Department of General Surgery, Division of Gastrointestinal Surgery.
Department of Evidence-Based Medicine and Clinical Epidemiology.
Int J Surg. 2024 Apr 1;110(4):2338-2348. doi: 10.1097/JS9.0000000000000205.
The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis.
A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated.
A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P =0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P =0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P =0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P =0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: -24.89, 95% CI: -45.21 to -4.57; P =0.02) compared to APR.
Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data.
与腹会阴联合切除术（APR）相比，经括约肌间切除术（ISR）治疗低位直肠癌的疗效仍不明确。本研究旨在通过系统评价和荟萃分析比较 ISR 和 APR 治疗低位直肠癌患者的肿瘤学结局。
系统检索 Cochrane 图书馆、PubMed、EMBASE 和 MEDLINE 数据库，检索时间截至 2022 年 1 月 12 日。主要结局指标包括 5 年无病生存率（5y-DFS）和 5 年总生存率。次要结局指标包括环周切缘受累、局部复发、围手术期结局和其他长期结局。计算每个结局测量的合并优势比、均数差或风险比（HR）及其 95%CI。
定性分析共纳入 20 项非随机对照研究，其中 1217 例患者接受 ISR 治疗，1135 例患者接受 APR 治疗。两组 5y-DFS（HR：0.84，95%CI：0.55-1.29；P=0.43）和 5 年总生存率（HR：0.93，95%CI：0.60-1.46；P=0.76）差异无统计学意义。我们对报告匹配 T 分期和肿瘤距离的五项研究的结果进行了另一项汇总分析。与 APR 相比，ISR 组的 5y-DFS（HR：0.76，95%CI：0.45-1.30；P=0.31）和 5y-LRFS（局部无复发生存率）（HR：0.72，95%CI：0.29-1.78；P=0.48）相当。同时，ISR 在降低手术时间（均数差：-24.89，95%CI：-45.21 至-4.57；P=0.02）方面与 APR 等效，同时具有同等的局部控制和围手术期结局。
尽管由于偏倚风险和数据有限，这一结果需要仔细考虑并进一步研究，但我们的结果表明，ISR 手术不会影响患者的长期生存和安全性。
