胃癌术后残胃发生癌变的Meta分析

Meta-analysis of gastric stump cancer after gastrectomy for gastric cancer

目的研究胃癌术后残胃癌的临床病理特征及预后，比较广义残胃癌与狭义残胃癌的临床病理特征差异，并比较残胃癌与原发近端胃癌根治手术的预后。 方法计算机检索Cochrane Library、Medline、PubMed、万方中文数据库、中国知网（CNKI）和维普期刊网残胃癌相关临床研究文献，检索日期限于建库至2017年12月31日。文献纳入标准：（1）经病理学或组织学证实为胃癌行根治性切除术后残胃上发生的癌，不限定时间间隔；（2）回顾性或前瞻性队列临床研究；（3）至少包含患者性别、胃癌手术吻合方式、诊断残胃癌间隔时间、发生部位、治疗方式、病理分化程度、病理分期、淋巴结转移率、预后等其中一项；（4）同一研究机构或作者发表的相似研究，选取样本量大、最新发表的文献。文献排除标准：（1）摘要、综述、个案报道、会议记录、述评和重复研究；（2）首次疾病非胃癌的研究。将胃癌术后发生的残胃癌分为广义残胃癌（发病不计间隔时间）和狭义残胃癌（间隔时间10年及以上）两组。采用Stata13.0软件进行Meta分析，并用SPSS 21.0进行统计学处理。结果最终纳入27篇文献，共1463例胃癌术后残胃癌患者，其中男性1146例，女性317例。广义残胃癌组和狭义残胃癌组患者分别为921例和542例。两组临床资料比较，首次吻合方式、肿瘤分化类型、病理T分期、术后病理TNM分期以及远处转移率的差异无统计学意义（χ2= 2.341，0.926，0.350，0.965，2.311，均P 〉 0.05）。狭义残胃癌组较广义残胃癌组男性患者（82.8%比75.7%，χ2= 9.909，P= 0.002）、肿瘤位于吻合口处者（37.8%比26.1%，χ2= 18.091，P= 0.000）、行根治性切除术者（84.2%比70.3%，χ2= 11.738，P= 0.001）以及术后淋巴结阳性者（45.8%比34.5%，χ2=6.319，P= 0.012）比例更高，肿瘤体积更大[（5.9 ± 2.2）cm比（4.5 ± 1.9）cm，t= 9.151，P= 0.000]。狭义残胃癌组5年总体生存人数和术后病理Ⅲ～Ⅳ期5年生存人数比例均高于广义残胃癌组（42.7%比30.6%，χ2= 10.938，P= 0.000；27.5%比18.1%，χ2= 4.128，P= 0.042）；而术后病理Ⅰ～Ⅱ期的两组其5年生存人数比例差异则无统计学意义（67.3%比67.0%，χ2= 0.015，P= 0.92）。残胃癌与原发近端胃癌根治性切除术后5年生存率差异无统计学意义（RR= 1.04，95%CI：0.79～1.36，P= 0.805）；相同病理分期的两组患者5年生存率差异也无统计学意义（Ⅰ～Ⅱ期：RR= 1.08，95%CI：0.93～1.26，P= 0.328；Ⅲ～Ⅳ期：RR= 0.59，95%CI：0.33～1.04，P= 0.111）。结论胃癌术后的广义与狭义残胃癌临床病理特征存在部分差异，而其预后与原发近端胃癌相同。

Objective To study the clinicopathological features and prognosis of gastric stump cancer （GSC） following subtotal gastreetomy for gastric cancer, to compare the elinieopathologiedifferences between narrow GSC and generalized GSC, and to compare the prognosis between GSC and primary proximal gastric cancer （PPGC） after radical resection. Methods Literatures of GSC-associated clinical study were searched by computer from the Cochrane Library, Medline, PubMed, CNKI, Wanfang and VIP databases, and the retrieval period was from the establishment of database to December 31, 2017. Inclusion criteria： （1）GSC was defined as a carcinoma arising in the gastric remnant after radical gastrectomy for gastric cancer, and confirmed by the pathological or histological examination, the elapsed time from the initial operation was not considered in the definition. （2） Retrospective or prospective clinical cohort study. （3） Study included at least one of below items： gender, anastomotic type in gastric cancer surgery, the interval between the initial surgery and diagnosis of GSC, the location, treatment, pathological differentiation, pathologic stage, lymph node metastasis rate and prognosis of GSC. （4） When similar studies were reported by the same institution or author, either the better quality study or the newest publication was chosen. Exclusion criteria： （1） Abstracts, reviews, case reports, meeting record, editorials and repeated research. （2） Studies including patients with initial non-gastric cancer. In this study, gastric stump cancer（GSC） after gastric cancer was divided into two groups： the incidence without limit interval time （generalized GSC group） and above 10 years （narrow GSC group）. Selective trials were Meta-analyzed by the Stata13.0 software and statistical analysis was performed using SPSS 21.0 software. Results A total of 27 literatures were finally enrolled, which comprised 1463 GSC patients, including 1146 males and 317 females. The generalized group and narrow GSC group had 921 and 542 patients respectively. The generalized GSC group and the narrow GSC group did not significantly differ in terms of previous reconstruction mode, types of differentiation, pathologic T staging, postoperative pathology tumor-node-metastases staging, and distant metastasis rate （X2= 2.341, 0.926, 0.350, 0.965, 2.311 respectively, all P 〉 0.05）. As compared to generalized GSC group, narrow GSC group had higher ratio of male patients （82.8% vs. 75.7%, X2=9.909, P=0.002）, more lesions locating in anastomotic stoma （37.8% vs. 26.1%, X2= 18.091, P=0.000）, higher ratio of patients undergoing radical resection （84.2% vs. 70.3%, X2= 11.738, P = 0.001 ）, higher positive rate of postoperative lymph node （45.8% vs. 34.5%, X2 = 6.319, P = 0.012）, and larger size of tumor [（5.9±2.2） cm vs. （4.5±1.9） cm, t = 9.151, P= 0.000]. The overall 5-year survival rate and postoperative pathology stage Ⅲ～Ⅳ survival ratio in narrow GSC group were higher compared to general GSC group （42.7% vs. 30.6% and 27.5% vs. 18.1%, respectively）, which were significantly different （X2 = 10.938, P = 0.000; X2 = 4.128, P = 0.042）, while the postoperative pathology stage Ⅰ～Ⅱ survival ratio was not significantly different between two groups （67.3% vs. 67.0% respectively, X2= 0.015, P= 0.92）. There was no significant difference in the 5-year survival rate between GSC with radical resection and PPGC （RR= 1.04, 95%CI：0.79-1.36, P = 0.805） and the 5-year survival rate of same postoperative pathology stage was not significantly different between two groups （ Ⅰ～Ⅱ stage： RR = 1.08, 95%CI：0.93-1.26, P = 0.328; Ⅲ～Ⅳ stage： RR = 0.59, 95%CI： 0.33-1.04, P = 0.111 ）. Conclusions There are some different clinicopathological features between the generalized and the narrow GSC after gastric cancer surgery. The prognosis of GSC after radical resection is similar to primary proximal gastric cancer.