全结肠系膜切除术治疗结肠癌的临床疗效与安全性评价

doi:10.3877/cma.j.issn.1674-0793.2020.02.019

目的

系统评价结肠癌患者行全结肠系膜切除术（CME）的手术安全性、手术标本质量和远期预后效果。

方法

计算机检索PubMed、ScienceDirect、Cochrane、Scopus、中国知网和万方数据库中发表的相关文献，时间从建库至2018年12月。提取手术安全性、手术标本质量和远期生存率研究结果。

结果

共纳入15项研究8 914例患者。与传统非全结肠系膜切除术（NCME）组相比，CME组术后并发症明显增多（RR=1.23，95% CI：1.08~1.40），清扫的淋巴结数目更多（WMD=8.42，95% CI：4.71~12.13），肿瘤至血管高位结扎处的距离更长（WMD=18.43，95% CI：16.18~20.69），切除肠系膜的面积更大（WMD=35.07，95% CI：12.78~57.36），患者3年生存率（HR=0.72，95% CI：0.61~0.86）和5年生存率（HR=0.55，95% CI：0.42~0.73）更高（均P<0.01）。

结论

CME可以有效改善手术标本质量，延长术后远期生存率，但手术并发症的发生率较高，手术安全性问题应引起注意。

关键词: 结肠肿瘤, 结肠切除术, Meta分析, 全结肠系膜切除术

Objective

To evaluate the safety, sample quality and long-term prognosis of complete mesocolic excision (CME) for colorectal cancer.

Methods

The relevant documents published in PubMed, ScienceDirect, Cochrane, Scopus, CNKI and Wanfang databases were searched by computer from the establishment of the database to December 2018. The results of safety, quality and long-term survival were extracted.

Results

A total of 8 914 patients from 15 studies were included in this Meta-analysis. Compared with non-complete mesocolic excision (NCME) group, CME group had more complications (RR=1.23, 95% CI: 1.08-1.40), more lymph nodes (WMD=8.42, 95% CI: 4.71-12.13), longer distance from tumor to high ligation of blood vessels (WMD=18.43, 95% CI: 16.18-20.69), larger area of mesentery (WMD=35.07, 95% CI: 12.78-57.36). The 3-, 5- year survival rates of the patients in CME group were both higher (HR=0.72, 95% CI: 0.61-0.86; HR=0.55, 95% CI: 0.42-0.73; both P<0.01).

Conclusion

CME can effectively improve the quality of surgical specimens and prolong the long-term survival rate, but the incidence of surgical complications is high, so the safety of operation should be concerned.

Key words: Colonic neoplasms, Colectomy, Meta-analysis, Complete mesocolic excision

表1 纳入研究信息汇总（CME/NCME）

纳入研究(发表年)	研究时间(年)	国家	MINORS评分	分期^a	病例量(例)^b	年龄(岁) ^b	性别(%)^b,c	右半结肠癌占比(%)^b
West (2010)^[11]	1999—2008	德国	11	Ⅰ~Ⅳ	49/40	-	49/48	61/40
West (2010)^[12]	2008—2009	丹麦	13	Ⅰ~Ⅳ	93/170	70/72	60/44	44/34
Bertelsen (2011)^[13]	2007—2009	丹麦	13	Ⅰ~Ⅳ	93/105	70/73	56/50	50/57
Galizia (2014)^[14]	2004—2012	意大利	14	A~D	45/58	67/68	49/57	100/100
Storli (2014)^[15]	2007—2008	挪威	15	Ⅰ~Ⅲ	84/105	73/73	52/51	45/44
Siani (2015)^[16]	2008—2013	意大利	11	Ⅰ~Ⅲ	75/40	-	-	100/100
Bernhoff (2015)^[17]	2001—2008	瑞典	13	Ⅰ~Ⅲ	684/625	75/75	40/45	100/100
Bertelsen (2015)^[18]	2008—2011	丹麦	12	Ⅰ~Ⅲ	364/1 031	72/73	52/46	46/44
Bertelsen (2016)^[19]	2008—2013	丹麦	13	Ⅰ~Ⅲ	529/1 701	72/73	51/47	47/46
Merkel (2016)^[20]	1978—2014	德国	14	Ⅰ~Ⅲ	1 099/920	66/65	59/52	31/17
Thorsen(2016)^[21]	2007—2014	挪威	14	-	49/49	67/65	39/41	100/100
Agalianos (2017)^[22]	2006—2011	希腊	14	Ⅰ~Ⅲ	145/145	68/72	61/54	29/40
Gao (2018)^[6]	2012—2016	中国	14	Ⅰ~Ⅲ	220/110	68/73	55/49	58/52
Gian (2018)^[23]	2001—2014	瑞士	14	Ⅰ~Ⅳ	71/84	74/74	55/50	85/82
Abdelkhalek (2018)^[7]	2010—2015	埃及	13	Ⅰ~Ⅳ	52/79	66/58	50/52	48/49

