内镜支架减压对比肠造口减压对梗阻性结直肠癌择期手术近远期疗效影响的Meta分析

doi:10.3877/cma.j.issn.1674-0793.2023.01.016

目的

比较急诊造口减压和内镜支架减压后择期手术切除治疗梗阻性结直肠癌的近远期效果。

方法

检索PubMed、Embase、Cochrane Library、中国知网、万方数据库已公开发表的有关造口减压对比内镜支架减压后序贯择期手术切除的梗阻性结直肠癌近远期效果的文献，提取的数据采用RevMan 5.3软件进行Meta分析。

结果

共10篇回顾性病例对照研究纳入汇总分析，Newcastle-Ottawa Scale评分范围为6~8分，其中高质量文献6篇。总样本量为1 807例，包括造口组939例，支架组868例。汇总分析结果提示，支架组两次手术间隔时间短于造口组（WMD=13.37，95% CI：7.88~18.86，P<0.000 01），但造口组择期手术一期吻合率高于支架组（OR=1.58，95% CI：1.10~2.26，P=0.01），3年总生存率也高于支架组（HR=0.77，95% CI：0.61~0.97，P=0.02）。两组在择期手术入路方式、永久性造口率、总体并发症和围手术期死亡率方面比较，差异均无统计学意义。

结论

肠造口减压和内镜支架减压对梗阻性结直肠癌患者后续择期行结直肠癌根治术的安全性相近，但是肠造口减压患者的总生存率更高，远期疗效方面更胜一筹。

关键词: 肠造口, 内镜支架, 梗阻性结直肠癌, 减压, 择期手术, Meta分析

Objective

To compare the short-and long-term efficacy after endoscopic stent versus stoma decompression as a bridge to elective resection for obstructive colorectal cancer.

Methods

The databases such as PubMed, Embase, Cochrane Library, CNKI, WanFang data were searched to retrieve literature comparing stoma decompression with endoscopic stent as a bridge to surgery for obstructive colorectal cancer. Data were extracted and analyzed using RevMan 5.3 statistical software.

Results

Ten retrospective case-control studies were finally retrieved, with 6-8 points by the Newcastle-Ottawa Scale, 6 of which were high-quality literatures. A total of 1 807 cases were included in the study, 939 of whom were divided into stoma group and 868 were stent group. Compared to the stoma group, the stent group was associated with significantly shorter time interval between decompression surgery and elective resection for obstructive colorectal cancer (WMD=13.37, 95% CI: 7.88-18.86, P<0.000 01). However, the stoma group showed better primary anastomotsis (OR=1.58, 95% CI: 1.10-2.26, P=0.01) and 3-year overall survival than the stent group (HR=0.77, 95% CI: 0.61-0.97, P=0.02). No significant differences were found in terms of surgical approach, permanent stoma, overall complication and perioperative mortality between the two groups.

Conclusions

The stoma decompression as a bridge to surgery provides similar safety with endoscopic stent for patients with obstructive colorectal cancer undergoing subsequent elective radical resection. However, stoma decompression has advantages of long-term efficacy, providing higher overall survival.

Key words: Stoma, Endoscopic stent, Obstructive colorectal cancer, Decompression, Elective resection, Meta-analysis

图1 文献筛选流程图

表1 纳入各文献的基本临床资料

第一作者	发表年	国家	研究类型	原始文献样本量(例)		年龄(岁)		性别(男/女,例）		病变部位(例)	主要结局指标
第一作者	发表年	国家	研究类型	造口组	支架组	造口组	支架组	造口组	支架组	病变部位(例)	主要结局指标
Amelung^[7]	2016	新西兰	非随机	42	44	64.9(35~89)	69.9(53~86)	24/18	20/24	盲/升/肝区/横：22/20/13/31	①②③⑤⑥
Amelung^[8]	2016	新西兰	非随机	37	51	66.63±13.2	71.8±13.1	14/23	25/26	脾曲/降/乙：7/15/66	①②③④⑤⑥⑦⑧
Axmarker^[9]	2021	瑞士	非随机	125	71	66(36~91)	72(41~91)	72/53	40/31	结肠/直肠：143/53	⑤⑥⑦⑧
Jung^[10]	2020	韩国	非随机	27	23	69(41~88)	70(48~84)	12/15	15/8	结/直肠：17/10(造口组)；21/2(支架组)	①②④⑤
Kondo^[11]	2022	日本	非随机	32	65	71(64~80)	73(67~79)	16/16	46/19	结肠/直肠：78/19	①②⑤⑦⑧
Mege^[12]	2019	法国	非随机	327	191	71±15	72±14	185/142	95/96	脾曲/降/乙/直：76/109/313/20	④⑤⑥⑦⑧
Öistämö^[13]	2016	瑞士	非随机	23	20	67±12	71±10	13/10	7/13	脾曲/降/乙/直乙：7/9/25/2	①③④⑤
Tanis^[14]	2015	新西兰	非随机	135	196	68(29~91)	71(34~92)	76/59	119/77	脾曲/降/乙：40/51/240	②③⑤⑥
Veld^[15]	2020	新西兰	非随机	121	121	69.8±11	70.1±12.1	72/49	73/48	脾曲/降/乙：14/41/187	①②③⑤⑥⑦⑧
曾维根^[16]	2021	中国	非随机	70	86	62.5±12	64.6±9.8	38/32	44/42	脾曲/降/乙：22/22/112	①②④⑤⑥⑦⑧

