背景：为了全面比较开放Duhamel（OD）的效果，腹腔镜辅助Duhamel(LD),经肛门直肠内穿刺（TEPT），和腹腔镜辅助直肠内穿刺（LEPT）在Hirschsprung疾病中的应用。
方法：PubMed，Embase,科克伦图书馆,WebofScience,CNKI,万方,和VIP进行了全面搜索，直到2022年8月4日。结果为手术相关指标和并发症相关指标。建议评估的分级，使用开发和评估（GRADE）方法来评估证据质量。网络图,森林地块,为所有结果绘制了排行榜和等级概率。对于测量数据，报告了加权平均差(WMD)和95%可信度区间(CrIs)；对于枚举数据，计算相对风险(RR)和95%CrIs。
结果：纳入了对4781名患者的62项研究，2039名TEPT患者，1669名LEPT患者，951例OD患者和122例LD患者。OD组的术中失血量多于LEPT组（合并的WMD=44.00，95％CrI：27.33，60.94）。与LEPT相比，TEPT期间患者失血更多（合并WMD=13.08，95％CrI：1.80，24.30）。在术中失血方面,LEPT最有可能是最佳程序（79.76％）。接受OD的患者胃肠功能恢复时间明显延长，与接受LEPT的患者相比（合并WMD=30.39，95％CrI：16.08，44.94）。TEPT组的胃肠功能恢复时间明显长于LEPT组（合并WMD=11.49，95％CrI：0.96，22.05）。关于胃肠功能恢复时间，LEPT最有可能是最佳手术（98.28％）。OD与LEPT患者的住院时间更长（合并WMD=5.24，95％CrI：2.98，7.47）。TEPT组的住院时间明显长于LEPT组（合并的WMD=1.99，95％CrI：0.37，3.58）。就住院时间而言，LEPT最有可能成为最有效的手术。与LD组相比，LEPT组的并发症发生率显着降低（合并RR=0.24，95％CrI：0.12，0.48）。与LEPT相比，OD与并发症发生率显著增加相关(合并RR=5.10,95%CrI:3.48,7.45)。接受TEPT的患者的并发症发生率明显高于接受LEPT的患者（合并RR=1.98，95％CrI：1.63，2.42）。对于并发症，LEPT最有可能具有最佳效果（99.99％）。与LEPT组相比，OD组吻合口漏的发生率显著增加(合并RR=5.35,95%CrI:1.45,27.68).关于吻合口漏，LEPT的可能性最高（63.57％）。OD组感染发生率明显高于LEPT组(合并RR=4.52,95%CrI:2.45,8.84)。TEPT组的感染率明显高于LEPT组（合并RR=1.87，95％CrI：1.13，3.18）。LEPT最有可能是与感染有关的最佳手术（66.32％）。与LEPT相比，OD与明显较高的污染发生率相关（合并RR=1.91，95％CrI：1.16，3.17）。LEPT患者最有可能不发生污染（86.16％）。与LD相比，LEPT在降低便秘发生率方面显著更有效(合并RR=0.39,95%CrI:0.15,0.97)。LEPT最可能不会导致便秘（97.81％）。LEPT与Hirschprung相关性小肠结肠炎（HAEC）的发病率显着低于LD（合并RR=0.34，95％CrI：0.13，0.85）。OD组的HAEC发生率明显高于LEPT组（合并RR=2.29，95％CrI：1.31，4.0）。TEPT组的HAEC发生率明显高于LEPT组（合并RR=1.74，95％CrI：1.24，2.45）。就HAEC而言，LEPT最有可能是最佳操作（98.76％）。
结论：LEPT可能是优于OD的手术，LD和TEPT改善手术情况和并发症，为先天性巨结肠病的治疗提供参考。
BACKGROUND: To comprehensively compare the effects of open
Duhamel (OD), laparoscopic-assisted
Duhamel (LD), transanal endorectal pull-through (TEPT), and laparoscopic-assisted endorectal pull-through (LEPT) in Hirschsprung disease.
