环周黏膜预切开内镜黏膜切除术与内镜黏膜下剥离术治疗直肠神经内分泌肿瘤疗效的Meta分析

Meta-analysis of endoscopic mucosal resection with circumferential incision and endoscopic submucosal dissection for the treatment of rectal neuroendocrine neoplasm

目的系统评价环周黏膜预切开内镜黏膜切除术(EMR-CI)与内镜黏膜下剥离术(ESD)治疗直肠神经内分泌肿瘤(RNEN)的安全性和有效性。方法计算机检索PubMed、the Cochrane Library、EMBASE、Web of Science、SinoMed、中国知网(CNKI)、万方数据和维普数据库等多个中英文数据库,检索时限为从建库至2022年11月22日。收集关于EMR-CI和ESD治疗RNEN疗效的中英文文献。按照纳入和排除标准,对文献进行筛选和数据提取,并对纳入文献采用纽卡斯尔-渥太华量表(NOS),进行方法学质量评价,使用Rev Man 5.3软件进行Meta分析。结果最终纳入7篇临床对照研究。EMR-CI组199例,ESD组443例。有效性结局指标Meta分析结果显示,EMR-CI组组织学完全切除率与ESD组比较,差异无统计学意义(OR=0.56,95%CI:0.30~1.02,P=0.060);EMR-CI组内镜下完整切除率与ESD组比较,差异无统计学意义(OR=0.33,95%CI:0.09~1.17,P=0.090);EMR-CI组病变直径较ESD组小,差异有统计学意义(WMD=-0.86,95%CI:-1.33~-0.40,P=0.000);EMR-CI组手术时间明显短于ESD组,差异有统计学意义(WMD=-12.48,95%CI:-16.42~-8.54,P=0.000);EMR-CI组水平切缘阳性率与ESD组比较,差异无统计学意义(OR=1.74,95%CI:0.64~4.75,P=0.280);EMR-CI组垂直切缘阳性率高于ESD组,差异有统计学意义(OR=2.41,95%CI:1.09~5.32,P=0.030)。因局部复发率和远处转移率发生率极低,无法进行Meta分析。安全性结局指标Meta分析结果显示,并发症总发生率、出血发生率和穿孔发生率比较,差异均无统计学意义(P>0.05)。结论EMR-CI治疗RNEN,可以在明显节约手术时间和不增加手术并发症的前提下,达到与ESD相似的内镜下完整切除率、组织学完全切除率和水平切缘阳性率,但需注意该术式与ESD在垂直切缘阳性率方面的差异。

Objective To evaluate the safety and effectiveness of endoscopic mucosal resection with circumferential incision(EMR-CI)and endoscopic submucosal dissection(ESD)for the rectal neuroendocrine neoplasm(RNEN).Methods Databases such as PubMed,the Cochrane Library,Embase,Web of Science,SinoMed,China National Knowledge Infrastructure(CNKI),Wanfang Data and Weipu database were searched by computer.The retrieval time limit was Nov.22,2022.The Chinese and English literatures on the efficacy of EMR-CI vs ESD in treatment of RNEN patients were collected.According to inclusion and exclusion criteria,the included literatures were screened,extracted data,and evaluated the methodological quality by Newcastle-Ottawa scale(NOS),Meta-analysis was performed using Rev Man 5.3 software.Results Seven clinical control studies were included,including 199 cases in the EMR-CI group and 443 cases in the ESD group.Results of Meta-analysis of validity outcome indicators,there was no significant difference in histological complete resection rate between the EMR-CI group and the ESD group(OR=0.56,95%CI:0.30~1.02,P=0.060);The endosopic complete resection rate of EMR-CI was similar to that of ESD with no significant difference(OR=0.33,95%CI:0.09~1.17,P=0.090);The size of lesions removed by EMR-CI was smaller than that of ESD with significant difference(WMD=-0.86,95%CI:-1.33~-0.40,P=0.000);The time EMR-CI required to remove the lesion was significantly shorter than that of ESD(WMD=-12.48,95%CI:-16.42~-8.54,P=0.000).The positive rate of horizontal resection margin of EMR-CI was similar to that of ESD,with no significant difference(OR=1.74,95%CI:0.64~4.75,P=0.280);The positive rate of vertical resection margin was significantly higher than that of ESD(OR=2.41,95%CI:1.09~5.32,P=0.030).Due to the low local recurrence rate and distant metastasis rate,Meta-analysis couldn't be compared.Safety outcome index showed that,there were no significant differences in the incidence of total complications,bleeding and perforation among groups.Conclusion In the treatment of RNEN,EMR-CI can achieve the endosopic complete resection,histological complete resection and positive rate of horizontal resection margin similar to ESD without increasing surgical complications and significantly saving surgical time.However,attention should be paid to the differences between EMR-CI and ESD in positive rate of vertical resection margin.