引用文本：李坤, 许淑梅, 李洪涛, 等. 新辅助化疗后腹腔镜与开腹胃癌根治术治疗进展期胃癌的疗效对比研究：一项基于倾向评分匹配的回顾性队列研究[J/CD]. 消化肿瘤杂志（电子版）, 2026, 18(3): 415-431.

作者：李坤1，许淑梅1，李洪涛1，陈玉宝2

单位：1. 中国人民解放军联勤保障部队第九四〇医院 普通外科，甘肃 兰州730050；2. 中国人民解放军联勤保障部队第九四三医院 普通外科，甘肃 武威 733000

Authors：Li Kun1, Xu Shumei1, Li Hongtao1，Chen Yubao2

Unit：1. Department of General Surgery, the 940th Hospital of Joint Logistic Support Force, PLA, Lanzhou 730050, Gansu, China；2. Department of General Surgery, the 943rd Hospital of Joint Logistic Support Force, PLA, Wuwei 733000, Gansu, China

摘要：

目的 比较新辅助化疗后腹腔镜与开腹胃癌根治术治疗进展期胃癌的围手术期结果和长期生存结局。方法 回顾性分析2012年1月至2022年12在中国人民解放军联勤保障部队第九四〇医院普外科接受新辅助化疗后行胃癌根治术的537例进展期胃癌患者的临床资料，根据手术方式分为腹腔镜组（n=186）与开腹组（n=351）。采用1∶1倾向评分匹配平衡两组基线资料，卡钳值设为0.02，协变量包括患者的年龄、性别、体重指数、美国麻醉医师协会评分、年龄校正Charlson合并症指数、营养风险筛查2002评分、肿瘤大小、肿瘤位置、肿瘤分化程度、cT分期、cN分期、cTNM分期、手术切除范围、重建方式等基线特征。观察指标包括肿瘤治疗反应及术后病理学结果，围手术期相关指标，术后1、2、3、5年总生存（overall survival, OS）率和无病生存（disease-free survival, DFS）率。采用Kaplan-Meier法计算生存率，Cox比例风险回归模型分析预后影响因素。结果 经倾向评分匹配后成功匹配226例患者（腹腔镜组和开腹组各113例），匹配后两组所有协变量的标准化均数差绝对值均＜0.1。倾向评分匹配后两组的肿瘤治疗反应及术后病理学结果差异无统计学意义（均P＞0.05）。与开腹组相比，腹腔镜组手术时间延长（P=0.002），但腹腔镜组术中出血量较少（P＜0.001）、术后首次下床活动时间更早（P=0.033）、术后胃肠功能恢复时间更快（P＜0.001）、术后住院时间缩短（P=0.001）。两组的淋巴结清扫数目、术后首次进食时间、术后并发症发生率及术后辅助化疗周期数差异均无统计学意义（均P＞0.05）。中位随访时间为65.77（16.85，90.58）个月，腹腔镜组和开腹组术后1、2、3、5年OS率分别为85.84%和83.28%、76.99%和70.32%、64.62%和65.21%、56.64%和58.99%；DFS率分别为71.01%和66.32%、63.72%和59.03%、57.24%和49.86%、52.91%和43.56%，两组差异均无统计学意义（均P＞0.05）。多因素Cox比例风险回归分析显示，肿瘤分化程度（P=0.038）、ypTNM分期（P=0.035）、脉管浸润（P=0.022）、神经浸润（P=0.036）、肿瘤退缩分级（P=0.041）是OS期的独立影响因素；ypTNM分期（P=0.032）、脉管浸润（P=0.015）、神经浸润（P=0.028）、肿瘤退缩分级（P=0.036）是DFS期的独立影响因素。手术方式并非影响患者OS期和DFS期的独立因素（均P＞0.05）。结论 在接受新辅助化疗后的进展期胃癌患者中，腹腔镜手术相较于开腹手术具有明显的微创与快速恢复优势，且在淋巴结清扫、并发症控制及远期生存方面与开腹手术相当。影响患者预后的主要因素为肿瘤病理学特征及新辅助化疗病理缓解情况，而非手术方式。本研究支持在有经验的中心，腹腔镜手术可作为新辅助化疗后进展期胃癌患者的安全有效治疗选择之一。

