出现并发症（有并发症组）。术后发生并发症的中位时间为3（1~11）d。其中外科并发症发生率7.9%（60/764），包括腹腔出血13例（1.7%），吻合口漏12例（1.6%），切口感染10例（1.3%），吻合口出血8例（1.0%），残胃无力7例（0.9%），腹腔感染4例（0.5%），十二指肠残端漏4例（0.5%），小肠梗阻2例（0.3%）；非外科并发症发生率1.4%（11/764），包括肺部感染6例（0.8%），心血管疾病5例（0.7%）。有2例（0.3%）因腹腔严重感染致败血症而死亡；9例（1.2%）经二次手术治疗后恢复（其中5例为腹腔出血，2例为吻合口漏，2例为十二指肠残端漏），其余患者均经保守治疗后痊愈。相比无并发症组，有并发症组体质指数≥24 kg/m(2)[42.3%（30/71）比24.2%（168/693），χ(2)=10.881，P=0.001]、合并疾病[64.8%（46/71）比33.5%（232/693），χ(2)=27.277，P<0.001]、联合脏器切除[70.4%（50/71）比20.5%（142/693），χ(2)=85.338，P<0.001]及pTNM分期Ⅲ期[70.4%（50/71）比40.1%（278/693），χ(2)=24.196，P<0.001]的患者比例高，术后肛门排气时间晚[（4.2±2.1）d比（2.9±1.2）d，t=4.621，P=0.023]，住院时间明显延长[（34.6±12.6）d比（14.2±6.2）d，t=9.862，P<0.001]，住院费用也显著增高[（126.8±64.5）千元比（85.2±35.8）千元，t=11.235，P<0.001]。多因素分析结果显示，体质指数≥24 kg/m(2)（OR=3.762，95%CI：1.960~8.783，P=0.035）、有合并疾病（OR=8.620，95%CI：1.862~29.752，P<0.001）、进行联合脏器切除（OR=6.210，95%CI：1.357~21.568，P=0.026）和pTNM分期为Ⅲ期（OR=4.752，95%CI：1.214~12.658，P<0.001）是影响腹腔镜胃癌D(2)根治术后早期并发症发生的独立危险因素。 结论： 腹腔镜胃癌D(2)根治术安全可行，术后早期并发症可在治疗后获得满意疗效。对于肿瘤分期晚、体质指数高、有合并疾病及进行联合脏器切除者，要加强围手术期管理。.