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中华普通外科学文献(电子版)

中华普通外科学文献(电子版) ›› 2019, Vol. 13 ›› Issue (04) : 327 -336. doi: 10.3877/cma.j.issn.1674-0793.2019.04.019

所属专题： 文献；

循证医学

经肛门与传统腹腔镜全系膜切除术在中低位直肠癌中可行性与安全性的Meta分析
赵葳1, 曾祥1, 殷红专2,†()   
  1. 1. 110000　沈阳，中国医科大学附属盛京医院社会服务部
    2. 110000　沈阳，中国医科大学附属盛京医院结直肠肛门病外科
  • 收稿日期:2019-02-24 出版日期:2019-08-01
  • 通信作者: 殷红专
  • 基金资助:
    辽宁省自然科学基金资助项目(201602869)

Feasibility and safety of transanal total mesorectal excision and traditional laparoscopic total mesorectal in middle-low rectal cancer: a Meta-analysis

Wei Zhao1, Xiang Zeng1, Hongzhuan Yin2,†()   

  1. 1. Social Service Department, Shengjing Hospital of China Medical University, Shenyang 110000, China
    2. Deparment of Colorectal Anus Surgery, Shengjing Hospital of China Medical University, Shenyang 110000, China
  • Received:2019-02-24 Published:2019-08-01
  • Corresponding author: Hongzhuan Yin
  • About author:
    Corresponding author: Yin Hongzhuan, Email:
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引用本文：

赵葳, 曾祥, 殷红专. 经肛门与传统腹腔镜全系膜切除术在中低位直肠癌中可行性与安全性的Meta分析[J]. 中华普通外科学文献(电子版), 2019, 13(04): 327-336.

Wei Zhao, Xiang Zeng, Hongzhuan Yin. Feasibility and safety of transanal total mesorectal excision and traditional laparoscopic total mesorectal in middle-low rectal cancer: a Meta-analysis[J]. Chinese Archives of General Surgery(Electronic Edition), 2019, 13(04): 327-336.

目的

系统性评价经肛门全直肠系膜切除（TaTME）与腹腔镜全直肠系膜切除（LaTME）治疗中低位直肠癌的术中、术后指标，并发症及其病理学结果，分析TaTME术式可行性及安全性。

方法

通过检索Pubmed、EMBase、Cochrane Library、中国知网、万方、重庆维普国内外大型数据库，筛选2015年2月至2019年4月间发表的关于TaTME与LaTME治疗中低位直肠癌的相关文献。文献质量标准采用纽卡斯尔-渥太华量表（NOS），采用Revman 5.3软件进行Meta分析，敏感性分析异质性结果。

结果

共13篇文献1 096例患者符合纳入标准，包括TaTME组515例，LaTME组581例。与LaTME组相比，TaTME组具有高质量的CRM距离（MD=0.95，95%CI=0.61~1.29，P<0.001），低CRM阳性率（OR=0.35，95%CI=0.16~0.78，P=0.010），高质量的全直肠系膜切除（OR=2.41，95%CI=1.29~4.51，P=0.006），低中转开腹率（OR=0.20，95%CI=0.07~0.58，P=0.003），Clavien-Dindo分级3级及以上术后并发症发生率（OR=0.54，95%CI=0.32~0.92，P=0.020）、术后排尿障碍发生率低（OR=0.54，95%CI=0.31~0.94，P=0.030）及低非计划性二次入院率（OR=0.44，95%CI=0.27~0.73，P=0.001）。两组在DRM阳性率及切除距离、淋巴结清扫数量、术中失血量、手术持续时间以及总并发症、肠梗阻、吻合口瘘发生率等方面差异无统计学意义。

结论

相较于LaTME术式，TaTME治疗中低位直肠癌可以得到更高质量的标本，术后危重并发症发生率明显降低，术式可行且安全。

关键词: 直肠肿瘤, 全直肠系膜切除术, 经肛门, 腹腔镜
Objective

To systematically evaluate the intraoperative and postoperative indicators, complications and pathological results of transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME) in the treatment of middle and low rectal cancer, and to analyze the feasibility and safety of TaTME.

Methods

The database both at home and abroad including Pubmed, EMBase, Cochrane Library, CNKI, Wanfang, VIP were searched between February 2015 and April 2019. All eligible studies associated with the treatment of middle and low rectal cancer with TaTME and LaTME were systematically analyzed. Newcastle-Ottawa Scale (NOS) and Revman 5.3 software were used to conduct Meta-analysis and sensitivity analysis of heterogeneous results.

