腹腔镜辅助与开腹手术治疗进展期胃癌安全性与有效性的Meta分析
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摘要
目的系统评价腹腔镜辅助与开腹手术治疗进展期胃癌的安全性、有效性。方法检索PubMed、Embase、Cochrane library、中国知网、维普和万方等数据库2008年6月至2018年6月间的有关腹腔镜辅助和开腹手术治疗进展期胃癌的对比研究文献,对纳入研究行质量评价并提取数据资料,采用RevMan 5.3软件进行Meta分析。结果共纳入12项研究,其中英文文献7篇,中文文献5篇;2篇随机对照临床试验,10篇回顾性非随机对照研究;样本量合计4 199例,腹腔镜组2 118例,开腹组2 081例。Meta分析结果表明:与开腹组比较,腹腔镜组手术时间更长(WMD=26.32,P=0.01),失血量少(WMD=-109.84,P=0.00),淋巴结清扫数目、近端切缘距离及远端切缘距离差异无统计学意义(WMD值分别为1.2,-0.20,-0.01,均P>0.05),排气时间、进食时间、住院时间均显著优于开腹组(WMD值分别为-0.57,-0.67,-3.14,均P<0.05),术后并发症发生率更低(OR=0.75,P=0.00),1年总生存率、5年总生存率与开腹组比较差异均无统计学意义(OR分别为1.17,3.36,均P>0.05)。敏感性分析显示上述结果稳定;漏斗图分析未观察到明显发表偏倚。结论腹腔镜辅助进展期胃癌根治术安全可行,术中创伤更小,术后恢复更快,有望达到与开腹手术相同的根治效果。
Objective To systematic evaluate the safety and efficacy of laparoscopic-assisted versus open radical gastrectomy for advanced gastric cancer.Methods We retrieved the comparative studies on laparoscopic-assisted and open radical gastrectomy for advanced gastric cancer from the databases of PubMed, Embase, Cochrane Library, China Knowledge Network, VIP and Wanfang published from June 2008 to June 2018.The qualities of studies were evaluated and the relevant clinical data analyzed.Meta-analysis was performed with RevMan 5.3 software.Results A total of 12 studies were included, including 7 English articles, 5 Chinese articles, 2 randomized controlled trials(RCTs) and 10 respective non-controlled trials(RNTs).With a total sample size of 4 199, laparoscopic(n=2 118) and open(n=2 081) groups were designated.As compared with open gastrectomy group, laparoscopic-assisted gastrectomy group achieved a longer operative duration(WMD=26.32, P=0.01) and a smaller volume of blood loss(WMD=-109.84, P=0.00); no significant differences existed in number of harvested lymph node dissection, proximal resection margin or distal resection margin(WMD=1.2,-0.20,-0.01; all P>0.5).The time to flatus and oral intake and duration of hospitalization stay were significantly shorter than those of open group(WMD=-0.57,-0.67,-3.14; all P<0.05); the incidence of postoperative complications was lower(OR=0.75, P=0.00); 1/5-year overall survival rate showed no significant inter-group difference(OR=1.17, 3.36, P>0.05).Sensitivity analysis revealed the stability of the above results.And funnel plot indicated no significant publication bias.Conclusion With faster postoperative recovery, laparoscopic-assisted radical gastrectomy is both safe and feasible.It is expected to achieve a comparable radical efficacy as conventional open surgery.
Objective To systematic evaluate the safety and efficacy of laparoscopic-assisted versus open radical gastrectomy for advanced gastric cancer.Methods We retrieved the comparative studies on laparoscopic-assisted and open radical gastrectomy for advanced gastric cancer from the databases of PubMed, Embase, Cochrane Library, China Knowledge Network, VIP and Wanfang published from June 2008 to June 2018.The qualities of studies were evaluated and the relevant clinical data analyzed.Meta-analysis was performed with RevMan 5.3 software.Results A total of 12 studies were included, including 7 English articles, 5 Chinese articles, 2 randomized controlled trials(RCTs) and 10 respective non-controlled trials(RNTs).With a total sample size of 4 199, laparoscopic(n=2 118) and open(n=2 081) groups were designated.As compared with open gastrectomy group, laparoscopic-assisted gastrectomy group achieved a longer operative duration(WMD=26.32, P=0.01) and a smaller volume of blood loss(WMD=-109.84, P=0.00); no significant differences existed in number of harvested lymph node dissection, proximal resection margin or distal resection margin(WMD=1.2,-0.20,-0.01; all P>0.5).The time to flatus and oral intake and duration of hospitalization stay were significantly shorter than those of open group(WMD=-0.57,-0.67,-3.14; all P<0.05); the incidence of postoperative complications was lower(OR=0.75, P=0.00); 1/5-year overall survival rate showed no significant inter-group difference(OR=1.17, 3.36, P>0.05).Sensitivity analysis revealed the stability of the above results.And funnel plot indicated no significant publication bias.Conclusion With faster postoperative recovery, laparoscopic-assisted radical gastrectomy is both safe and feasible.It is expected to achieve a comparable radical efficacy as conventional open surgery.
