经肛门与传统腹腔镜全系膜切除术在中低位直肠癌中可行性与安全性的Meta分析

Feasibility and safety of transanal total mesorectal excision and traditional laparoscopic total mesorectal in middle-low rectal cancer: a Meta-analysis

目的系统性评价经肛门全直肠系膜切除(TaTME)与腹腔镜全直肠系膜切除(La TME)治疗中低位直肠癌的术中、术后指标,并发症及其病理学结果,分析Ta TME术式可行性及安全性。方法通过检索Pubmed、EMBase、Cochrane Library、中国知网、万方、重庆维普国内外大型数据库,筛选2015年2月至2019年4月间发表的关于TaTME与LaTME治疗中低位直肠癌的相关文献。文献质量标准采用纽卡斯尔-渥太华量表(NOS),采用Revman 5.3软件进行Meta分析,敏感性分析异质性结果。结果共13篇文献1 096例患者符合纳入标准,包括Ta TME组515例,La TME组581例。与La TME组相比,Ta TME组具有高质量的CRM距离(MD=0.95,95%CI=0.61~1.29,P<0.001),低CRM阳性率(OR=0.35,95%CI=0.16~0.78,P=0.010),高质量的全直肠系膜切除(OR=2.41,95%CI=1.29~4.51,P=0.006),低中转开腹率(OR=0.20,95%CI=0.07~0.58,P=0.003),Clavien-Dindo分级3级及以上术后并发症发生率(OR=0.54,95%CI=0.32~0.92,P=0.020)、术后排尿障碍发生率低(OR=0.54,95%CI=0.31~0.94,P=0.030)及低非计划性二次入院率(OR=0.44,95%CI=0.27~0.73,P=0.001)。两组在DRM阳性率及切除距离、淋巴结清扫数量、术中失血量、手术持续时间以及总并发症、肠梗阻、吻合口瘘发生率等方面差异无统计学意义。结论相较于La TME术式,TaTME治疗中低位直肠癌可以得到更高质量的标本,术后危重并发症发生率明显降低,术式可行且安全。

Objective To systematically evaluate the intraoperative and postoperative indicators,complications and pathological results of transanal total mesorectal excision(Ta TME) and laparoscopic total mesorectal excision(La TME) in the treatment of middle and low rectal cancer, and to analyze the feasibility and safety of Ta TME. Methods The database both at home and abroad including Pubmed,EMBase, Cochrane Library, CNKI, Wanfang, VIP were searched between February 2015 and April 2019.All eligible studies associated with the treatment of middle and low rectal cancer with Ta TME and La TME were systematically analyzed. Newcastle-Ottawa Scale(NOS) and Revman 5.3 software were used to conduct Meta-analysis and sensitivity analysis of heterogeneous results. Results A total of thirteen articles including 1 096 cases met the inclusion criteria, including 515 cases in group Ta TME and 581 cases in group La TME. Compared with group La TME, group Ta TME had longer CRM distance(MD=0.95, 95%CI=0.61-1.29,P<0.001), lower CRM positive rate(OR=0.35, 95%CI=0.16-0.78, P=0.010), higher quality TME(OR=2.41, 95%CI=1.29-4.51, P=0.006), lower rate of conversion to laparotomy(OR=0.20, 95%CI=0.07-0.58, P=0.003), Clavien-Dindo grade≥3 complications(OR=0.54, 95%CI=0.32-0.92, P=0.020), incidence of postoperative urination disorders(OR=0.54, 95%CI=0.31-0.94, P=0.030) and lower unplanned secondary admission(OR=0.44, 95%CI=0.27-0.73, P=0.001). There were no significant differences in DRM positive rate, resection distance, number of lymph node dissection, intraoperative blood loss, duration of operation,incidence of total complications, incidence of intestinal obstruction and anastomotic leakage between the two groups. Conclusion Compared with La TME, Ta TME can obtain higher specimens quality in the treatment of middle and low rectal cancer, the incidence of serious complications after operation is significantly reduced, and the operation is feasible and safe.