表1 纳入研究信息汇总（CME/NCME）

纳入研究(发表年)	研究时间(年)	国家	MINORS评分	分期^a	病例量(例)^b	年龄(岁) ^b	性别(%)^b,c	右半结肠癌占比(%)^b
West (2010)^[11]	1999—2008	德国	11	Ⅰ~Ⅳ	49/40	-	49/48	61/40
West (2010)^[12]	2008—2009	丹麦	13	Ⅰ~Ⅳ	93/170	70/72	60/44	44/34
Bertelsen (2011)^[13]	2007—2009	丹麦	13	Ⅰ~Ⅳ	93/105	70/73	56/50	50/57
Galizia (2014)^[14]	2004—2012	意大利	14	A~D	45/58	67/68	49/57	100/100
Storli (2014)^[15]	2007—2008	挪威	15	Ⅰ~Ⅲ	84/105	73/73	52/51	45/44
Siani (2015)^[16]	2008—2013	意大利	11	Ⅰ~Ⅲ	75/40	-	-	100/100
Bernhoff (2015)^[17]	2001—2008	瑞典	13	Ⅰ~Ⅲ	684/625	75/75	40/45	100/100
Bertelsen (2015)^[18]	2008—2011	丹麦	12	Ⅰ~Ⅲ	364/1 031	72/73	52/46	46/44
Bertelsen (2016)^[19]	2008—2013	丹麦	13	Ⅰ~Ⅲ	529/1 701	72/73	51/47	47/46
Merkel (2016)^[20]	1978—2014	德国	14	Ⅰ~Ⅲ	1 099/920	66/65	59/52	31/17
Thorsen(2016)^[21]	2007—2014	挪威	14	-	49/49	67/65	39/41	100/100
Agalianos (2017)^[22]	2006—2011	希腊	14	Ⅰ~Ⅲ	145/145	68/72	61/54	29/40
Gao (2018)^[6]	2012—2016	中国	14	Ⅰ~Ⅲ	220/110	68/73	55/49	58/52
Gian (2018)^[23]	2001—2014	瑞士	14	Ⅰ~Ⅳ	71/84	74/74	55/50	85/82
Abdelkhalek (2018)^[7]	2010—2015	埃及	13	Ⅰ~Ⅳ	52/79	66/58	50/52	48/49

图1 文献筛选流程图

表2 两种术式的手术安全性研究

纳入研究(发表年)	病例量(例)		手术时间(min) ^a		术中出血量(ml)^a		并发症［例(%)］		术后病死率［例(%)］
纳入研究(发表年)	CME	NCME	CME	NCME	CME	NCME	CME	NCME	CME	NCME
Gao (2018)^[6]	220	110	175±10	180±11	80±8	110±25	43(19.5)	14(12.7)	-	-
Abdelkhalek (2018)^[7]	52	79	135±8	180±18	105±5	200±25	2(3.8)	5(6.3)	-	-
Bertelsen (2011)^[13]	105	93	-	-	250±256	217±356	19(18.1)	14(15.1)	6(5.7)	8(8.6)
Galizia (2014)^[14]	45	58	178±21	130±20	280±40	200±30	6(13.3)	7(12.1)	-	-
Bertelsen (2016)^[19]	529	1 701	-	-	-	-	110(20.8)	329(19.3)	33(6.2)	83(4.9)
Merkel (2016)^[20]	1 099	920	-	-	-	-	234(21.3)	143(15.5)	30(2.7)	25(2.7)
Gian (2018)^[23]	71	84	174±48	155±52	100±127	300±658	-	-	5(7.0)	0(0)