引文
[1] Goh PM, Khan AZ, So JB, et al.Early experience with laparoscopic radical gastrectomy for advanced gastric cancer[J].Surg Laparosc Endosc Percutan Tech, 2001, 11(2):83-87.DOI:10.1097/00019509-200104000-00003.
[2] Olmi S, Giorgi R, Cioffi S, et al.Total and Subtotal Laparoscopic Gastrectomy for the Treatment of Advanced Gastric Cancer:Morbidity and Oncological Outcomes[J].J Laparoendosc Adv Surg Tech A, 2018,28(3):278-285.DOI:10.1089/lap.2017.0372.
[3] Athanasiou T, Al-Ruzzeh S, Kumar P, et al.Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patients[J].Ann Thorac Surg, 2004,77(2):745-753.DOI:10.1016/j.athoracsur.2003.07.002.
[4] 张辉,臧卫东,卓长华,等.进展期胃中上部癌行腹腔镜与开腹根治性全胃切除术的围手术期疗效比较[J].中国临床医学,2010,17(3):341-344.DOI:10.3969/j.issn.1008-6358.2010.03.012.
[5] Chen QY, Huang CM, Lin JX, et al.Laparoscopy-assisted versus open D2 radical gastrectomy for advanced gastric cancer without serosal invasion:a case control study[J].World J Surg Oncol, 2012,10(1):1-9.DOI:10.1186/1477-7819-10-248.
[6] Chun HT, Kim KH, Kim MC, et al.Comparative study of laparoscopy-assisted versus open subtotal gastrectomy for pT2 gastric cancer[J].Yonsei Med J, 2012, 53(5):952-959.DOI:10.3349/ymj.2012.53.5.952.
[7] Lin JX, Huang CM, Zheng CH, et al.Laparoscopy-assisted gastrectomy with D_2 lymph node dissection for advanced gastric cancer without serosa invasion:a matched cohort study from South China[J].World J Surg Oncol, 2013,11(1):1-9.DOI:10.1186/1477-7819-11-4.
[8] 叶民峰,陶锋,徐关根,等.腹腔镜辅助与开腹胃癌根治术治疗进展期胃癌的临床疗效分析[J].中华外科杂志,2013,51(5):396-399.DOI:10.3760/cma.j.issn.0529-5815.2013.05.005.
[9] 李平,黄昌明,郑朝辉,等.进展期胃癌行腹腔镜与开腹D_2淋巴结清扫术近期疗效对比分析[J].中国实用外科杂志,2013,33(12):1044-1047.
[10] Gordon AC, Kojima K, Inokuchi M, et al.Long-term comparison of laparoscopy-assisted distal gastrectomy and open distal gastrectomy in advanced gastric cancer.Surg Endosc, 2013,27(2):462-470.DOI:10.1007/s00464-012-2459-1.
[11] 刘江文,孙琳,仝德峰,等.远端进展期胃癌腹腔镜辅助与开腹D_2根治术淋巴结清扫的临床对照研究.中国微创外科杂志,2014,14(11):981-983,986.DOI:10.3969/j.issn.1009-6604.2014.11.004.
[12] Zhang Y, Qi F, Jiang Y, et al.Long-term follow-up after laparoscopic versus open distal gastrectomy for advanced gastric cancer[J].Int J Clin Exp Med, 2015,8(8):13564-13570.
[13] Hao Y, Yu P, Qian F, et al.Comparison of laparoscopy-assisted and open radical gastrectomy for advanced gastric cancer:A retrospective study in a single minimally invasive surgery center[J].Medicine (Baltimore), 2016,95(25):e3936.DOI:10.1097/MD.0000000000003936.
[14] Hu Y, Huang C, Sun Y, et al.Morbidity and Mortality of Laparoscopic Versus Open D_2 Distal Gastrectomy for Advanced Gastric Cancer:A Randomized Controlled Trial[J].J Clin Oncol, 2016,34(12):1350-1357.DOI:10.1200/JCO.2015.63.7215.
[15] 林建贤,黄昌明,郑朝辉,等.腹腔镜与传统开腹远侧胃大部切除术治疗局部进展期胃癌的疗效对比研究[J].中华外科杂志,2016,54(10):755-760.DOI:10.3760/cma.j.issn.0529-5815.2016.10.007.
[16] Kim HH, Han SU, Kim MC, et al.Long-term results of laparoscopic gastrectomy for gastric cancer:a large-scale case-control and case-matched Korean multicenter study[J].J Clin Oncol, 2014, 32(7):627-633.DOI:10.1200/JCO.2013.48.8551.
[17] He H, Shen Z, Wang X, et al.Survival benefit of greater number of lymph nodes dissection for advanced node-negative gastric cancer patients following radical gastrectomy[J].Jpn J Clin Oncol, 2016,46(1):63-70.DOI:10.1093/jjco/hyv159.
