Zhang Jun-Jie, Guo Bao-Ling, Zheng Qiu-Xiang, Chen Zhi-Yong
Deparment of Surgical Oncology, The First People's Hospital of Fuyang Hangzhou, Hangzhou 311400, China.
Department of Oncology, Longyan First Hospital, Affiliated to Fujian Medical University, Longyan 364000, China.
Comb Chem High Throughput Screen. 2019;22(3):153-159. doi: 10.2174/1386207322666190415102505.
Only a limited number of studies considered the combined chemo-radiation therapy after surgery for treating locally advanced rectal cancer. Comparative studies on laparoscopic and open procedures indicated that laparoscopy surgery may be associated with fewer postoperative complications. Despite encouraging results from rectal cancer patients who received neoadjuvant chemo-radiotherapy prior to laparoscopic surgery, the acceptance of this procedure remains controversial, and conflicting evidence exists only in the form of retrospective trials.
Since laparoscopic surgery was introduced into clinical practice to treat rectal cancer after neoadjuvant chemo-radiotherapy, it has been discussed controversially whether laparoscopic surgery can be performed as effectively as an open procedure. To overcome the biases inherent in any nonrandomized comparison, we analyzed the propensity-matched analysis and randomized clinical trial. In this study, we set out to determine whether laparoscopic resection was non-inferior to open resection in treatment outcomes of rectal cancer after neoadjuvant chemo-radiotherapy.
Publications on laparoscopic surgery in comparison with open thoracotomy in treatment outcomes of rectal cancer after neo-adjuvant chemo-radiotherapy to November 2017 were collected. Summary hazard ratios (HRs) of endpoints of interest such as 3-OS (overall survival), 3-DFS (disease-free survival), and individual postoperative complications were analyzed in all trials. By using fixed- or random-effects models according to the heterogeneity, meta-analysis Revman 5.3 software was applied to analyze combined pooled HRs.
A total of 6 trials met our inclusion criteria. The pooled analysis of 3-DFS showed that laparoscopic surgery did not improve disease -free survival, compared with open thoracotomy (OR =1.48, 95% CI 0.95 - 2.29; P = 0.08), as well with the 3-OS (OR=0.96, 95%CI=0.66-1.41, P=0.084). The pooled result of duration of surgery indicated that laparoscopic surgery had a tendency towards a longer surgery time (SMD= 43.96, 95% CI 34.04- 53.88; P < 0.00001) and a shorter hospital stay (SMD= -0.97, 95% CI -1.75- -0.18; P=0.02). However, no significant differences between laparoscopic surgery and open thoracotomy were observed in terms of the meta-analysis on the number of removed lymph nodes (SMD =-0.37, 95% CI -0.1.77 - 1.03; P = 0.60), blood loss (SMD =-21.30, 95% CI -0.48.36 - 5.77; P = 0.12), positive circumferential resection margin (OR =0.73, 95% CI 0.22- 2.48; P = 0.61) or postoperative complications (OR =0.89, 95% CI 0.67 - 1.17; P = 0.40) l.
The current data supported the concept that laparoscopic surgery had correlated with a longer operative time but a shorter hospital stay, without superior advantages in short-term survival rates or oncologic efficiency for locally treating advanced rectal cancer after neoadjuvant chemoradiotherapy. However, prospective investigation on long-term oncological results from laparoscopic surgery is required in the future to verify the benefits of laparoscopic surgery over open surgery after chemo-radiation therapy for treating locally advanced rectal cancer.
仅有少数研究考虑了手术后联合放化疗治疗局部晚期直肠癌。腹腔镜手术与开放手术的对比研究表明，腹腔镜手术可能术后并发症更少。尽管接受新辅助放化疗后的直肠癌患者取得了令人鼓舞的结果，但该手术的接受度仍存在争议，且相互矛盾的证据仅以回顾性试验的形式存在。
自从腹腔镜手术被引入临床用于治疗新辅助放化疗后的直肠癌以来，对于腹腔镜手术是否能与开放手术一样有效一直存在争议。为了克服任何非随机比较中固有的偏差，我们分析了倾向匹配分析和随机临床试验。在本研究中，我们旨在确定在新辅助放化疗后直肠癌的治疗结果方面，腹腔镜切除术是否不劣于开放切除术。
收集截至2017年11月关于腹腔镜手术与开放手术治疗新辅助放化疗后直肠癌疗效比较的文献。在所有试验中分析了感兴趣的终点指标的汇总风险比（HRs），如3年总生存期（OS）、3年无病生存期（DFS）和个体术后并发症。根据异质性使用固定效应或随机效应模型，应用Meta分析Revman 5.3软件分析合并的汇总HRs。
共有6项试验符合我们的纳入标准。3年DFS的汇总分析显示，与开放手术相比，腹腔镜手术并未改善无病生存期（OR =1.48，95%CI 0.95 - 2.29；P = 0.08），3年OS也是如此（OR=0.96，95%CI=0.66 - 1.41，P=0.084）。手术时长的汇总结果表明，腹腔镜手术倾向于手术时间更长（标准化均数差= 43.96，95%CI 34.04 - 53.88；P < 0.00001）和住院时间更短（标准化均数差= -0.97，95%CI -1.75 - -0.18；P=0.02）。然而，在切除淋巴结数量（标准化均数差 = -0.37，95%CI -0.177 - 1.03；P = 0.60）、失血量（标准化均数差 = -21.30，95%CI -0.4836 - 5.77；P = 0.12）、环周切缘阳性（OR =0.73，95%CI 0.22 - 2.48；P = 0.61）或术后并发症（OR =0.89，95%CI 0.67 - 1.17；P = 0.40）的Meta分析方面，未观察到腹腔镜手术与开放手术之间存在显著差异。
目前的数据支持这一观点，即腹腔镜手术与更长的手术时间相关，但住院时间更短，在新辅助放化疗后局部治疗晚期直肠癌的短期生存率或肿瘤学疗效方面没有优势。然而，未来需要对腹腔镜手术的长期肿瘤学结果进行前瞻性研究，以验证腹腔镜手术相对于放化疗后开放手术治疗局部晚期直肠癌的益处。
