腹腔镜下全系膜切除术与开腹根除术治疗直肠癌的Meta分析

Laparoscopic Total Mesorectal Excision versus Open Total Mesorectal Excision for Rectal Cancer: A Meta-Analysis

目的系统性评价腹腔镜下全系膜切除术(laparoscopic total mesorectal excision,LTME)与开腹全系膜根除术(open total mesorectal excision,OTME)治疗直肠癌的有效性及安全性。方法计算机检索PubMed、The Cochrane Library(2014年第4期)、EMbase、CNKI、CBM及WanFang Data,查找所有比较LTME与OTME根治直肠癌有效性及安全性的随机对照试验(RCT),检索时限均为从建库至2014年4月8日。同时手检纳入研究的参考文献。由2位评价者按照纳入与排除标准独立筛选文献、提取资料和评价纳入研究的方法学质量后,采用RevMan 5.2软件进行Meta分析。结果最终纳入15个RCT,共2 268例患者。Meta分析结果显示:1有效性方面,两组切除肠管长度[MD=–0.52,95%CI(–1.29,0.25),P=0.18]、清扫淋巴结数目[MD=–0.11,95%CI(–0.75,0.52),P=0.73]、1年生存率[RR=0.99,95%CI(0.96,1.02),P=0.52]、3年生存率[RR=0.99,95%CI(0.93,1.04),P=0.63]无明显差异;LTME组的5年生存率低于OTME组[RR=1.23,95%CI(1.01,1.50),P=0.04]。2安全性方面,与OTME组相比,LTME手术时间更长[MD=29.64,95%CI(14.90,44.39),P<0.000 1],术中出血量更少[MD=–105.51,95%CI(–133.95,–77.08),P<0.000 01],术后留置导尿管时间[MD=–2.02,95%CI(–2.20,–1.83),P<0.000 01]、术后肛门排气时间[MD=–0.99,95%CI(–1.35,–0.62),P<0.000 01]和住院时间更短[MD=–3.47,95%CI(–4.20,–2.74),P<0.000 01];LTME术后吻合口瘘[RR=0.67,95%CI(0.37,1.22),P=0.19]和切口感染发生率[RR=0.43,95%CI(0.26,0.73),P=0.002]更低,但两组肠梗阻发生率[RR=0.53,95%CI(0.28,1.00),P=0.05]无明显差异。结论现有证据表明,LTME和OTME有效性无明显差异,但LTME术中出血量少、留置导尿管时间短、术后肛门排气时间短、住院时间短、术后并发症少。受纳入研究数量和质量所限,上述结论尚需进一步开展更多大样本、多中心、高质量的RCT加以验证。

Objective To systematically review the ettectiveness and safety of laparoscopic total mesorectal. excision（LTME） vs. open total mesorectal excision （OTME） in treating rectal cancer. Methods Randomized controlled trials （RCTs） about LTME vs. OTME for rectal cancer were searched in PubMed〉 The Cochrane Library （Issue 4, 2014）, EMbase, CNKI, CBM and WanFang Data from the date of their establishment to April 2014. Other relevant journals and references of included studies were also searched manually. Two reviewers independently screened literature according to the inclusion and exclusion criteria, extracted data and assessed methodological quality of included studies. Meta-analysis was then conducted using RevMan 5.2. Results A total of fifteen RCTs involving 2 268 patients were enrolled, The re- sults of meta-analysis indicated that： a） for effectiveness, LTME and OTME were alike in resection length of the intestine （MD= -0.52, 95%CI -1.29 to 0.25, P=0.18）, dissection number of lymph nodes （MD= -0.11, 95%CI -0.75 to 0.52, P=0.73）, 1-year survival rate （RR=0.99, 95%CI 0.96 to 1.02, P=0.52）, and 3-year survival rate （RR=0.99, 95%CI 0.93 to 1.04, P=0.63） with no significant difference. For safety, LTME had longer operation time （MD=29.64, 95%CI 14.90 to 44.39, P〈0.000 1）; caused less intra-operative bleeding （MD= -105.51, 95%CI -133.95 to -77.08, P〈0.000 01）; and shortened post-operative anal exsufflation time （MD= -0.99,95%CI -1.35 to -0.62, P〈0.000 01）, catheterization time （MD= -2.02, 95%CI -2.20 to-1.83, P〈0.000 01） as well as hospital stay （MD-- -3.47, 95%CI -4.20 to -2.74, P〈0.000 01）. Besides, LTME had less post- operative complications such as anastomotic leak （RR=0.67, 95%CI 0.37 to 1.22, P^0.19） and wound infection （RR=0.43, 95%CI 0.26 to 0.73, P=0.002）. However, LTME and OTME were alike in the incidence of intestinal obstruction （RR=0.53, 9S%CI 0.28 to 1.00, P--0.05）. Conclusion Current evidence indicates that LTME and OTME are alike in effectiveness, but LTME could cause less bleeding, shorten time of catheterization, post-operative anal exsufflation and hospital stay with less post-operative complications. Due to the limited quantity and quality of the included studies, more larger sam- ple, multicenter, high quality RCTs are needed to verify the above conclusion.