Department of General and Colorectal Surgery, Glan Clwyd Hospital, The Betsi Cadwaladr University Health Board, Rhyl, United Kingdom.
Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom.
Surgery. 2020 Sep;168(3):486-496. doi: 10.1016/j.surg.2020.04.063. Epub 2020 Jun 30.
To compare outcomes of total mesorectal excision with or without lateral pelvic lymph node dissection for the treatment of rectal cancer.
The electronic data sources were explored to capture all studies comparing total mesorectal excision with and without lateral pelvic lymph node dissection in patients undergoing operation for rectal cancer. Random effects modelling was utilized for the analyses. The uncertainties associated with varying follow-up periods among the included studies were resolved by analysis of time-to-event outcomes.
Eighteen comparative studies enrolling 6,133 patients were eligible. No difference was found between the 2 groups in terms of overall survival (hazard ratio: 0.92, 95% confidence interval 0.77-1.10, P = .36, I = 67%), overall survival at maximum follow-up (odds ratio: 1.02, 95% confidence interval 0.83-1.25, P = .86, I = 22%), 5-year overall survival (odds ratio: 1.01, 95% confidence interval 0.78-1.30, P = .94, I = 50%), disease-free survival (hazard ratio: 1.25, 95% confidence interval 0.87-1.82, P = .23, I = 74%), disease-free survival at maximum follow-up (odds ratio 1.07, 95% confidence interval 0.88-1.31, P = .50, I = 0%), 5-year disease-free survival (odds ratio: 1.07, 95% confidence interval 0.86-1.32, P = .54, I = 0%), local recurrence (odds ratio: 1.01, 95% confidence interval 0.72-1.42, P = .97, I = 34%), distant recurrence (odds ratio: 0.96, 95% confidence interval 0.62-1.46, P = .84, I = 18%), and total recurrence (odds ratio: 0.97, 95% confidence interval 0.72-1.29, P = .82, I = 0%). Total mesorectal excision with lateral pelvic lymph node dissection resulted in longer operative time (mean difference: 116.02, 95% confidence interval 89.20-142.83, P < .00001, I = 68%) and higher risks of postoperative complications (odds ratio: 1.59, 95% confidence interval 1.14-2.24, P = .007, I = 0%), urinary dysfunction (odds ratio: 6.66, 95% confidence interval 3.31-13.39, P < .00001, I = 23%), and sexual dysfunction (odds ratio: 9.67, 95% confidence interval 2.38-39.26, P = .002; I = 51%). The results remained consistent through separate analyses for randomized trials, observational studies, and patients with or without neoadjuvant chemoradiotherapy.
The available evidence suggests that lateral pelvic lymph node dissection results in greater postoperative morbidity, urinary dysfunction, and sexual dysfunction without improving recurrence and survival. Further evidence is needed from randomized controlled trials to enable experts in the nerve-sparing surgical experiences and neoadjuvant therapy experience to advise on the best treatment strategies for the management of rectal cancer patients including those with possible positive nodes on pretreatment imaging.
比较直肠全系膜切除术联合或不联合侧方盆腔淋巴结清扫术治疗直肠癌的效果。
检索电子数据库以获取所有比较直肠全系膜切除术联合与不联合侧方盆腔淋巴结清扫术治疗直肠癌患者的研究。采用随机效应模型进行分析。通过对时间事件结局的分析解决了纳入研究随访时间不同的不确定性。
纳入 18 项比较研究共 6133 例患者。两组患者在总生存（风险比：0.92，95%置信区间 0.77-1.10，P=0.36，I=67%）、最大随访时总生存（比值比：1.02，95%置信区间 0.83-1.25，P=0.86，I=22%）、5 年总生存（比值比：1.01，95%置信区间 0.78-1.30，P=0.94，I=50%）、无病生存（风险比：1.25，95%置信区间 0.87-1.82，P=0.23，I=74%）、最大随访时无病生存（比值比 1.07，95%置信区间 0.88-1.31，P=0.50，I=0%）、5 年无病生存（比值比：1.07，95%置信区间 0.86-1.32，P=0.54，I=0%）、局部复发（比值比：1.01，95%置信区间 0.72-1.42，P=0.97，I=34%）、远处复发（比值比：0.96，95%置信区间 0.62-1.46，P=0.84，I=18%）和总复发（比值比：0.97，95%置信区间 0.72-1.29，P=0.82，I=0%）方面无差异。联合侧方盆腔淋巴结清扫术的直肠全系膜切除术导致手术时间更长（平均差值：116.02，95%置信区间 89.20-142.83，P<0.00001，I=68%），术后并发症风险更高（比值比：1.59，95%置信区间 1.14-2.24，P=0.007，I=0%），包括尿功能障碍（比值比：6.66，95%置信区间 3.31-13.39，P<0.00001，I=23%）和性功能障碍（比值比：9.67，95%置信区间 2.38-39.26，P=0.002；I=51%）。通过对随机试验、观察性研究和接受或未接受新辅助放化疗的患者的单独分析，结果仍然一致。
现有证据表明，侧方盆腔淋巴结清扫术增加了术后发病率、尿功能障碍和性功能障碍，而没有改善复发和生存。需要来自随机对照试验的进一步证据，以便具有神经保护手术经验和新辅助治疗经验的专家能够就直肠癌患者的最佳治疗策略提供建议，包括那些在预处理影像学上可能有阳性淋巴结的患者。
