Arezzo Alberto, Passera Roberto, Salvai Alessandro, Arolfo Simone, Allaix Marco Ettore, Schwarzer Guido, Morino Mario
Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Turin, Italy,
Surg Endosc. 2015 Feb;29(2):334-48. doi: 10.1007/s00464-014-3686-4. Epub 2014 Jul 10.
This review of cancer outcomes is based on key literature searches of the medical databases and meta-analysis of short-term benefits of laparoscopy in rectal cancer treatment.
We carried out a systematic review of randomized clinical trials (RCTs) and prospective non-randomized controlled trials (non-RCTs) published between January 2000 and September 2013 listed in the MEDLINE and EMBASE databases (PROSPERO Registration number: CRD42013005076). The primary endpoint was clearance of the circumferential resection margin. Meta-analysis was performed using a fixed-effect model, and sensitivity analysis by a random-effect model; subgroup analysis was performed on subsets of patients with extraperitoneal cancer of the rectum. Relative risk (RR) and mean difference (MD) were used as outcome measures.
Twenty-seven studies (10,861 patients) met the inclusion criteria; eight were RCTs (2,659 patients). The RCTs reported involvement of the circumferential margin in 7.9 % of patients who underwent laparoscopic and in 6.9 % of those undergoing open surgery; the overall RR was 1.00 (95 % confidence interval 0.73-1.35) with no heterogeneity. Subgroup analysis of patients with extraperitoneal cancer showed equivalent involvement of the circumferential margin in the two treatment groups. Although significantly more lymph nodes were retrieved in the surgical specimen after open surgery, the MD of -0.56 was of marginal clinical significance. The sensitivity and subgroup analyses revealed no other significant differences between laparoscopic and open surgery in the rate of R0 resections, distal margin clearance, mesorectal fascia integrity, or local recurrence at 5 years.
Based on the evidence from RCTs and non-RCTs, the short-term benefit and oncological adequacy of laparoscopic rectal resection appear to be equivalent to open surgery, with some evidence potentially pointing to comparable long-term outcomes and oncological adequacy in selected patients with primary resectable rectal cancer.
本癌症结局综述基于对医学数据库的关键文献检索以及腹腔镜在直肠癌治疗中短期获益的荟萃分析。
我们对MEDLINE和EMBASE数据库中列出的2000年1月至2013年9月发表的随机临床试验（RCT）和前瞻性非随机对照试验（非RCT）进行了系统综述（PROSPERO注册号：CRD42013005076）。主要终点是环周切缘的切净情况。采用固定效应模型进行荟萃分析，随机效应模型进行敏感性分析；对直肠腹膜外癌患者亚组进行亚组分析。采用相对危险度（RR）和平均差（MD）作为结局指标。
27项研究（10861例患者）符合纳入标准；8项为RCT（2659例患者）。RCT报告显示，接受腹腔镜手术的患者中环周切缘受累率为7.9%，接受开放手术的患者中为6.9%；总体RR为1.00（95%置信区间0.73 - 1.35），无异质性。直肠腹膜外癌患者的亚组分析显示，两个治疗组中环周切缘受累情况相当。虽然开放手术后手术标本中获取的淋巴结明显更多，但MD为-0.56，临床意义不大。敏感性分析和亚组分析显示，在R0切除率、远切缘切净情况、直肠系膜筋膜完整性或5年局部复发率方面，腹腔镜手术和开放手术之间没有其他显著差异。
基于RCT和非RCT的证据，腹腔镜直肠切除术的短期获益和肿瘤学疗效似乎与开放手术相当，有一些证据可能表明，对于部分可切除的原发性直肠癌患者，其长期结局和肿瘤学疗效也相当。
