中低位直肠癌经肛门与腹腔镜全直肠系膜切除术后近期疗效荟萃分析

Short-term outcomes after total mesorectal excision for middle and low rectal cancer: transanal versus laparoscopic approach——a meta analysis

目的 :比较经肛门全直肠系膜切除术(transanal total mesorectal excision,TaTME)与腹腔镜全直肠系膜切除术(laparoscopic total mesorectal excision,LaTME)治疗中低位直肠癌的安全性和有效性。方法:为比较TaTME与LaTME近期疗效,检索Pubmed、Web of Science、中国知网(CNKI)、中国生物医学文献数据库、万方医学数据库发表的临床研究。系统复习和荟萃分析基于优选报告的条目(Preferred Reporting Items for Systematic Reviews and MetaAnalysis)。数据模型采用固定效应或随机效应模型。研究结果的主要指标为手术时间、术中出血量、肿瘤大小、中转开腹率、住院时间、淋巴结清扫数目、肿瘤切缘与肛门距离、远端切缘(distal resection margin,DRM)阳性率、环周切缘(circumferential resection margin,CRM)阳性率、术后并发症。结果:共纳入9项中低位直肠癌研究,其中随机对照试验1项,前瞻性研究8项。荟萃分析显示,与LaTME(n=438)组相比,TaTME(n=451)组中转开腹率[风险比(risk ratio,RR)=0.13,P=0.002]和DRM阳性率(RR=0.39,P=0.003)显著降低。两组在手术时间(RR=15.48,P=0.18)、术中出血量(RR=2.34,P=0.81)、术后并发症发生(RR=1.05,P=0.72)、住院时间(RR=-0.91,P=0.14)、肿瘤大小(RR=0.04,P=0.55)、淋巴结清扫数目(RR=-0.71,P=0.17)、肿瘤切缘与肛门距离(RR=-1.26,P=0.20)和CRM阳性率(RR=0.77,P=0.53)差异无统计学意义。结论:TaTME具有与LaTME同等的手术安全性。当DRM存在风险时,TaTME可能是低位、超低位直肠癌的良好选择。

Objective To compare the safety and efficacy of transanal total mesorectal excision(TaTME) and laparoscopic total mesorectal excision(LaTME) for middle and low rectal cancer. Methods This study searched the clinical studies systematically comparing the short-term efficacy of TaTME and LaTME published in PubMed, Web of Science,CNKI, China Biology Medicine disc and Wanfang medical database. Systematic reviews and meta-analysis were conducted to base on the Preferred Reporting Items for Systematic Evaluation and Meta-Analysis. Fixed-effects model or randomeffects model was used for evaluation of data. Parameters of outcome evaluation included operation time, intraoperative blood loss, tumor size, conversion rate, length of hospital stay, number of lymph node dissection, distance of rectal lesion from anal verge, positive rate of distal resection margin(DRM), positive rate of circumferential resection margin(CRM), and postoperative complications. Results Nine studies with 1 of randomized controlled trial and 8 of prospective study were included to compare the outcomes of 451 TaTME and 438 LaTME in middle and low rectal cancer. TaTME had a significantly lower rate of conversion to open surgery(RR=0.13, P=0.002) and a lower DRM positive rate(RR=0.17, P<0.03)when compared to LaTME. There was no significant difference between two groups in operative time(RR=15.48, P=0.18),intraoperative blood loss(RR=2.34, P=0.81), postoperative complications(RR=1.05, P=0.72), length of hospital stay(RR=-0.91,P=0.14), tumor size(RR=0.04, P=0.55), number of lymph nodes dissection(RR=-0.71, P=0.17), distance of rectal lesion from anal verge(RR=-1.26, P=0.20) and positive rate of CRM(RR=0.77, P=0.53). Conclusions TaTME has the surgical safety same as LaTME. When the distal resection margin is at risk, TaTME may be a good choice for low and ultra-low rectal cancer.