表2 两种术式的手术安全性研究

纳入研究(发表年)	病例量(例)		手术时间(min) ^a		术中出血量(ml)^a		并发症［例(%)］		术后病死率［例(%)］
纳入研究(发表年)	CME	NCME	CME	NCME	CME	NCME	CME	NCME	CME	NCME
Gao (2018)^[6]	220	110	175±10	180±11	80±8	110±25	43(19.5)	14(12.7)	-	-
Abdelkhalek (2018)^[7]	52	79	135±8	180±18	105±5	200±25	2(3.8)	5(6.3)	-	-
Bertelsen (2011)^[13]	105	93	-	-	250±256	217±356	19(18.1)	14(15.1)	6(5.7)	8(8.6)
Galizia (2014)^[14]	45	58	178±21	130±20	280±40	200±30	6(13.3)	7(12.1)	-	-
Bertelsen (2016)^[19]	529	1 701	-	-	-	-	110(20.8)	329(19.3)	33(6.2)	83(4.9)
Merkel (2016)^[20]	1 099	920	-	-	-	-	234(21.3)	143(15.5)	30(2.7)	25(2.7)
Gian (2018)^[23]	71	84	174±48	155±52	100±127	300±658	-	-	5(7.0)	0(0)

图2 两种术式安全性比较的森林图　A为手术时间；B为术中出血量；C为手术并发症；D为术后病死率

表3 两种术式的手术标本质量研究

纳入研究(发表年)	病例量(例)		切除肠管的长度(mm)^a		肿瘤到血管高位结扎处的距离(mm) ^a		切除系膜面积(mm²)^a		清扫淋巴结总数(个)^a
纳入研究(发表年)	CME	NCME	CME	NCME	CME	NCME	CME	NCME	CME	NCME
Gao (2018)^[6]	220	110	208±11	212±13	144±26	121±28	131±8	91±6	24±3	20±2
Abdelkhalek (2018)^[7]	52	79	-	-	-	-	-	-	23±4	12±1
West (2010)^[11]	49	40	-	-	-	-	-	-	30±4	18±3
West (2010)^[12]	93	170	315±30	247±13	105±33	84±25	145±88	87±35	28±2	18±2
Bertelsen (2011)^[13]	92	80	-	-	96±34	71±22	-	-	27±1	25±1
Galizia (2014)^[14]	45	58	288±27	274±41	106±13	87±17	-	-	20±9	15±6
Storli (2014)^[15]	84	40	262±145	274±192	-	-	-	-	16±10	15±7
Siani (2015)^[16]	75	40	235±37	213±25	103±5	87±9	154±16	141±12	29±5	19±7
Bertelsen (2015)^[18]	364	1 031	-	-	-	-	-	-	36.5±15.9	20.9±10
Bertelsen (2016)^[19]	529	1 701	-	-	-	-	-	-	36±4	20±2
Thorsen (2016)^[21]	49	49	242±72	232±73	-	-	-	-	38±13	21±9
Gian (2018)^[23]	71	84	-	-	-	-	-	-	32±17	23±13

