直肠癌根治术保留左结肠动脉的疗效评价与Meta分析

Efficacy evaluation and meta⁃analysis of left colonic artery preservation in radical resection of rectal cancer

目的采用系统评价的方法来探讨直肠癌根治术中保留左结肠动脉(LCA)与不保留LCA对病人术后近远期疗效的差异。方法通过检索维普、中国知网、万方、PubMed、Cochrane、EMBase等数据库中关于直肠癌根治术术中不同位置结扎肠系膜下动脉(IMA)的所有相关文献,检索年限为数据库建库以来至2019年1月。根据文献纳入和排除标准,两位研究人员独立进行文献的筛选、数据提取和质量评价,最后进行结果分析。结果最终纳入20篇文献,共有5652例研究对象纳入研究,其中不保留LCA组有2589例,保留LCA组有3063例。在直肠癌根治性切除术中未保留LCA组,在吻合口漏发生率(OR=1.56,95%CI:1.31~1.86,P<0.00001)、吻合口残端缺血性改变(OR=5.32,95%CI:2.37~11.91,P<0.0001)、预防性造口发生率(OR=1.74,95%CI:1.48~2.04,P<0.00001)均较保留组高且差异有统计学意义,而在IMA根部淋巴结清扫数(MD=-0.09,95%CI:-0.22~0.04,P=0.19)、术后尿潴留发生率(OR=1.08,95%CI:0.80~1.45,P=0.62)、术后性功能障碍(OR=0.98,95%CI:0.61~1.58,P=0.92)、术后住院时间(MD=0.03,95%CI:-0.18~0.24,P=0.76)、局部复发(OR=1.30,95%CI:0.61~2.79,P=0.50)、远处转移(OR=1.15,95%CI:0.65~2.05,P=0.63)两组均差异无统计学意义。结论直肠癌根治术保留LCA组与不保留组相比,在降低术后吻合口漏的发生率同时肿瘤的根治性能够得到保障,并不会增加术后相关并发症,且两组远期疗效差异无统计学意义。

Objective A systematic review was conducted to investigate the difference between the left and right colonic artery(LCA)preservation and non⁃LCA preservation in patients with radical rectal cancer after surgery.Methods All literatures related to ligation of the inferior mesenteric artery(IMA)at different locations during radical rectal cancer surgery were retrieved from da⁃tabases including VIP,CNKI,WanFang,PubMed,Cochrane,EMBase,etc.The retrieval period was from the establishment of the da⁃tabase to January 2019.Based on the inclusion and exclusion criteria,the two researchers independently performed literature screen⁃ing,data extraction and quality assessment,and finally performed the analysis.Results A total of 20 articles were included,and 5652 patients were included in the study,of which 2589 patients did not retain the left colon artery and 3063 patients retained the left colon artery.The incidence of anastomotic leakage(OR=1.56,95%CI:1.31⁃1.86,P<0.00001),ischemic changes of anastomot⁃ic stump(OR=5.32,95%CI:2.37⁃11.91,P<0.0001)and prophylactic stoma(OR=1.74,95%CI:1.48⁃2.04,P<0.00001)were all higher in the group without LCA during radical resection of rectal cancer,and the differences were statistically significant.How⁃ever,no differences were found between the two group in the IMA root lymph node dissection(MD=-0.09,95%CI:-0.22⁃0.04,P=0.19),postoperative incidence of urinary retention(OR=1.08,95%CI:0.80⁃1.45,P=0.62),postoperative sexual dysfunction(OR=0.98,95%CI:0.61⁃1.58,P=0.92),postoperative length of hospital stay(MD=0.03,95%CI:-0.18-0.24,P=0.76),local recur⁃rence(OR=1.03,95%CI:0.61⁃2.79,P=0.50)and distant metastasis(OR=1.15,95%CI:0.65⁃2.05,P=0.63).Conclusion Com⁃pared with the group without reservation,retained LCA for rectal cancer can reduce the incidence of postoperative anastomotic fistu⁃la and at the same time ensure the radical resection of the tumor,without increasing postoperative complications,and the difference in long⁃term efficacy is not statistically significant.