直肠癌系膜切除程度中手术入路影响的荟萃分析

Meta-analysis of the impact of surgical approach on the grade of mesorectal excision in rectal cancer.

机构信息

Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland.

出版信息

Br J Surg. 2017 Nov;104(12):1609-1619. doi: 10.1002/bjs.10664.

DOI:10.1002/bjs.10664

PMID:29044484

Abstract

BACKGROUND

The subspecialization of colorectal surgeons, and improvements in the quality of mesorectal excision have revolutionized rectal cancer surgery. With the increasing use of minimally invasive techniques, the completeness of the mesorectal excision has been questioned. This study aimed to assess the pathological outcomes of open versus laparoscopic rectal resection.

METHODS

A meta-analysis of RCTs was undertaken. The primary endpoint was the adequacy of the mesorectal excision. Secondary endpoints included circumferential resection margin and distance to resection margins.

RESULTS

Four studies were included, reporting on 2319 patients; 972 (41·9 per cent) had open and 1347 (58·1 per cent) had laparoscopic resections. Meta-analysis of adequacy of the mesorectal excision showed a small difference in achieving an intact mesorectum in favour of open surgery (risk ratio (RR) 1·06, 95 per cent c.i. 1·02 to 1·10; P = 0·001). Superficial defects were more common in laparoscopic surgery (RR 0·70, 0·54 to 0·89; P = 0·004). Deep mesorectal defects (RR 0·78, 0·51 to 1·20; P = 0·256), circumferential margin (CRM) positivity (RR 0·85, 0·62 to 1·16; P = 0·310), and distance to radial (mean difference (MD) -0·06, 95 per cent c.i. -0·10 to 0·23; P = 0·443) and distal (MD 0·03, -0·06 to 0·12; P = 0·497) margins were all similar. A complete resection (intact mesorectum, negative CRM and distal margin) was achieved in 350 of 478 patients (73·2 per cent) in the laparoscopic group and 372 of 457 (81·4 per cent) in the open group (risk difference (RD) 8 (95 per cent c.i. 3 to 13) per cent; P = 0·003). However, an acceptable mesorectum (intact or superficial defects only) was present in 1254 of 1308 (95·9 per cent) and 916 of 949 (96·5 per cent) in the laparoscopic and open groups respectively (RD 1 (-1 to 3) per cent; P = 0·263).

CONCLUSION

Small differences in mesorectal quality were evident between open and laparoscopic rectal resections. This may be attributable to use of laparoscopic instruments; however, to date minor defects have not affected oncological outcomes.

摘要

背景

结直肠外科医生的专业化以及中直肠切除术质量的提高彻底改变了直肠癌手术。随着微创技术的广泛应用，中直肠切除术的完整性受到了质疑。本研究旨在评估开腹与腹腔镜直肠切除术的病理结果。

方法

对随机对照试验进行荟萃分析。主要终点是中直肠切除的充分性。次要终点包括环周切缘和切缘距离。

结果

纳入四项研究，共报道 2319 例患者；972 例（41.9%）接受开腹手术，1347 例（58.1%）接受腹腔镜手术。中直肠切除充分性的荟萃分析显示，开腹手术在获得完整中直肠方面有轻微优势（风险比（RR）1.06，95%置信区间 1.02 至 1.10；P=0.001）。腹腔镜手术中更常见浅层缺陷（RR 0.70，0.54 至 0.89；P=0.004）。深层中直肠缺陷（RR 0.78，0.51 至 1.20；P=0.256）、环周切缘阳性（RR 0.85，0.62 至 1.16；P=0.310）和距离放射状（平均差值（MD）-0.06，95%置信区间-0.10 至 0.23；P=0.443）和远端（MD 0.03，-0.06 至 0.12；P=0.497）的边缘相似。腹腔镜组 478 例患者中有 350 例（73.2%）和开腹组 457 例患者中有 372 例（81.4%）达到完整切除（完整中直肠、阴性环周切缘和远端切缘）（风险差异（RD）8（95%置信区间 3 至 13）%；P=0.003）。然而，腹腔镜组和开腹组分别有 1308 例（95.9%）和 949 例（96.5%）患者存在可接受的中直肠（仅有完整或浅层缺陷）（RD 1（-1 至 3）%；P=0.263）。