目的 探讨腹腔镜胃中上部癌保脾脾门淋巴结清扫手术时间延长的相关因素及其对患者疗效的影响.方法 采用回顾性病例对照研究方法.收集2011年1月至2013年12月福建医科大学附属协和医院317例胃中上部癌患者的临床病理资料.患者行腹腔镜胃中上部癌保脾脾门淋巴结清扫术.以中位手术时间为截点,手术时间≥24 min定义为长时间组(148例),手术时间＜24 min定义为短时间组(169例).首先分析影响腹腔镜胃中上部癌保脾脾门淋巴结清扫手术时间的相关因素,进一步探讨手术时间对患者术后的影响.正态分布的计量资料以(x)±s表示,采用独立样本t检验.计数资料和单因素分析采用x2检验,多因素分析采用Logistic回归模型.结果 单因素分析结果显示:患者性别、BMI、脾叶动脉支数、脾叶动脉分型、胃短动脉支数、术者经验是影响脾门淋巴结清扫手术时间延长的危险因素(x2=7.268,21.551,14.960,23.791,6.987,26.995,P＜0.05).多因素分析结果显示:男性、BMI≥25 kg/m2、脾叶动脉支数≥3支、分散型脾叶动脉、术者经验≤40例是影响其手术时间延长的独立危险因素(OR=2.935,8.539,2.775,2.084,8.555;95％可信区间:1.485 ～5.802,2.979 ～ 24.476,1.279 ～6.021,1.217～3.569,3.239 ～22.592,P＜0.05).长时间组患者脾门区域出血量为(19±11)mL,术后进食半流质食物时间为(9.0±5.7)d,术后住院时间为(13 ±9)d,短时间组患者分别为(13±10)mL、(7.8±2.4)d和(12 ±5)d,两组比较,差异有统计学意义(t=5.274,2.501,2.147,P＜0.05).317例患者发生术后并发症23例.其中长时间组并发症发生率为5.41％(8/148),短时间组为8.88％(15/169),两组并发症发生率比较,差异无统计学意义(x2=1.223,P＞0.05).长时间组与短时间组患者病死率分别为0.68％(1/148)和0.59％(1/169),两组比较,差异无统计学意义(x2=0.009,P＞0.05).结论 腹腔镜胃中上部癌保脾脾门淋巴结清扫手术时间延长与患者性别、BMI、脾叶动脉支数、脾叶动脉分型和术者经验密切相关.初学者应选择合适的患者开展该技术,以缩短手术的时间,有利于患者术后恢复.%Objective To explore the impact factors and effect of longer operation time of laparoscopic spleen-preserving splenic hilar lymph node dissection (SHLND).Methods The method of retrospective casecontrol study was adopted.The clinicopathological data of the 317 patients with upper-or middle-third gastric cancer who underwent laparoscopic spleen-preserving SHLND at the Fujian Medical University Union Hospital between January 2011 and December 2013 were collected.Median operation time was served as a cut-off point, 148 patients with operation time ≥24 minutes and 169 patients with operation time ＜ 24 minutes were allocated into the long time group and short time group, respectively.Impact factors affecting the operation time of laparoscopic spleen-preserving SHLND were analyzed firstly, and then operation time affecting clinical effect of patients was explored.Measurement data with normal distribution were presented as (x) ± s and analyzed using an independent sample t test.Count data and univariate analysis were done using the chi-square test.Multivariate analysis was done using the Logistic regression model.Results The gender, body mass index (BMI), number of splenic lobar arteries, type of splenic lobar arteries, number of short gastric arteries and experiences of surgeons were factors affecting longer operation time of SHLND in the univariate analysis (x2 =7.268, 21.551, 14.960, 23.791, 6.987, 26.995, P ＜ 0.05).The male, BMI ≥ 25 kg/m2 , splenic lobar arteries ≥ 3, dispersion-type of splenic lobar arteries and experiences of surgeons≤40 cases were independent risk factors affecting longer operation time of laparoscopic spleen-preserving SHLND in the multivariate analysis (OR =2.935, 8.539, 2.775, 2.084, 8.555;95％ confidence interval: 1.485-5.802, 2.979-24.476, 1.279-6.021, 1.217-3.569, 3.239-22.592, P ＜ 0.05).The volume of blood loss in the splenic hilar area, time for postoperative semi-fluid diet intake and duration of postoperative hospital stay were (19 ± 11) mL, (9.0 ± 5.7) days and (13 ± 9) days in the long time group and (13 ± 10)mL, (7.8 ±2.4)days and (12 ± 5)days in the short time group,respectively, with significant differences between the 2 groups (t =5.274, 2.501,2.147, P ＜ 0.05).Of 317 patients, 23 patients had postoperative complications, with the incidence of complications was 5.41％ (8/148) in the long time group and 8.88％ (15/169) in the short time group, with no significant difference between the 2 groups (x2=1.223, P ＞0.05).The mortalities were 0.68％ (1/148)in the long time group and 0.59％ (1/169)in the short time group, with no significant difference between the 2 groups (x2 =0.009, P ＞ 0.05).Conclusion Longer operation time of laparoscopic spleen-preserving SHLND is closely associated with gender, BMI, number of splenic lobar arteries, type of splenic lobar arteries and experiences of surgeons, and it should be performed selectively for inexperienced surgeons in order to reduce operation time and enhance postoperative recovery of patients.
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