非小细胞肺癌合并慢性阻塞性肺疾病患者围手术期综合管理有效性和安全性的系统评价及Meta分析

Efficacy and safety of perioperative comprehensive management in patients with nonsmall cell lung cancer combined with chronic obstructive pulmonary disease: A systematic review and meta-analysis

目的系统评价围手术期综合管理措施对非小细胞肺癌(non-small cell lung cancer,NSCLC)合并慢性阻塞性肺疾病(chronic obstructive pulmonary disease,COPD)患者的有效性及安全性。方法计算机检索PubMed、EMbase、The Cochrane Library、中国生物医学文献数据库、中国知网、万方数据库,纳入所有关于NSCLC合并COPD的临床研究。检索时间为数据库建库至2017年11月1日。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Stata 14.0软件进行Meta分析。结果共纳入20个研究1 079例NSCLC合并COPD患者。Meta分析结果表明:在肺功能方面,围手术期综合管理可改善患者第一秒用力呼气量(FEV1)、用力肺活量(FVC)、最大自主通气量(MVV)、预计术后一秒率(ppoFEV1%)、肺一氧化碳弥散量(DLCO)和第一秒用力呼气率(FEV1%),且与治疗前的差异有统计学意义[分别为:MD=–0.47,95%CI(–0.62,–0.32),P<0.000 01;MD=–0.17,95%CI(–0.22,–0.11),P<0.000 01;MD=–4.24,95%CI(–5.37,–3.11),P<0.000 01;MD=–7.54,95%CI(–8.33,–6.76),P<0.000 01;MD=–1.33,95%CI(–2.16,–0.50),P=0.002;MD=–6.93,95%CI(–9.45,–4.41),P<0.000 1],但一氧化碳弥散率(DLCO%)和最大负荷量通气(VEmax)方面差异无统计学意义[MD=–2.91,95%CI(–11.31,5.50),P=0.5;MD=0.18,95%CI(–2.23,2.58),P=0.89];在心功能方面,综合管理可改善患者最大摄氧量(VO2max)、6分钟步行距离(6MWD)和无氧阈值(AT),且与治疗前的差异有统计学意义[MD=–2.28,95%CI(–3.41,–1.15),P<0.000 1;MD=–57.77,95%CI(–77.90,–37.64),P<0.000 1;MD=–2.71,95%CI(–3.30,–2.12),P<0.000 1];和常规治疗相比,综合治疗可明显减少术后肺部短期并发症,明显缩短住院时间[OR=0.39,95%CI(0.26,0.58),P<0.000 01;MD=–2.38,95%CI(–3.86,–0.89),P=0.002]。结论围手术期综合管理可明显改善NSCLC合并COPD患者的肺功能,减少术后肺部短期并发症,缩短住院时间,具有良好的有效性及安全性。

Objective To evaluate the efficacy and safety of perioperative comprehensive management in nonsmall cell lung cancer(NSCLC) with chronic obstructive pulmonary disease(COPD). Methods Clinical studies about effect of different perioperative comprehensive management on patients with early NSCLC combined with COPD were searched from PubMed, EMbase, The Cochrane Library, CBM, CNKI and WanFang databases from inception to November 1 st, 2017. 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 Stata 14.0 softwares. Results A total of 20 articles were identified including 1 079 patients. The results of meta-analysis showed that perioperative comprehensive management improved the forced vital capacity(FVC), maximum minute ventilation(MVV), predictive value of postoperative one-second rate(ppoFEV1%), carbon monoxide diffusing capacity(DLCO) and percent forced expiratory volume in one second(FEV1%)(MD=–0.47, 95%CI –0.62 to –0.32, P<0.000 01;MD=–0.17, 95%CI –0.22 to –0.11,P<0.000 01;MD=–4.24, 95%CI –5.37 to –3.11, P<0.000 01;MD=–7.54, 95%CI –8.33 to –6.76, P<0.000 01;MD=–1.33,95%CI –2.16 to –0.50, P=0.002;MD=–6.93, 95%CI –9.45 to –4.41, P<0.000 1, respectively). However, there was no significant difference in the rate of DLCO(DLCO%) and ventilation at maximal workload(VEmax) between pre-and post-management(MD=–2.91, 95%CI –11.31 to 5.50, P=0.5;MD= 0.18, 95%CI –2.23 to 2.58, P=0.89, respectively). With regard to cardiac function, perioperative comprehensive management improved the maximal oxygen consumption(VO2 max), 6-minute walk distance(6 MWD) and anaerobic threshold(AT)(MD=–2.28, 95%CI –3.41 to –1.15, P<0.000 1;MD=–57.77, 95%CI –77.90 to –37.64, P<0.000 1;MD=–2.71, 95%CI –3.30 to –2.12, P<0.000 1, respectively). As to complications, compared with conventional treatment group, perioperative comprehensive management group had fewer postoperative short-term complications(OR=0.39, 95%CI 0.26 to 0.58, P<0.000 01). Besides, perioperative comprehensive management also shortened hospital stay(MD=–2.38, 95%CI –3.86 to –0.89, P=0.002). Conclusion Perioperative comprehensive management can significantly improve lung function in patients with NSCLC combined with COPD,reduce short-term postoperative pulmonary complications and shorten the hospital stay with good efficacy and safety.