经肛全直肠系膜切除术与机器人及腹腔镜辅助全直肠系膜切除术临床疗效和安全性比较的网状Meta分析

Network meta-analysis comparing the clinical outcomes and safety of robotic,laparoscopic,and transanal total rectal mesenteric resection for rectal cancer

目的系统性评价机器人辅助全直肠系膜切除术(RTME)、腹腔镜辅助全直肠系膜切除术(laTME)与经肛全直肠系膜切除术(taTME)的临床疗效和安全性。方法通过计算机检索PubMed、Embase、Cochrane Library和Ovid数据库,查阅2017年1月到2022年1月期间发表的对比RTME、laTME与taTME 3种不同手术方式临床疗效的英文文献,采用NOS量表与JADAD评分表对回顾性队列研究和随机对照试验进行进行文献质量评价,应用Review Manager软件及R软件进行直接Meta分析和网状Meta分析。结果最终纳入29篇文献,共计8339例直肠癌患者。直接Meta分析结果显示,与taTME相比,RTME术后的住院时间更长。网状Meta分析结果显示,与laTME比较,taTME住院时间更短(MD=-0.86,95%CI:-1.70~-0.096,P=0.036);与RTME相比,taTME术后吻合口漏发生率(OR=0.60,95%CI:0.39~0.91,P=0.018)以及肠梗阻发生率(OR=0.55,95%CI:0.31~0.94,P=0.037)均更低,差异均有统计学意义(均P<0.05)。3种手术方式在清扫淋巴结数目、直肠下切缘长度以及环周切缘阳性率上的差异均无统计学意义(均P>0.05)。本次研究采用节点分析法进行不一致性检验,结果显示,6个结局指标的直接比较和间接比较结果之间的差异均无统计学意义(均P>0.05),不存在明显的直接证据和间接证据总体不一致性。结论与RTME和laTME相比,taTME在直肠癌根治性及手术近期疗效方面更具有优势。

Objective To methodically assess the clinical effectiveness and safety of robot-assisted total rectal mesenteric resection(RTME),laparoscopic-assisted total rectal mesenteric resection(laTME),and transanal total rectal mesenteric resection(taTME).Methods A computer search was conducted on PubMed,Embase,Cochrane Library,and Ovid databases to identify English-language reports published between January 2017 and January 2022 that compared the clinical efficacy of the three surgical procedures of RTME,laTME,and taTME.The quality of the studies was evaluated using the NOS and JADAD scales for retrospective cohort studies and randomized controlled trials,respectively.Direct meta-analysis and reticulated meta-analysis were performed using Review Manager software and R software,respectively.Results Twenty-nine publications comprising 8,339 patients with rectal cancer were ultimately included.The direct meta-analysis indicated that the length of hospital stay was longer after RTME than after taTME,whereas according to the reticulated meta-analysis the length of hospital stay was shorter after taTME than after laTME(MD=-0.86,95%CI:-1.70 to-0.096,P=0.036).Moreover,the incidence of anastomotic leak was lower after taTME than after RTME(OR=0.60,95%CI:0.39 to 0.91,P=0.018).The incidence of intestinal obstruction was also lower after taTME than after RTME(OR=0.55,95%CI:0.31 to 0.94,P=0.037).All of these differences were statistically significant(all P<0.05).There were no statistically significant differences between the three surgical procedures regarding the number of lymph nodes cleared,length of the inferior rectal margin,or rate of positive circumferential margins(all P>0.05).An inconsistency test using nodal analysis revealed no statistically significant differences between the results of direct and indirect comparisons of the six outcome indicators(all P>0.05).Furthermore,we detected no significant overall inconsistency between direct and indirect evidence.Conclusion taTME has advantages over RTME and laTME,in terms of radical and surgical short-term outcomes in patients with rectal cancer.