不同手术方式对早期非小细胞肺癌患者术后肺功能影响的Meta分析

The influence of different operation to pulmonary function in patients with early stage non-small cell lung cancer: a meta-analysis

目的系统评价肺段切除术与肺叶切除术比较和电视胸腔镜辅助手术(VATS)与传统开胸术比较对早期非小细胞肺癌(non-small cell lung cancer,NSCLC)术后肺功能恢复的影响。方法计算机检索Pub Med、EMbase、The Cochrane Library、CBM和CNKI数据库,检索时限均从建库至2016年10月1日,搜集不同手术方式对早期NSCLC患者术后肺功能影响的临床研究。由2位评价员独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用Rev Man 5.3和Meta Analyst软件进行Meta分析。结果共纳入25个研究,包括2 924例早期NSCLC患者。Meta分析结果表明:(1)与肺叶切除术组比较,肺段切除术组手术前后第一秒用力呼气率的差值(ΔFEV_1%)[MD=–0.03,95%CI(–0.03,–0.03),P<0.001]和手术前后用力肺活量预测值百分比的差值(ΔFVC%)[MD=–0.09,95%CI(–0.11,–0.06),P<0.001]较好;而在手术前后第一秒用力呼气量的差值方面(ΔFEV_1)[MD=0.01,95%CI(–0.10,0.11),P=0.92],两组差异无统计学意义。(2)VATS与传统开胸术比较,VATS组在术前与术后3月的ΔFEV_1[MD=–0.19,95%CI(–0.27,–0.10),P<0.001]、ΔFVC[MD=–0.20,95%CI(–0.37,–0.03),P=0.02]、ΔFEV_1%[MD=–0.03,95%CI(–0.06,–0.01),P<0.001]、术前与术后≥6月最大通气量的差值(ΔMVV)[MD=–5.95,95%CI(–10.38,–1.52),P=0.008]方面均优于传统开胸术组,其差异均有统计学意义;而两组在一氧化碳弥散率的差值(ΔD L C O%)[M D=–0.0 4,9 5%C I(–0.0 9,0.0 2),P=0.1 6]、术前与术后≥6月ΔFEV_1%[MD=–0.02,95%CI(–0.06,0.02),P=0.32]、ΔFEV_1[MD=1.13,95%CI(–0.92,3.18),P=0.28]方面,差异均无统计学意义。结论肺段切除术治疗早期NSCLC对术后肺功能的保护作用优于肺叶切除术。VATS对术后3个月和6个月的通气功能保护作用更好。受纳入研究的数量和质量限制,上述结论尚需开展更多高质量研究予以验证。

Objective To systematically review the postoperative recovery of lung function in patients with early stage non-small cell lung cancer （NSCLC） after different operation, such as lobectomy versus segmentectomy and video- assisted thoracoscopic surgery （VATS） versus traditional open chest surgery. Methods Clinical studies about effect of different surgical methods on lung function in patients with early NSCLC were searched from PubMed, EMbase, The Cochrane Library, CBM and CNKI databases from inception to October ist, 2016. Two researchers independently screened literature, extracted data and evaluated the risk of bias of included studies, and then meta-analysis was conducted by RevMan 5.3 and MetaAnalyst software. Results A total of 25 studies involving 2 924 patients were included. Theresults of meta-analysis showed that： compared with lobectomy group, one-second rate difference （△FEV1%） （MD=-0.03, 95%CI -0.03 to -0.03, P〈0.001） and predictive value of forced vital capacity difference （△FVC%） （MD=-0.09, 95%CI -0.11 to -0.06, P〈0.001） of preoperative to postoperative in segmentectomy group were higher. However, there was no significant difference between two groups in first second forced expiratory volume difference （△FEV1） （MD=0.01, 95%CI -0.10 to 0.11, P=0.92）. Compared with thoracotomy group, VATS group had lower △FEV1 （MD=-0.19, 95%CI -0.27 to -0.10, P〈0.0001）, AFVC （MD=-0.20, 95%CI -0.37 to -0.03, P=0.02）, △FEV1% （MD=-0.03, 95%CI -0.06 to -0.01, P〈0.001） of preoperative to postoperative （≤ 3 months）, and maximum minute ventilation （AMVV） （MD=-5.59, 95%CI -10.38 to -1.52, P=0.008） of preoperative to postoperative （≥ 6 months）. However, there were no statistically significant differences in difference of carbon monoxide diffusion rate （△DLCO%） （MD=-0.04, 95%CI -0.09 to 0.02, P=0.16）, △FEV1% （MD=-0.02, 95%CI -0.06 to 0.02, P=0.32） and AFEV1 （MD=1.13, 95%CI -0.92 to 3.18, P=0.28）. Conclusion The protective effect of segmentectomy on postoperative pulmonary function is better than that of lobectomy. VATS has a protective effect on the ventilation function within 3 months and 6 months after surgery. Due to limited quantity and quality of included studies, the above conclusions are needed to be validated by more high quality studies.