表3 两种术式的手术标本质量研究

纳入研究(发表年)	病例量(例)		切除肠管的长度(mm)^a		肿瘤到血管高位结扎处的距离(mm) ^a		切除系膜面积(mm²)^a		清扫淋巴结总数(个)^a
纳入研究(发表年)	CME	NCME	CME	NCME	CME	NCME	CME	NCME	CME	NCME
Gao (2018)^[6]	220	110	208±11	212±13	144±26	121±28	131±8	91±6	24±3	20±2
Abdelkhalek (2018)^[7]	52	79	-	-	-	-	-	-	23±4	12±1
West (2010)^[11]	49	40	-	-	-	-	-	-	30±4	18±3
West (2010)^[12]	93	170	315±30	247±13	105±33	84±25	145±88	87±35	28±2	18±2
Bertelsen (2011)^[13]	92	80	-	-	96±34	71±22	-	-	27±1	25±1
Galizia (2014)^[14]	45	58	288±27	274±41	106±13	87±17	-	-	20±9	15±6
Storli (2014)^[15]	84	40	262±145	274±192	-	-	-	-	16±10	15±7
Siani (2015)^[16]	75	40	235±37	213±25	103±5	87±9	154±16	141±12	29±5	19±7
Bertelsen (2015)^[18]	364	1 031	-	-	-	-	-	-	36.5±15.9	20.9±10
Bertelsen (2016)^[19]	529	1 701	-	-	-	-	-	-	36±4	20±2
Thorsen (2016)^[21]	49	49	242±72	232±73	-	-	-	-	38±13	21±9
Gian (2018)^[23]	71	84	-	-	-	-	-	-	32±17	23±13

图3 两种术式质量研究结果比较的森林图　A为切除肠管长度；B为清扫淋巴结数目；C为肿瘤到血管高位结扎处的距离；D为切除肠系膜的面积

表4 两种术式的手术预后比较

纳入研究(发表年)	病例数(例)		3年生存率(%)		HR(95% CI)	5年生存率(%)		HR(95% CI)
纳入研究(发表年)	CME	NCME	CME	NCME	HR(95% CI)	CME	NCME	HR(95% CI)
Galizia (2014)^[14]	45	58	94^a	84^a	0.97(0.11~8.86)	90^a	74^a	0.40(0.17~1.27)
Storli (2014)^[15]	84	105	88^b	79^b	0.36(0.14~0.72)	-	-	-
Bernhoff (2015)^[17]	684	625	72^c	65^c	0.79(0.64~0.97)	-	-	-
Bertelsen (2015)^[18]	364	1 031	87^c	80^c	0.64(0.47~0.88)	-	?	-
Merkel (2016)^[20]	429	414	-	-	-	91^a	79^a	0.54(0.38~0.77)
Agalianos (2017)^[22]	145	145	-	-	-	81^b	71^b	0.66(0.38~1.13)
Gao (2018)^[6]	218	107	98^b	97^b	0.67(0.16~2.87)	-	-	-

表4 两种术式的手术预后比较

纳入研究(发表年)	病例数(例)		3年生存率(%)		HR(95% CI)	5年生存率(%)		HR(95% CI)
纳入研究(发表年)	CME	NCME	CME	NCME	HR(95% CI)	CME	NCME	HR(95% CI)
Galizia (2014)^[14]	45	58	94^a	84^a	0.97(0.11~8.86)	90^a	74^a	0.40(0.17~1.27)
Storli (2014)^[15]	84	105	88^b	79^b	0.36(0.14~0.72)	-	-	-
Bernhoff (2015)^[17]	684	625	72^c	65^c	0.79(0.64~0.97)	-	-	-
Bertelsen (2015)^[18]	364	1 031	87^c	80^c	0.64(0.47~0.88)	-	?	-
Merkel (2016)^[20]	429	414	-	-	-	91^a	79^a	0.54(0.38~0.77)
Agalianos (2017)^[22]	145	145	-	-	-	81^b	71^b	0.66(0.38~1.13)
Gao (2018)^[6]	218	107	98^b	97^b	0.67(0.16~2.87)	-	-	-

图4 两种术式患者预后研究结果比较的森林图　A为3年生存率；B为5年生存率

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Clinical efficacy and safety of complete mesocolic excision in the treatment of colon cancer

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Clinical efficacy and safety of complete mesocolic excision in the treatment of colon cancer