Results

A total of thirteen articles including 1 096 cases met the inclusion criteria, including 515 cases in group TaTME and 581 cases in group LaTME. Compared with group LaTME, group TaTME had longer CRM distance (MD=0.95, 95%CI=0.61-1.29, P<0.001), lower CRM positive rate (OR=0.35, 95%CI=0.16-0.78, P=0.010), higher quality TME (OR=2.41, 95%CI=1.29-4.51, P=0.006), lower rate of conversion to laparotomy (OR=0.20, 95%CI=0.07-0.58, P=0.003), Clavien-Dindo grade≥3 complications (OR=0.54, 95%CI=0.32-0.92, P=0.020), incidence of postoperative urination disorders (OR=0.54, 95%CI=0.31-0.94, P=0.030) and lower unplanned secondary admission (OR=0.44, 95%CI=0.27-0.73, P=0.001). There were no significant differences in DRM positive rate, resection distance, number of lymph node dissection, intraoperative blood loss, duration of operation, incidence of total complications, incidence of intestinal obstruction and anastomotic leakage between the two groups.

Conclusion

Compared with LaTME, TaTME can obtain higher specimens quality in the treatment of middle and low rectal cancer, the incidence of serious complications after operation is significantly reduced, and the operation is feasible and safe.

Key words: Rectal neoplasms, Total mesorectal excision, Transanal, Laparoscopes
图1 文献检索筛选流程图
表1 纳入文献研究特征汇总
第一作者 研究设计 年份 国家/地区 研究例数 性别(例，男/女) 年龄(岁,Ta/La) ASA Ⅰ~Ⅱ/Ⅲ~Ⅳ BMI (Ta/La) 肿瘤距离肛缘(cm,Ta/La) 辅助放疗(例，是/否) NOS评分
合计 Ta La 合计 Ta La Ta La Ta La
Fernández-Hevia [9] C 2015 西班牙 74 37 37 46/28 24/13 22/15 64.5/69.5 30/7 25/12 23.7/25.1 NA 28/9 23/14 9
De’ Angelis [10] CM 2015 法国 64 32 32 42/22 21/11 21/11 64.91/67.16 31/1 31/1 25.19/24.53 4/3.7 27/5 23/9 8
Chen[11] C 2016 中国 150 50 100 114/36 38/12 76/24 57.3/58.3 33/17 69/31 24.2/24.6 5.8/6.7 NA NA 9
Lelong[12] C 2017 法国 72 34 38 45/27 23/11 22/16 NA 30/4 36/2 NA NA 30/4 35/3 9
Marks[13] C 2016 美国 34 17 17 NA NA NA 59/60 NA NA 26.4/25.9 NA 17/0 17/0 8
Bjoern[14] C 2018 丹麦 85 49 36 53/32 37/12 16/20 64.88/62.42 41/8 35/1 26.57/25.45 8.35/8.14 8/41 8/28 8
Perdawood[15] C 2018 丹麦 200 100 100 141/59 72/28 69/31 67.33/66.86 80/20 89/11 25.65/25.43 NA 18/82 27/73 7
Roodbeen[16] C 2018 荷兰 82 41 41 66/16 34/7 32/9 62.5/66 36/5 38/3 26.7/26.1 5/4.5 18/23 18/23 9
Chang[17] C 2018 中国 46 23 23 26/20 13/10 13/10 62.4/62.9 20/3 22/1 25.8/25.0 4.3/5.9 8/15 14/9 8
Veltcamp Helbach [18] C 2018 荷兰 54 27 27 38/16 18/9 20/7 68/62.7 25/2 25/2 27.6/26.1 NA 18/9 22/5 8
Chen[19] CM 2018 中国台湾 103 39 64 71/32 29/10 42/22 62/64 33/6 58/6 25.4/24.6 4.3/5.8 15/24 31/33 9
Mege[20] CM 2018 法国 68 34 34 46/22 23/11 23/11 58/59 33/1 32/2 25/25 NA 29/5 29/5 7
梁海峰[21] C 2019 中国 64 32 32 29/37 14/18 15/19 55.2/53.8 27/5 28/4 24.8/25.7 NA NA NA 8
图2 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术治疗中低位直肠癌环周切缘（CRM）阳性率的Meta分析
图3 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术治疗中低位直肠癌环周切缘（CRM）距离的Meta分析
图4 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术治疗中低位直肠癌远端切缘（DRM）阳性率的Meta分析
图5 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术治疗中低位直肠癌远端切缘（DRM）距离的Meta分析
图6 经经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术在中低位直肠癌非计划性二次入院发生率的Meta分析
图7 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术在中低位直肠癌淋巴结清扫数量的Meta分析
图8 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术在中低位直肠癌术中失血量的Meta分析
图9 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术在中低位直肠癌手术持续时间的Meta分析
图10 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术在中低位直肠癌术后Clavien-Dindo≥3级并发症发生率的Meta分析
图11 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术在中低位直肠癌术后总并发症发生率的Meta分析
图12 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术在中低位直肠癌直肠系膜完全和几乎完全切除率的Meta分析
图13 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术在中低位直肠癌术后肠梗阻发生率的Meta分析
图14 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术在中低位直肠癌中转开腹率的Meta分析
图15 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术在中低位直肠癌术后吻合口瘘发生率的Meta分析
图16 经肛门（TaTME）与传统腹腔镜（LaTME）全系膜切除术在中低位直肠癌术后排尿障碍发生率的Meta分析
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