MethodsThe retrospective case-control study was conducted. The clinicopathological data of 506 patients (328 males and 178 females, average age 60 years with the range of 24-85 years) who underwent laparoscopic radical distal gastrectomy+ D2 lymph nodes dissection in the 8 clinical centers between March 2016 and November 2018 were collected, including 143 in the First Affiliated Hospital of Xiamen University, 66 in the Affiliated Hospital of Qinghai University, 66 in the Second Affiliated Hospital of Wenzhou Medical University, 64 in the Zhongshan Hospital of Xiamen University, 54 in the Affiliated Hangzhou First people′s Hospital of Zhejiang University School of Medicine, 48 in the Zhangzhou Affiliated Hospital of Fujian Medical University, 35 in the Affiliated Quanzhou First Hospital of Fujian Medical University, 30 in the Second Affiliated Hospital of Xiamen Medical College. The maximum thickness of subcutaneous fat at the level of umbilicus (USCF), the maximum vertical distance between the anterior abdominal skin and the back skin at the level of the umbilicus (UAPD), the maximum horizontal distance between the anterior abdominal skin and the back skin at the level of the umbilicus (UTD), the maximum vertical distance between the anterior abdominal skin and the back skin at the level of the xiphoid bone (XAPD), the maximum horizontal distance between the anterior abdominal skin and the back skin at the level of the xiphoid bone (XTD), the distance between the anterior abdominal skin and the root of celiac artery (CAD) and the maximum horizontal distance at a right angle to CAD (CATD) were measured using preoperative imaging examinations. Observation indicators: (1) intraoperative and postoperative situations; (2) follow-up situations; (3) risk factors analysis of perioperative complications; (4) influence of body shape related indexes on intraoperative situations and postoperative recovery: ① Pearson univariate correlation analysis, ② liner regression model analysis. Follow-up using outpatient examination and telephone interview was performed to detect the postoperative survival and tumor recurrence or metastasis up to December 2018. Measurement data with normal distribution were represented as Mean±SD. Measurement data with skewed distribution were described as M (range). Comparisons of count data were analyzed using the chi-square test. Comparisons of ordinal data were analyzed by Mann-Whitney U non-parametric test. Risk factors of perioperative complications of laparoscopic distal gastrectomy were analyzed by Logistic regression model. Influence of body shape related indexes on intraoperative situations and postoperative recovery was analyzed by Pearson univariate correlation analysis and liner regression model.
Results(1)Intraoperative and postoperative situations: all the 506 patients underwent successful laparoscopic distal gastrectomy, including 103 with Billroth Ⅰ anastomosis, 140 with Billroth Ⅱ anastomosis, 201 with Billroth Ⅱ+ Braun anastomosis, 62 with Roux-en-Y anastomosis. The operation time, volume of intraoperative blood loss, number of lymph nodes dissected, time to postoperative anal exsufflation, time for initial fluid diet intake, time for initial semi-fluid diet intake and duration of postoperative hospital stay were (233±44)minutes, (102±86)mL, 34±13, (3.6±1.5)days, (5.8±3.3)days, (8.3±3.8)days, (12.2±5.7)days respectively in the 506 patients. Of 506 patients, 196 were defined as pathological stage Ⅰ, 122 were defined as pathological stage Ⅱ and 188 were defined as pathological stage Ⅲ postoperatively. Of 506 patients, 93 had 106 times of perioperative complications, including 33 times of pulmonary and upper respiratory infection, 12 times of incisional infection, 11 times of anastomotic leakage, 11 times of abdominal infection, 8 times of intestinal obstruction, 8 times of gastroplegia, 6 times of abdominal hemorrhage, 5 times of bacteremia, 3 times of anastomotic hemorrhage, 3 times of lymph fluid leakage, 2 times of pancreatic leakage, 1 time of urinary infection, 1 time of anatomotic stenosis, 1 time of deep venous thrombosis and 1 time of pulmonary embolism; the same patient can merge multiple complications. Eleven patients were in the Clavien-Dindo classification ≥Ⅲ. (2) Follow-up situations: 465 of 506 patients were followed up for 1-32 months with a median time of 12 months. During the follow-up, 451 had postoperative survival and 38 had tumor recurrence or metastasis. (3) Risk factors analysis of perioperative complications. ① Results of univariate analysis showed that age, body mass index(BMI), preoperative hemoglobin, preoperative serum albumin and XAPD were related factors affecting perioperative complications of laparoscopic distal gastrectomy (χ2=10.289, 7.427, 5.269, 5.481, 4.285, P<0.05). ② Results of multi-variate analysis showed that age, BMI, preoperative serum albumin were independent related factors affecting perioperative complications of laparoscopic distal gastrectomy (odds ratio=1.033, 1.118, 0.937, 95% interval confidence: 1.011-1.057, 1.025-1.219, 0.887-0.990, P<0.05). (4) Influence of body shape related indexes on intraoperative situations and postoperative recovery. ① Results of Pearson univariate correlation analysis showed correlations between UAPD, XAPD, CAD, CATD and volume of intraoperative blood loss (r=0.107, 0.169, 0.179, 0.106, P<0.05), between UAPD, XAPD, CAD and the number of lymph nodes dissected (r=-0.137, -0.143, -0.173, P<0.05), between USCF, XAPD and time to postoperative anal exsufflation (r=0.122, 0.109, P<0.05), between USCF, XAPD, CAD and time for initial fluid diet intake (r=0.132, 0.108, 0.132, P<0.05), between USCF, XAPD and duration of postoperative hospital stay (r=0.116, 0.100, P<0.05). ② Results of liner regression model analysis showed a positive correlation between CAD and volume of intraoperative blood loss (r=6.776), a negative correlation between CAD and the number of lymph nodes dissected (r=-0.841), with statistically significant differences (t=2.410, -1.992, P<0.05); a positive correlation between USCF and time to postoperative anal exsufflation (r=0.170), between USCF and time for initial fluid diet intake (r=0.365), between USCF and duration of postoperative hospital stay (r=0.636) respectively, with statistically significant differences (t=2.188, 1.981, 2.107, P<0.05).
