Hajibandeh Shahin, Hajibandeh Shahab, Navid Ahmad, Sarma Diwakar Ryali, Eltair Mokhtar, Mankotia Rajnish, Thompson Christopher Vaun, Torrance Andrew W, Peravali Rajeev
Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.
Department of General Surgery, The Pennine Acute Hospitals NHS Trust, North Manchester General Hospital, Manchester, UK.
Int J Colorectal Dis. 2019 May;34(5):787-799. doi: 10.1007/s00384-019-03281-7. Epub 2019 Apr 6.
To evaluate comparative outcomes of medial-to-lateral and lateral-to-medial colorectal mobilisation in patients undergoing laparoscopic colorectal surgery.
We conducted a systematic search of electronic databases and bibliographic reference lists. Perioperative mortality and morbidity, procedure time, length of hospital stay, rate of conversion to open procedure, and number of harvested lymph nodes were the outcome parameters. Combined overall effect sizes were calculated using fixed-effects or random-effects models.
We identified eight comparative studies reporting a total of 1477 patients evaluating outcomes of medial-to-lateral (n = 626) and lateral-to-medial (n = 851) approaches in laparoscopic colorectal resection. The medial-to-lateral approach was associated with significantly lower rate of conversion to open (odds ratio (OR) 0.43, P = 0.001), shorter procedure time (mean difference (MD) - 32.25, P = 0.003) and length of hospital stay (MD - 1.54, P = 0.02) compared to the lateral-to-medial approach. However, there was no significant difference in mortality (risk difference (RD) 0.00, P = 0.96), overall complications (OR 0.78, P = 0.11), wound infection (OR 0.84, P = 0.60), anastomotic leak (OR 0.70, P = 0.26), bleeding (OR 0.60, P = 0.50), and number of harvested lymph nodes (MD - 1.54, P = 0.02) between two groups. Sub-group analysis demonstrated that the lateral-to-medial approach may harvest more lymph nodes in left-sided colectomy (MD - 1.29, P = 0.0009). The sensitivity analysis showed that overall complications were lower in the medial-to-lateral group (OR 0.72, P = 0.49).
Our meta-analysis (level 2 evidence) showed that medial-to-lateral approach during laparoscopic colorectal resection may reduce procedure time, length of hospital stay and conversion to open procedure rate. Moreover, it may probably reduce overall perioperative morbidity. However, both approaches carry similar risk of mortality, and have comparable ability to harvest lymph nodes. Future high-quality randomised trials are required.
评估接受腹腔镜结直肠手术患者中，由内侧向外侧和由外侧向内侧结肠游离术的比较结果。
我们对电子数据库和参考文献列表进行了系统检索。围手术期死亡率和发病率、手术时间、住院时间、转为开放手术的比例以及获取的淋巴结数量为观察指标。使用固定效应或随机效应模型计算合并总体效应量。
我们确定了8项比较研究，共报告了1477例患者，评估了腹腔镜结直肠切除术中由内侧向外侧（n = 626）和由外侧向内侧（n = 851）两种手术方式的结果。与由外侧向内侧手术方式相比，由内侧向外侧手术方式转为开放手术的比例显著更低（优势比（OR）0.43，P = 0.001），手术时间更短（平均差（MD）-32.25，P = 0.003），住院时间更短（MD -1.54，P = 0.02）。然而，两组在死亡率（风险差（RD）0.00，P = 0.96）、总体并发症（OR 0.78，P = 0.11）、伤口感染（OR 0.84，P = 0.60）、吻合口漏（OR 0.70，P = 0.26）、出血（OR 0.60，P = 0.50）以及获取的淋巴结数量（MD -1.54，P = 0.02）方面无显著差异。亚组分析表明，在左侧结肠切除术中，由外侧向内侧手术方式可能获取更多淋巴结（MD -1.29，P = 0.0009）。敏感性分析显示，由内侧向外侧组的总体并发症更低（OR 0.72，P = 0.49）。
我们的荟萃分析（2级证据）表明，腹腔镜结直肠切除术中由内侧向外侧的手术方式可能会缩短手术时间、住院时间并降低转为开放手术的比例。此外，它可能会降低总体围手术期发病率。然而，两种手术方式的死亡风险相似，获取淋巴结的能力相当。未来需要高质量的随机试验。