表1 纳入各文献的基本临床资料

第一作者	发表年	国家	研究类型	原始文献样本量(例)		年龄(岁)		性别(男/女,例）		病变部位(例)	主要结局指标
第一作者	发表年	国家	研究类型	造口组	支架组	造口组	支架组	造口组	支架组	病变部位(例)	主要结局指标
Amelung^[7]	2016	新西兰	非随机	42	44	64.9(35~89)	69.9(53~86)	24/18	20/24	盲/升/肝区/横：22/20/13/31	①②③⑤⑥
Amelung^[8]	2016	新西兰	非随机	37	51	66.63±13.2	71.8±13.1	14/23	25/26	脾曲/降/乙：7/15/66	①②③④⑤⑥⑦⑧
Axmarker^[9]	2021	瑞士	非随机	125	71	66(36~91)	72(41~91)	72/53	40/31	结肠/直肠：143/53	⑤⑥⑦⑧
Jung^[10]	2020	韩国	非随机	27	23	69(41~88)	70(48~84)	12/15	15/8	结/直肠：17/10(造口组)；21/2(支架组)	①②④⑤
Kondo^[11]	2022	日本	非随机	32	65	71(64~80)	73(67~79)	16/16	46/19	结肠/直肠：78/19	①②⑤⑦⑧
Mege^[12]	2019	法国	非随机	327	191	71±15	72±14	185/142	95/96	脾曲/降/乙/直：76/109/313/20	④⑤⑥⑦⑧
Öistämö^[13]	2016	瑞士	非随机	23	20	67±12	71±10	13/10	7/13	脾曲/降/乙/直乙：7/9/25/2	①③④⑤
Tanis^[14]	2015	新西兰	非随机	135	196	68(29~91)	71(34~92)	76/59	119/77	脾曲/降/乙：40/51/240	②③⑤⑥
Veld^[15]	2020	新西兰	非随机	121	121	69.8±11	70.1±12.1	72/49	73/48	脾曲/降/乙：14/41/187	①②③⑤⑥⑦⑧
曾维根^[16]	2021	中国	非随机	70	86	62.5±12	64.6±9.8	38/32	44/42	脾曲/降/乙：22/22/112	①②④⑤⑥⑦⑧

表2 纳入原始文献的NOS量表质量评价结果(分)

作者	病例的定义和诊断	病例的代表性	对照的定义	病例和对照的可比性	暴露的调查和评估方法	病例和对照的调查方法是否相同	无应答率	总分
Amelung^[7]	1	1	1	1	1	1	1	7
Amelung^[8]	1	1	0	1	1	1	1	6
Axmarker^[9]	1	1	1	1	1	1	1	7
Jung^[10]	1	1	0	1	1	1	1	6
Kondo^[11]	1	1	1	1	1	1	1	7
Mege^[12]	1	1	1	2	1	1	1	8
Öistämö^[13]	1	1	0	1	1	1	1	6
Tanis^[14]	1	1	1	2	1	1	1	8
Veld^[15]	1	1	0	1	1	1	1	6
曾维根^[16]	1	1	1	1	1	1	1	7

表2 纳入原始文献的NOS量表质量评价结果(分)

作者	病例的定义和诊断	病例的代表性	对照的定义	病例和对照的可比性	暴露的调查和评估方法	病例和对照的调查方法是否相同	无应答率	总分
Amelung^[7]	1	1	1	1	1	1	1	7
Amelung^[8]	1	1	0	1	1	1	1	6
Axmarker^[9]	1	1	1	1	1	1	1	7
Jung^[10]	1	1	0	1	1	1	1	6
Kondo^[11]	1	1	1	1	1	1	1	7
Mege^[12]	1	1	1	2	1	1	1	8
Öistämö^[13]	1	1	0	1	1	1	1	6
Tanis^[14]	1	1	1	2	1	1	1	8
Veld^[15]	1	1	0	1	1	1	1	6
曾维根^[16]	1	1	1	1	1	1	1	7

图2 两组患者两次手术间隔时间的Meta分析森林图

图3 两组患者择期手术入路方式的Meta分析森林图

图4 两组患者择期手术一期吻合率的Meta分析森林图

图5 两组患者择期手术后永久性造口率的Meta分析森林图

图6 两组患者择期手术后总体并发症的Meta分析森林图

图7 两组患者择期手术围手术期死亡率的Meta分析森林图

图8 两组患者3年总体生存率的Meta分析森林图

图9 两组患者3年无瘤生率的Meta分析森林图

图10 以术后总体并发症为指标的漏斗图

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Endoscopic stent decompression versus stoma decompression on short- and long-term efficacy as a bridge to elective resection for obstructive colorectal cancer: A meta-analysis

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Endoscopic stent decompression versus stoma decompression on short- and long-term efficacy as a bridge to elective resection for obstructive colorectal cancer: A meta-analysis