腹腔镜与开腹手术比较治疗肝癌合并肝硬化患者疗效的Meta分析

Efficacy of laparoscopic versus open hepatectomy on the hepatocellular carcinoma patients with cirrhosis:a meta-analysis

目的比较腹腔镜肝切除(LH)与开腹肝切除(OH)治疗肝癌合并肝硬化的疗效。方法计算机检索Pub Med、EMbase、Web of Science、The Cochrane Library、CBM、Wan Fang Data和CNKI数据库,搜集比较LH与OH治疗肝癌合并肝硬化患者疗效的队列研究,检索时限均从建库至2017年11月31日。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用Rev Man 5.3软件进行Meta分析。结果共纳入15个队列研究,包括1 720例患者。Meta分析结果显示:与OH相比,LH术中出血量更少[MD=–226.94,95%CI(–339.87,–114.01),P<0.000 1]、输血率更低[OR=0.48,95%CI(0.27,0.83),P=0.009]、并发症更少[OR=0.32,95%CI(0.23,0.45),P<0.000 01]、住院时间更短[MD=–3.66,95%CI(–5.19,–2.14),P<0.000 01]、死亡率更低[OR=0.47,95%CI(0.24,0.92),P=0.03]、切缘较宽[OR=0.78,95%CI(0.20,1.36),P=0.009],1年生存率[OR=2.47,95%CI(1.35,4.51),P=0.003]、3年生存率[OR=1.62,95%CI(1.11,2.36),P=0.01]、5年生存率[OR=1.58,95%CI(1.19,2.10),P=0.002]及1年无病生存率[OR=1.69,95%CI(1.20,2.39),P=0.003]更高。但两组在手术时间[MD=28.64,95%CI(–7.53,64.82),P=0.12]、肿瘤大小[MD=–0.37,95%CI(–0.75,0.02),P=0.06]、3年无病生存率[OR=1.14,95%CI(0.86,1.51),P=0.36]和5年无病生存率[OR=0.99,95%CI(0.77,1.28),P=0.97]方面差异无统计学意义。结论 LH治疗肝癌合并肝硬化患者的术中、术后短期效果更好,且具有较好的长期预后。受纳入研究数量和质量限制,上述结论尚待更多高质量研究予以验证。

Objectives To systematically review the efficacy of laparoscopic hepatectomy （LH） and open hepatectomy （OH） on the hepatocellular carcinoma patients with cirrhosis. Methods PubMed, EMbase, Web of Science, The Cochrane Library, CBM, CNKI, WanFang Data and VIP databases were searched online to collect the cohort studies of LH vs. OH on hepatocellular carcinoma patients with cirrhosis from inception to November 31^st, 2017. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies, then, meta-analysis was performed by using RevMan 5.3 software. Results A total of 15 cohort studies involving 1 720 patients were included. The results of meta-analysis showed that： compared with OH, LH had less blood loss （MD=-226.94, 95%CI -339.87 to -114.01, P〈0.000 1）, lower transfusion rate （OR=0.48, 95%CI 0.27 to 0.83, P=0.009）, less occurrence of complications （OR=0.32, 95%CI 0.23 to 0.45, P〈0.000 01）, shorter postoperative hospital stay （MD=-3.66, 95%CI -5.19 to -2.14, P〈0.000 01）, lower mortality rate （OR=0.47, 95%CI 0.24 to 0.92, P=0.03）, wider surgical margin （OR-0.78, 95%CI 0.20 to 1.36, P=0.009）, higher 1, 3 and 5-year survival rate （OR-2.47, 95%CI 1.35 to 4.51, P=0.003; OR=1.62, 95%CI 1.11 to 2.36, P=0.01; OR=1.58, 95%CI 1.19 to 2.10, P=0.002, respectively） and 1-year disease free survival rate （OR-1.69, 95%CI=1.20 to 2.39, P=0.003）. There were no significant differences in operation time （MD=28.64, 95%CI -7.53 to 64.82, P=0.12）, tumor size （MD=-0.37, 95%CI -0.75 to 0.02, P=0.06）, 3-year disease free survival rate （OR=1.14, 95%CI 0.86 to 1.51, P=0.36） and 5-year disease free survival rate （OR=0.99, 95%CI 0.77 to 1.28, P=0.97） between the two groups. Conclusions The perioperation and short-term postoperative outcomes of LH are significant in HCC patients with cirrhosis, and which have good long-term prognosis. Due to limited quality and quantity of the included studies, more high quality studies are required to verify above conclusions.