METHODS: PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang, and VIP were comprehensively searched up to August 4, 2022. The outcomes were operation-related indicators and complication-related indicators. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence. Network plots, forest plots, league tables and rank probabilities were drawn for all outcomes. For measurement data, weighted mean differences (WMDs) and 95% credibility intervals (CrIs) were reported; for enumeration data, relative risks (RRs) and 95%CrIs were calculated.
RESULTS: Sixty-two studies of 4781 patients were included, with 2039 TEPT patients, 1669 LEPT patients, 951 OD patients and 122 LD patients. Intraoperative blood loss in the OD group was more than that in the LEPT group (pooled WMD = 44.00, 95%CrI: 27.33, 60.94). Patients lost more blood during TEPT versus LEPT (pooled WMD = 13.08, 95%CrI: 1.80, 24.30). In terms of intraoperative blood loss, LEPT was most likely to be the optimal procedure (79.76%). Patients undergoing OD had significantly longer gastrointestinal function recovery time, as compared with those undergoing LEPT (pooled WMD = 30.39, 95%CrI: 16.08, 44.94). The TEPT group had significantly longer gastrointestinal function recovery time than the LEPT group (pooled WMD = 11.49, 95%CrI: 0.96, 22.05). LEPT was most likely to be the best operation regarding gastrointestinal function recovery time (98.28%). Longer hospital stay was observed in patients with OD versus LEPT (pooled WMD = 5.24, 95%CrI: 2.98, 7.47). Hospital stay in the TEPT group was significantly longer than that in the LEPT group (pooled WMD = 1.99, 95%CrI: 0.37, 3.58). LEPT had the highest possibility to be the most effective operation with respect to hospital stay. The significantly reduced incidence of complications was found in the LEPT group versus the LD group (pooled RR = 0.24, 95%CrI: 0.12, 0.48). Compared with LEPT, OD was associated with a significantly increased incidence of complications (pooled RR = 5.10, 95%CrI: 3.48, 7.45). Patients undergoing TEPT had a significantly greater incidence of complications than those undergoing LEPT (pooled RR = 1.98, 95%CrI: 1.63, 2.42). For complications, LEPT is most likely to have the best effect (99.99%). Compared with the LEPT group, the OD group had a significantly increased incidence of anastomotic leakage (pooled RR = 5.35, 95%CrI: 1.45, 27.68). LEPT had the highest likelihood to be the best operation regarding anastomotic leakage (63.57%). The incidence of infection in the OD group was significantly higher than that in the LEPT group (pooled RR = 4.52, 95%CrI: 2.45, 8.84). The TEPT group had a significantly increased incidence of infection than the LEPT group (pooled RR = 1.87, 95%CrI: 1.13, 3.18). LEPT is most likely to be the best operation concerning infection (66.32%). Compared with LEPT, OD was associated with a significantly higher incidence of soiling (pooled RR = 1.91, 95%CrI: 1.16, 3.17). Patients with LEPT had the greatest likelihood not to develop soiling (86.16%). In contrast to LD, LEPT was significantly more effective in reducing the incidence of constipation (pooled RR = 0.39, 95%CrI: 0.15, 0.97). LEPT was most likely not to result in constipation (97.81%). LEPT was associated with a significantly lower incidence of Hirschprung-associated enterocolitis (HAEC) than LD (pooled RR = 0.34, 95%CrI: 0.13, 0.85). The OD group had a significantly higher incidence of HAEC than the LEPT group (pooled RR = 2.29, 95%CrI: 1.31, 4.0). The incidence of HAEC was significantly greater in the TEPT group versus the LEPT group (pooled RR = 1.74, 95%CrI: 1.24, 2.45). LEPT was most likely to be the optimal operation in terms of HAEC (98.76%).
CONCLUSIONS: LEPT may be a superior operation to OD, LD and TEPT in improving operation condition and complications, which might serve as a reference for Hirschsprung disease treatment.
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