中国普外基础与临床杂志

中国普外基础与临床杂志

国内新辅助放化疗后行腹腔镜和开腹手术治疗直肠癌疗效的 meta 分析

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目的 比较国内新辅助放化疗后行腹腔镜与传统开腹手术在直肠癌治疗中的应用效果。 方法 检索中国知网、中国生物医学数据库、万方数据库、维普科技期刊、PubMed、Cochrane Library、Embase 等国内外数据库中发表的有关我国新辅助放化疗后行腹腔镜与传统开腹手术治疗直肠癌的文献,由两位评价员按纳入与排除标准独立筛选文献、提取资料并评价纳入研究的偏倚风险后采用 RevMan 5.3 软件进行 meta 分析。 结果 最终评审后共纳入行新辅助放化疗后进一步施行腹腔镜手术与传统开腹手术比较研究的文献 20 篇,其中 11 篇为随机对照研究,9 篇为非随机对照研究。本研究共纳入直肠癌患者 2 036 例,其中 1 021 例新辅助放化疗后行腹腔镜手术,1 015 例新辅助放化疗后行开腹手术。与行开腹手术比较,行腹腔镜手术的手术时间明显延长 [WMD=14.21,95% CI 为(1.92,26.51)]、术中出血量明显减少 [WMD=–38.96,95%CI 为(–60.29,–7.63)]、术后首次排气时间明显提前 [WMD=–0.86,95%CI 为(–1.14,–0.57)]、术后首次进食时间明显提前 [WMD=–0.89,95%CI 为(–1.15,–0.62)]、术后住院时间明显缩短 [WMD=–2.38,95%CI 为(–3.44,–1.32)]、保肛率明显增高 [OR=2.35,95%CI 为(1.67,3.30)]、局部复发率明显降低 [OR=0.25,95%CI 为(0.13,0.47)],而两种手术术中淋巴结切除数目 [WMD=–0.99,95%CI 为(–2.11,0.12)]和 3 年无瘤生存率 [OR=0.91,95%CI 为(0.54,1.54)]比较差异无统计学意义。与行开腹手术比较,行腹腔镜手术的术后总并发症 [OR=0.34,95% CI 为(0.26,0.43)]、吻合口漏 [OR=0.40,95% CI 为(0.22,0.73)]、肺部感染 [OR=0.32,95% CI 为(0.18,0.57)]、肠梗阻 [OR=0.30,95% CI 为(0.17,0.53)]及切口感染 [OR=0.39,95% CI 为(0.25,0.62)]发生率均明显降低,而 2 组的盆腔感染 [OR=0.64,95% CI 为(0.17,2.45)]、吻合口出血 [OR=0.54,95% CI 为(0.22,1.34)]、尿潴留 [OR=0.71,95% CI 为(0.34,1.48)]及尿路感染 [OR=1.22,95% CI 为(0.45,3.30)]发生率比较差异均无统计学意义。 结论 新辅助放化疗后,采用腹腔镜治疗仍较传统开腹手术更安全、有效及可靠,但是还需要更多的临床随机对照研究来提供更加准确可靠的结果。

Objective To compare efficacy of laparoscopic surgery and open surgery in treatment of rectal cancer after neoadjuvant chemoradiotherapy. Methods The relevant literatures were retrieved from databases including CNKI, CBM, Wanfang, VIP, PubMed, Cochrane Library, and Embase from 2007 to 2017, all the relevant randomized controlled trial (RCT) or non-randomized controlled trial (NRCT) of laparoscopic surgery versus open surgery in patients with rectal cancer were collected according to the inclusion and exclusion criterial. Two reviewers independently screened the literatures, extracted the data, and assessed the bias risk of the included studies. Then, the meta-analysis was performed using RevMan 5.3 software. Results A total of 11 RCTs and 9 NRCTs involving 2 036 patients with rectal cancer were included, of these, including 1 021 cases of laparoscopic surgery and 1 015 cases of open surgery. The results of the meta-analysis showed that the operation time was increased [WMD=14.21, 95% CI (1.92, 26.51)], the intraoperative blood loss [WMD=–38.96, 95% CI (–60.29, –7.63)], first postoperative exhaust time [WMD=–0.86, 95% CI (–1.14, –0.57)], first postoperative intake food time [WMD=–0.89, 95% CI (–1.15, –0.62)], and postoperative hospitalization time [WMD=–2.38, 95% CI (–3.44, –1.32)] were reduced in the laparoscopic surgery as compared with the open surgery; the rate of the sphincter-saving was increased [OR=2.35, 95% CI (1.67, 3.30)], the rates of the local recurrence [OR=0.25, 95% CI (0.13, 0.47)], postoperative overall complications [OR=0.34, 95% CI (0.26, 0.43)], infection of incision [OR=0.39, 95% CI (0.25, 0.62)], intestinal obstruction [OR=0.30, 95% CI (0.17, 0.53)], lung infection [OR=0.32, 95% CI (0.18, 0.57)], and anastomotic fistula [OR=0.40, 95% CI (0.22, 0.73)] were decreased in the laparoscopic surgery as compared with the open surgery; the intraoperative lymph node resection [WMD=–0.99, 95% CI (–2.11, 0.12)], the rates of the 3-year disease-free survival [OR=0.91, 95% CI (0.54, 1.54)], pelvic infection [OR=0.64, 95% CI (0.17, 2.45)], anastomotic bleeding [OR=0.54, 95% CI (0.22, 1.34)], urinary retention [OR=0.71, 95% CI (0.34, 1.48)], and urinary tract infection [OR=1.22, 95% CI (0.45, 3.30)] had no significant differences between these two surgeries. Conclusion Laparoscopy surgery is still safer, more effective, and more reliable than conventional open surgery after neoadjuvant chemoradiotherapy in rectal cancer, but it needs more clinical RCTs to further provide accurate and reliable results.

关键词: 新辅助放化疗; 腹腔镜; 开腹; 直肠癌; meta 分析

Key words: neoadjuvant chemoradiotherapy; laparoscopy; open surgery; rectal cancer; meta-analysis

引用本文: 侯松林, 刘带志, 蒋先虹, 廖海玲, 杨松, 陈小波, 李利发, 张广军, 周彤. 国内新辅助放化疗后行腹腔镜和开腹手术治疗直肠癌疗效的 meta 分析. 中国普外基础与临床杂志, 2018, 25(5): 578-591. doi: 10.7507/1007-9424.201711027 复制

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