Hou Sen, Wang Quan, Zhao Shidong, Liu Fan, Guo Peng, Ye Yingjiang
Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100044, People's Republic of China.
Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing, 100044, People's Republic of China.
World J Surg Oncol. 2021 Apr 21;19(1):130. doi: 10.1186/s12957-021-02243-0.
The application of side-to-end anastomosis (SEA) in sphincter-preserving resection (SPR) is controversial. We performed a meta-analysis to compare the safety and efficacy of SEA with colonic J-pouch (CJP) anastomosis, which had been proven effective in improving postoperative bowel function.
The protocol was registered in PROSPERO under number CRD42020206764. PubMed, Embase, Web of Science, and the Cochrane Register of Controlled Trials databases were searched. The inclusion criteria were randomized controlled trials (RCTs) that evaluated the safety or efficacy of SEA in comparison with CJP anastomosis. The outcomes included the pooled risk ratio (RR) for dichotomous variables and weighted mean differences (WMDs) for continuous variables. All outcomes were calculated with 95% confidence intervals (CI) by STATA software (Stata 14, Stata Corporation, TX, USA).
A total of 864 patients from 10 RCTs were included in the meta-analysis. Patients undergoing SEA had a higher defecation frequency at 12 months after SPR (WMD = 0.20; 95% CI, 0.14-0.26; P < 0.01) than those undergoing CJP anastomosis with low heterogeneity (I = 0%, P = 0.54) and a lower incidence of incomplete defecation at 3 months after surgery (RR = 0.28; 95% CI, 0.09-0.86; P = 0.03). A shorter operating time (WMD = - 17.65; 95% CI, - 23.28 to - 12.02; P < 0.01) was also observed in the SEA group without significant heterogeneity (I = 0%, P = 0.54). A higher anorectal resting pressure (WMD = 6.25; 95% CI, 0.17-12.32; P = 0.04) was found in the SEA group but the heterogeneity was high (I = 84.5%, P = 0.84). No significant differences were observed between the groups in terms of efficacy outcomes including defecation frequency, the incidence of urgency, incomplete defecation, the use of pads, enema, medications, anorectal squeeze pressure and maximum rectal volume, or safety outcomes including operating time, blood loss, the use of protective stoma, postoperative complications, clinical outcomes, and oncological outcomes.
The present evidence suggests that SEA is an effective anastomotic strategy to achieve similar postoperative bowel function without increasing the risk of complications compared with CJP anastomosis. The advantages of SEA include a shorter operating time, a lower incidence of incomplete defecation at 3 months after surgery, and better sphincter function. However, close attention should be paid to the long-term defecation frequency after SPR.
端端吻合术（SEA）在保留括约肌切除术（SPR）中的应用存在争议。我们进行了一项荟萃分析，以比较SEA与结肠J形贮袋（CJP）吻合术的安全性和有效性，后者已被证明可有效改善术后肠道功能。
该方案已在国际前瞻性系统评价注册库（PROSPERO）中注册，注册号为CRD42020206764。检索了PubMed、Embase、Web of Science和Cochrane对照试验注册库数据库。纳入标准为评估SEA与CJP吻合术相比的安全性或有效性的随机对照试验（RCT）。结局指标包括二分变量的合并风险比（RR）和连续变量的加权均数差（WMD）。所有结局指标均使用STATA软件（Stata 14，美国德克萨斯州Stata公司）计算95%置信区间（CI）。
该荟萃分析共纳入了来自10项RCT的864例患者。与接受CJP吻合术的患者相比，接受SEA的患者在SPR术后12个月时排便频率更高（WMD = 0.20；95%CI，0.14 - 0.26；P < 0.01），异质性较低（I = 0%，P = 0.54），且术后3个月时排便不完全的发生率较低（RR = 0.28；95%CI，0.09 - 0.86；P = 0.03）。SEA组的手术时间也较短（WMD = - 17.65；95%CI，- 23.28至 - 12.02；P < 0.01），且无显著异质性（I = 0%，P = 0.54）。SEA组的肛管静息压较高（WMD = 6.25；95%CI，0.17 - 12.32；P = 0.04），但异质性较高（I = 84.5%，P = 0.84）。在包括排便频率、急迫性发生率、排便不完全、护垫使用、灌肠、药物使用、肛管挤压压和最大直肠容量等疗效结局指标，或包括手术时间、失血、保护性造口使用、术后并发症、临床结局和肿瘤学结局等安全性结局指标方面，两组之间未观察到显著差异。
现有证据表明，与CJP吻合术相比，SEA是一种有效的吻合策略，可实现相似的术后肠道功能，且不增加并发症风险。SEA的优点包括手术时间较短、术后3个月时排便不完全的发生率较低以及括约肌功能较好。然而，应密切关注SPR术后的长期排便频率。
