微创与开腹胰十二指肠切除术围手术期安全性的Meta分析

Perioperative safety of minimally invasive and open pancreaticoduodenectomy： a Meta analysis

目的 系统评价微创与开腹胰十二指肠切除术围手术期的安全性.方法 以laparoscopic、laparoscopy、robotic、da Vinci、minimally invasive、pancreaticoduodenectomy、微创、腹腔镜、机器人、胰十二指肠切除术为关键词检索1989年至2013年中国期刊全文数据库（CNKI）、维普中文期刊数据库、PubMed、The Cochrane Library以及EMBASE等数据库中关于微创和开腹胰十二指肠切除术的随机对照研究和非随机对照研究.按照纳入与排除标准筛选文献,将纳入文献的患者分为微创手术组和开腹手术组,并将微创手术组进一步分为腹腔镜组和机器人组.提取数据后用RevMan 5.2软件进行Meta分析,比较微创与开腹行胰十二指肠切除术的疗效.计数资料采用优势比（OR）及95％可信区间（95％CI）表示,计量资料采用加权均数差（WMD）及95％ CI表示.采用I2对纳入的文献进行异质性分析.采用漏斗图分析可能潜在的发表偏倚,采用敏感性分析检测研究结果的稳定性.结果 10篇文献纳入本研究,共计690例患者,其中微创手术组235例（腹腔镜组128例,机器人组107例）,开腹手术组455例.Meta分析结果显示：微创手术组和开腹手术组围手术期总体并发症发生率、胰瘘发生率、胃排空障碍发生率、术后出血发生率、胆瘘发生率、再次手术率、病死率以及淋巴结清扫数目比较,差异无统计学意义（OR=0.75,1.01,0.98,1.50,0.94,0.56,1.06,WMD=2.29,95％ CI：0.40 ～ 1.41,0.67 ～ 1.53,0.55 ～ 1.77,0.76～2.94,0.37 ～2.38,0.26～ 1.20,0.48 ～2.32,-0.55～5.13,P＞0.05）.虽然微创手术组手术时间显著长于开腹手术组,但是微创手术组术中出血量显著减少,术后住院时间显著缩短,R0切除率显著提高（WMD=99.57,-355.70,-3.30,OR=0.49,95％ CI：36.99～162.15,-608.38 ～-103.01,-6.58～0.03,0.26～0.92,P＜0.05）.腹腔镜组手术时间显著长于开腹手术组（WMD =93.17,95％ C1：55.98 ～ 130.37,P＜0.05）.机器人组手术时间与开腹手术组相当（WMD=122.96,95％ CI：-48.48 ～ 294.40,P＞0.05）.腹腔镜组患者术后住院时间与开腹手术组比较,差异无统计学意义（WMD=-0.81,95％ CI：-5.08 ～ 3.45,P＞0.05）.机器人组患者术后住院时间显著短于开腹手术组（WMD=-6.82,95％CI：-13.21 ～-0.44,P＜0.05）.结论 微创手术的围手术期安全性与开腹手术相当,并且具有出血少和恢复快的优势.机器人进行手术可以明显缩短手术时间.在符合微创手术指征及难度不大时可行微创胰十二指肠切除术.

Objective To evaluate the perioperative safety of minimally invasive and open pancreaticoduodenectomy （PD）.Methods The China National Knowledge Infrastructure,VIP,PubMed,The Cochrane Library and EMBASE were searched with the key words of laparoscopic,laparoscopy,robotic,da Vinci,minimally invasive,pancreaticoduodenectomy,微创,腹腔境,机器人,胰十二指肠切除术 to retrieve literatures on minimally invasive and open pancreaticoduodenectomy.All the patients were divided into the minimally invasive PD group and the open PD group,and the patients in the minimally invasive PD group were further divided into the robotic PD group and the laparoscopic PD group.A meta analysis was carried out using the RevMan 5.2 software.The count data were represented by the odds ratio （OR） and 95% confidence interval （95% CI）,and the measurement data were represented by the weighted mean difference （WMD） and 95 % CI.Heterogeneity of the publication was analyzed using chi-square test,and the publication bias was analyzed using the funnel plots.The stability of results was analyzed using the sensitivity analysis.Results Ten literatures including 690 patients were selected.There were 235 patients in the minimally invasive PD group,and 455 in the open PD group; 107 patients were in the robotic PD group and 128 in the laparoscopic PD group.There were no significant difference in the incidence of postoperative complications,pancreatic fistula,delayed gastric emptying,postoperative hemorrhage,bile leakage,reoperation,mortality and number of lymph nodes dissected between the minimally invasive PD group and the open PD group （OR =0.75,1.01,0.98,1.50,0.94,0.56,1.06,WMD =2.29,95% CI：0.40-1.41,0.67-1.53,0.55-1.77,0.76-2.94,0.37-2.38,0.26-1.20,0.48-2.32,-0.55-5.13,P 〉 0.05）.Although the operation time of the minimally invasive PD group was significantly longer than the open PD group,lesser volume of blood loss,shorter duration of postoperative hospital stay and higher R0 resection rate was detected in the minimally invasive PD group （WMD =99.57,-355.70,-3.30,OR =0.49,95% CI：36.99-162.15,-608.38--103.01,-6.58-0.03,0.26-0.92,P 〈 0.05）.The operation time of the laparoscopic PD group was significantly longer than that of the open PD group （WMD =93.17,95% CI：55.98-130.37,P 〈 0.05）.The operation time of the robotic PD group was comparable to that of the open PD group （WMD =122.96,95% CI：-48.48-294.40,P 〉 0.05）.There was no significant difference in the duration of postoperative hospital stay between the laparoscopic PD group and the open PD group （WMD =-0.81,95% CI：-5.08-3.45,P 〉 0.05）.The operation time of the robotic PD group was significantly shorter than that of the open PD group （WMD=-6.82,95%CI：-13.21--0.44,P〈0.05）.Conclusions The perioperative safety of minimally invasive PD was comparable to open PD.Minimally invasive PD has the advantages of lesser blood loss and quick recovery of patients.Robotic PD could significantly decrease the operation time.Minimally invasive PD could be a reasonable alternative when the requirement of indications is fulfilled.