腹腔镜辅助与后矢状入路肛门成形术治疗中高位先天性肛门直肠畸形疗效比较的Meta分析

Efficacy of laparoscopic-assisted anorectoplasty versus posterior sagittal anorectoplasty for high/intermediate-type anorectal malformations: a Meta-analysis

目的通过Meta分析比较腹腔镜辅助肛门成形术(laparoscopic assisted anorectoplasty,LAARP)与后矢状入路肛门成形术(posterior sagittal anorectoplasty,PSARP)治疗中高位先天性肛门直肠畸形(anorectal malformations,ARMs)的临床疗效。方法检索PubMed、Embase、Cochrane图书馆、维普、万方、中国知网数据库,筛选出1998年1月至2023年1月发表的符合纳排标准的LAARP与PSARP治疗中高位ARMs的对照研究。分析主要结局指标包括手术时间、术中出血量、住院时间、术后并发症及排便功能。采用Egger's及Begg's检验分析纳入研究的发表偏倚,使用Stata 16.0软件进行数据分析。结果共纳入30项研究,1553例患儿,其中LAARP组829例,PSARP组724例。Meta分析结果显示LAARP组较PSARP组住院时间更短[WMD=-3.38,95%CI(-4.10~-2.65),P<0.001]、术中出血量更少[WMD=-8.99,95%CI(-11.42~-6.56),P<0.001]、术后切口感染/裂开发生率更低[RR=0.20,95%CI(0.11~0.36),P<0.001]、术后直肠测压肛管静息压力更高[WMD=6.39,95%CI(1.13~11.66),P=0.017]、高压区长度更长[WMD=0.97,95%CI(0.00~1.94),P=0.049]、术后自愿排便率更高[RR=1.12,95%CI(1.02~1.22),P=0.017]、Ⅱ/Ⅲ级便秘发生率更低[RR=0.25,95%CI(0.14~0.46),P<0.001],但直肠黏膜脱垂发生率更高[RR=1.73,95%CI(1.25~2.39),P=0.001]。LAARP组与PSARP组手术时间、术后总并发症发生率、肛门狭窄发生率、直肠肛门抑制反射阳性率、Kelly评分优良率,Ⅱ/Ⅲ级污粪发生率比较,差异无统计学意义。结论与PSARP相比,LAARP治疗中高位ARMs具有术中出血更少、术后伤口感染/裂开更少、住院时间更短、肛门排便功能更好等特点,但LAARP治疗中高位ARMs术后直肠黏膜脱垂发生率更高。

Objective To systematically compare the clinical outcomes of laparoscopic-assisted anorectoplasty(LAARP)versus posterior sagittal anorectoplasty(PSARP)for high/intermediate anorectal malformations(ARMs)by Meta-analysis.Methods From January 1998 to January 2023,the databases of PubMed,Embase,Cochrane Library,VIP,Wanfang and China National Knowledge Infrastructure(CNKI)were searched for randomized versus non-randomized controlled comparative studies of LAARP versus PSARP for high/intermediate ARMs.Operative timing,intraoperative volume of blood loss,hospitalization stay,postoperative complications and defecation function were extracted.Statistical analysis was conducted by STATA version 16.0.And Begg’s and Egger’s tests were performed for assessing the risks of bias.Results Thirty studies examining the effectiveness of LAARP(n=829)versus PSARP(n=724)were included for Meta-analysis.As compared with PSARP group,LAARP group had a shorter hospitalization stay[WMD=-3.38,95%CI(-4.10,-2.65),P<0.001],lesser hemorrhage[WMD=-8.99,95%CI(-11.42,-6.56),P<0.001],a lower incidence of incisional infection or dehiscence[RR=0.20,95%CI(0.11,0.36),P<0.001],higher rectal manometric anal canal resting pressure[WMD=6.39,95%CI(1.13,11.66),P=0.017],longer high-pressure zone length[WMD=0.97,95%CI(0.00,1.94),P=0.049],higher rate of voluntary bowel movements[RR=1.12,95%CI(1.02,1.22),P=0.017],lower incidence of grade II/III constipation[RR=0.25,95%CI(0.14,0.46),P<0.001]and a higher incidence of rectal prolapse[RR=1.73,95%CI(1.25,2.39),P=0.001].And the inter-group differences were statistically significant.No significant differences existed in operative duration,total postoperative complication rate,anal orifice stenosis rate,positive rectal anal inhibition reflex rate,Kelly’s clinical score or the incidence of grade II/III fecal soiling.Conclusions As compared with PSARP,applying LAARP for high/intermediate ARMs is characterized by lesser intraoperative hemorrhage,less postoperative wound infection/dehiscence,shorter hospitalization stay and better anal defecation function.However,there is a higher incidence of rectal prolapse during LAARP.