关键词：进展期胃癌；腹腔镜手术；胃癌根治术；新辅助化疗；倾向评分匹配；生存分析

Abstract：

Objective To compare the perioperative outcomes and long-term survival between laparoscopic radical gastrectomy and open radical gastrectomy for advanced gastric cancer (AGC) after neoadjuvant chemotherapy (NACT). Method A retrospective analysis was conducted on the clinical data of 537 patients with AGC who underwent radical gastrectomy after NACT in the Department of General Surgery of the 940th Hospital of Joint Logistic Support Force, PLA from January 2012 to December 2022. Patients were divided into a laparoscopic group (n=186) and an open group (n=351) based on surgical approach. A 1∶1 propensity score matching (PSM) was used to balance baseline characteristics between the two groups, with a caliper value set at 0.02. Covariates included patient age, sex, body mass index, American Society of Anesthesiologists score, age-adjusted Charlson comorbidity index (aCCI), nutritional risk screening 2002 (NRS 2002) score, tumor size, tumor location, tumor differentiation degree, cT stage, cN stage, cTNM stage, extent of surgical resection, and reconstruction methods. Observation indicators included tumor response and postoperative pathological findings, perioperative outcomes, as well as 1-, 2-, 3-, and 5-year overall survival (OS) and disease-free survival (DFS) rates. The Kaplan-Meier method was used to calculate survival rates, and Cox proportional hazards regression models were employed to analyze prognostic factors. Result After PSM, 226 patients were successfully matched (113 in each group). Baseline characteristics were balanced between the matched groups, with absolute standardized mean differences for all variables<0.1. There were no statistically significant differences in tumor response or postoperative pathological results between the two groups (all P>0.05). Compared to the open group, the laparoscopic group had a longer operative time (P=0.002), less intraoperative blood loss (P<0.001), earlier postoperative ambulation (P=0.033), faster recovery of gastrointestinal function (P<0.001), and a shorter postoperative hospital stay (P=0.001). There were no statistically significant differences between the two groups in the number of lymph nodes harvested, time to postoperative oral intake, the incidence of postoperative complications, and cycles of postoperative adjuvant chemotherapy (all P>0.05). The median follow-up time was 65.77 (16.85, 90.58) months. The 1-, 2-, 3-, and 5-year OS rates in the laparoscopic versus open group were 85.84% vs. 83.28%, 76.99% vs. 70.32%, 64.62% vs. 65.21%, and 56.64% vs. 58.99%, respectively; the corresponding DFS rates were 71.01% vs. 66.32%, 63.72% vs. 59.03%, 57.24% vs. 49.86%, and 52.91% vs. 43.56%, respectively. No statistically significant differences were found in survival rates between the two groups (P>0.05). Multivariate Cox regression analysis showed that tumor differentiation degree (P=0.038), ypTNM stage (P=0.035), lymphovascular invasion (P=0.022), perineural invasion (P=0.036), and tumor regression grade (P=0.041) were independent prognostic factors for OS. ypTNM stage (P=0.032), lymphovascular invasion (P=0.015), perineural invasion (P=0.028), and tumor regression grade (P=0.036) were independent prognostic factors for DFS. Surgical approach was not an independent prognostic factor for either OS or DFS (P>0.05). Conclusion For patients with AGC after NACT, laparoscopic surgery offers significant advantages in terms of minimal invasiveness and faster recovery compared to open surgery, while demonstrating comparable outcomes in lymph node dissection, complication control, and long-term survival. The main factors affecting patient prognosis are tumor pathological characteristics and the degree of pathological response to NACT, rather than the surgical approach. This study supports laparoscopic surgery as a safe and effective option for patients with AGC after NACT in experienced centers.

Key words：Advanced gastric cancer; Laparoscopic surgery; Radical gastrectomy; Neoadjuvant chemotherapy; Propensity score matching; Survival analysis

注：网络优先发布