目的:在早期直肠癌的治疗中,越来越多的研究表明,经肛门内镜显微手术是根治手术的替代方法之一,坚持全直肠系膜切除术,可在不影响治疗结局的前提下降低不良事件发生率.本荟萃分析的目的是比较经肛门内镜显微手术和根治性手术坚持全直肠系膜切除术的安全性和治疗效果,为临床治疗方案选择提供依据。
方法:我们检索了四个主要数据库的文献,PubMed,Embase,WebofScience,和Cochrane图书馆,没有时间限制。文献包括随机对照研究和队列研究,比较了经肛门内镜显微手术和坚持全直肠系膜切除术的根治性手术两种手术方式。从纳入的文献中提取经肛门内镜显微手术和根治性手术的治疗有效性和安全性结果,并使用RevMan5.4和stata17进行统计分析。
结果:最终,本研究共纳入13篇论文,包括5项随机对照研究和8项队列研究。Meta分析结果显示,经肛门内镜显微手术和根治性手术治疗远处转移(RR,0.59(0.34,1.02),P>0.05),总复发(RR,1.49(0.96,2.31),P>0.05),疾病特异性生存率(RR,0.74(0.09,1.57),P>0.05),suturelinine或吻合口漏的开裂(RR,0.57(0.30,1.06),P>0.05),术后出血(RR,0.47(0.22,0.99),P>0.05),和肺炎(RR,0.37,(0.10,1.40),P>0.05)均无明显差别。然而,它们在围手术期死亡率方面存在显著差异(RR,0.26(0.07,0.93,P<0.05)),局部复发(RR,2.51(1.53,4.21),P<0.05),_总生存率_(RR,0.88(0.74,1.00),P<0.05),无病生存率(RR,1.08(0.97,1.19),P<0.05),临时造口(RR,0.05(0.01,0.20),P<0.05),永久性造口(RR,0.16(0.08,0.33),P<0.05),术后并发症(RR,0.35(0.21,0.59),P<0.05),直肠疼痛(RR,1.47(1.11,1.95),P<0.05),操作时间(RR,-97.14(-115.81,-78.47),P<0.05),失血(RR,-315.52(-472.47,-158.57),P<0.05),和住院时间(RR,-8.82(-10.38,-7.26),P<0.05)。
结论:经肛门内镜显微手术似乎是早期直肠癌根治术的替代方法之一,但需要更多高质量的临床研究提供可靠的依据。
OBJECTIVE: In the treatment of early-stage rectal cancer, a growing number of studies have shown that transanal endoscopic microsurgery is one of the alternatives to radical surgery adhering to total mesorectal excision that can reduce the incidence of adverse events without compromising treatment outcomes. The purpose of this meta-analysis is to compare the safety and treatment effect of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision to provide a basis for clinical treatment selections.
METHODS: We searched the literatures of four major databases, PubMed, Embase, Web of science, and Cochrane Library, without limitation of time. The literatures included randomized controlled studies and cohort studies comparing two surgical procedures of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision. Treatment effectiveness and safety results of transanal endoscopic microsurgery and radical surgery were extracted from the included literatures and statistically analyzed using RevMan5.4 and stata17.
RESULTS: Ultimately, 13 papers were included in the study including 5 randomized controlled studies and 8 cohort studies. The results of the meta-analysis showed that the treatment effect and safety of both transanal endoscopic microsurgery and radical surgery in distant metastasis (RR, 0.59 (0.34, 1.02), P > 0.05), overall recurrence (RR, 1.49 (0.96, 2.31), P > 0.05), disease-specific-survival (RR, 0.74 (0.09, 1.57), P > 0.05), dehiscence of the sutureline or anastomosis leakage (RR, 0.57 (0.30, 1.06), P > 0.05), postoperative bleeding (RR, 0.47 (0.22, 0.99), P > 0.05), and pneumonia (RR, 0.37, (0.10, 1.40), P > 0.05) were not significantly different. However, they differ significantly in perioperative mortality (RR, 0.26 (0.07, 0.93, P < 0.05)), local recurrence (RR, 2.51 (1.53, 4.21), P < 0.05),_overall survival_ (RR, 0.88 (0.74, 1.00), P < 0.05), disease-free-survival (RR, 1.08 (0.97, 1.19), P < 0.05), temporary stoma (RR, 0.05 (0.01, 0.20), P < 0.05), permanent stoma (RR, 0.16 (0.08, 0.33), P < 0.05), postoperative complications (RR, 0.35 (0.21, 0.59), P < 0.05), rectal pain (RR, 1.47 (1.11, 1.95), P < 0.05), operation time (RR, -97.14 (-115.81, -78.47), P < 0.05), blood loss (RR, -315.52 (-472.47, -158.57), P < 0.05), and time of hospitalization (RR, -8.82 (-10.38, -7.26), P < 0.05).
CONCLUSIONS: Transanal endoscopic microsurgery seems to be one of the alternatives to radical surgery for early-stage rectal cancer, but more high-quality clinical studies are needed to provide a reliable basis.