[18] Biondi A,D’Ugo D,Cananzi FC,et al.Does a minimum number of 16 retrieved nodes affect survival in curatively resected gastric cancer?[J].Eur J Surg Oncol,2015,41(6):779-786.DOI:10.1016/j.ejso.2015.03.227.
[2] Olmi S, Giorgi R, Cioffi S, et al.Total and Subtotal Laparoscopic Gastrectomy for the Treatment of Advanced Gastric Cancer:Morbidity and Oncological Outcomes[J].J Laparoendosc Adv Surg Tech A, 2018,28(3):278-285.DOI:10.1089/lap.2017.0372.
[3] Athanasiou T, Al-Ruzzeh S, Kumar P, et al.Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patients[J].Ann Thorac Surg, 2004,77(2):745-753.DOI:10.1016/j.athoracsur.2003.07.002.
[4] 张辉,臧卫东,卓长华,等.进展期胃中上部癌行腹腔镜与开腹根治性全胃切除术的围手术期疗效比较[J].中国临床医学,2010,17(3):341-344.DOI:10.3969/j.issn.1008-6358.2010.03.012.
[5] Chen QY, Huang CM, Lin JX, et al.Laparoscopy-assisted versus open D2 radical gastrectomy for advanced gastric cancer without serosal invasion:a case control study[J].World J Surg Oncol, 2012,10(1):1-9.DOI:10.1186/1477-7819-10-248.
[6] Chun HT, Kim KH, Kim MC, et al.Comparative study of laparoscopy-assisted versus open subtotal gastrectomy for pT2 gastric cancer[J].Yonsei Med J, 2012, 53(5):952-959.DOI:10.3349/ymj.2012.53.5.952.
[7] Lin JX, Huang CM, Zheng CH, et al.Laparoscopy-assisted gastrectomy with D_2 lymph node dissection for advanced gastric cancer without serosa invasion:a matched cohort study from South China[J].World J Surg Oncol, 2013,11(1):1-9.DOI:10.1186/1477-7819-11-4.
[8] 叶民峰,陶锋,徐关根,等.腹腔镜辅助与开腹胃癌根治术治疗进展期胃癌的临床疗效分析[J].中华外科杂志,2013,51(5):396-399.DOI:10.3760/cma.j.issn.0529-5815.2013.05.005.
[9] 李平,黄昌明,郑朝辉,等.进展期胃癌行腹腔镜与开腹D_2淋巴结清扫术近期疗效对比分析[J].中国实用外科杂志,2013,33(12):1044-1047.
[10] Gordon AC, Kojima K, Inokuchi M, et al.Long-term comparison of laparoscopy-assisted distal gastrectomy and open distal gastrectomy in advanced gastric cancer.Surg Endosc, 2013,27(2):462-470.DOI:10.1007/s00464-012-2459-1.
[11] 刘江文,孙琳,仝德峰,等.远端进展期胃癌腹腔镜辅助与开腹D_2根治术淋巴结清扫的临床对照研究.中国微创外科杂志,2014,14(11):981-983,986.DOI:10.3969/j.issn.1009-6604.2014.11.004.
[12] Zhang Y, Qi F, Jiang Y, et al.Long-term follow-up after laparoscopic versus open distal gastrectomy for advanced gastric cancer[J].Int J Clin Exp Med, 2015,8(8):13564-13570.
[13] Hao Y, Yu P, Qian F, et al.Comparison of laparoscopy-assisted and open radical gastrectomy for advanced gastric cancer:A retrospective study in a single minimally invasive surgery center[J].Medicine (Baltimore), 2016,95(25):e3936.DOI:10.1097/MD.0000000000003936.
[14] Hu Y, Huang C, Sun Y, et al.Morbidity and Mortality of Laparoscopic Versus Open D_2 Distal Gastrectomy for Advanced Gastric Cancer:A Randomized Controlled Trial[J].J Clin Oncol, 2016,34(12):1350-1357.DOI:10.1200/JCO.2015.63.7215.
[15] 林建贤,黄昌明,郑朝辉,等.腹腔镜与传统开腹远侧胃大部切除术治疗局部进展期胃癌的疗效对比研究[J].中华外科杂志,2016,54(10):755-760.DOI:10.3760/cma.j.issn.0529-5815.2016.10.007.
[16] Kim HH, Han SU, Kim MC, et al.Long-term results of laparoscopic gastrectomy for gastric cancer:a large-scale case-control and case-matched Korean multicenter study[J].J Clin Oncol, 2014, 32(7):627-633.DOI:10.1200/JCO.2013.48.8551.
[17] He H, Shen Z, Wang X, et al.Survival benefit of greater number of lymph nodes dissection for advanced node-negative gastric cancer patients following radical gastrectomy[J].Jpn J Clin Oncol, 2016,46(1):63-70.DOI:10.1093/jjco/hyv159.
[18] Biondi A,D’Ugo D,Cananzi FC,et al.Does a minimum number of 16 retrieved nodes affect survival in curatively resected gastric cancer?[J].Eur J Surg Oncol,2015,41(6):779-786.DOI:10.1016/j.ejso.2015.03.227.