脾切除术在胃癌术后的生存获益及安全性的Meta分析

Survival benefits and safety of splenectomy to spleen preservation for gastric carcinoma: An updated meta-analysis

背景:在过去几十年中,脾切除术在胃癌术后患者的生存率,病死率及发病率中能否获益仍是个具有争议性的话题,特别是当肿瘤位于近端胃上1/3,或者脾门淋巴结阳性、分期较晚的进展期胃癌患者中,脾切除术的作用仍未明确。本篇Meta分析更新的目的在于重新评估脾切除术是否能在胃癌患者的生存及安全性上有获益。方法 :计算机检索Cochrane Library trials register,Medline,EMBASE,Pub Med上发表的所有随机对照研究。所有数据均由2名独立的研究者采用Rev Man5.3分别独立完成。本研究结果以5年总体生存率,术后死亡率,术后发病率和手术相关事件作为评价标准。结果 :最终,本研究纳入了4篇随机对照研究共978例患者,其中489例患者接受了胃切除术联合脾切除术。结果表明在胃癌患者中脾脏切除组有更高的发病率(RR=1.75,95%CI1.42,2.17,I^2=0%),差异具有统计学意义。在肿瘤侵犯程度较深(T3~T4)或者分期较晚的进展期胃癌(Ⅲ,IV)患者中,脾切除术组相对于脾脏保留组并没有增加生存率(RR=1.29,95%CI0.87,1.93,I^2=0%)。对于存在脾门淋巴结转移的胃癌患者,全胃切除联合脾切除术相并不能取得生存获益。在5年总体生存率,术后死亡率及手术相关事件上,两种手术方式并无明显统计学差异。结论 :无论在近端进展期胃癌或者脾门淋巴结阳性的患者中,脾切除术在生存率和安全性上均不能获益,反而会增加术后并发症的发病率。全胃切除联合脾切除的手术方式应该避免,除非肿瘤直接侵犯脾脏。

Background Over the past decades, whether the splenectomy benefits on survival, postoperative morbidity and mortality in gastric cancer remains controversial. The aim of updated meta-analysis is to evaluate survival benefits and safety of splenectomy in gastric cancer.Methods We identified randomized controlled trials to search in electronic databases including The Cochrane Library trials register, Medline, EMBASE, Pub Med. Data was extracted from the studies by 2 independent reviewers. Outcome measures were survival rates, postoperative morbidity and mortality even including the operation-related events. The meta-analysis was performed by Rev Man 5.3. Results: In our results, it showed lower postoperative morbidity in spleen preservation group with statistical significance(RR = 1.75, 95% CI 1.42-2.17,I2=0%) and the splenectomy did not increase the 5-year survival rate in the patients with deep tumor invasion(T3 ~ T4) or advanced stages(III, IV)(RR=1.29, 95% CI 0.87, 1.93, I2=0%). For gastric cancer patient with lymph node metastasis in the region of splenic hilum, total gastrectomy associated splenectomy has no obvious survival benefit compared with the gastrectomy plus region lymphadenectomy with spleen preservation. However, the overall 5-year survival rateand the postoperative mortality even the operation-related events including reoperation and operation time suggested no significant differences between two groups in gastric cancer.Conclusions Splenectomy did not show beneficial effect on survival rate compared with spleen preservation in gastric cancer no matter in patients with advanced stages or withsplenic hilumlymph node positive or with tumor located in up 1/3 gastric. Total gastrectomy associated with splenectomy should be avoided, except violating spleen directly.