中低位直肠癌经肛门与腹腔镜全直肠系膜切除术后近期疗效荟萃分析

doi:10.16139/j.1007-9610.2022.05.011

摘要/Abstract

摘要： 目的比较经肛门全直肠系膜切除术（transanal total mesorectal excision，TaTME）与腹腔镜全直肠系膜切除术（laparoscopic total mesorectal excision，LaTME）治疗中低位直肠癌的安全性和有效性。方法为比较TaTME与LaTME近期疗效，检索Pubmed、Web of Science、中国知网（CNKI）、中国生物医学文献数据库、万方医学数据库发表的临床研究。系统复习和荟萃分析基于优选报告的条目（Preferred Reporting Items for Systematic Reviews and Meta-Analysis）。数据模型采用固定效应或随机效应模型。研究结果的主要指标为手术时间、术中出血量、肿瘤大小、中转开腹率、住院时间、淋巴结清扫数目、肿瘤切缘与肛门距离、远端切缘（distal resection margin，DRM）阳性率、环周切缘（circumferential resection margin，CRM）阳性率、术后并发症。结果共纳入9项中低位直肠癌研究，其中随机对照试验1项，前瞻性研究8项。荟萃分析显示，与LaTME（n=438）组相比，TaTME（n=451）组中转开腹率[风险比（risk ratio，RR）=0.13，P=0.002]和DRM阳性率（RR=0.39，P=0.003）显著降低。两组在手术时间（RR=15.48，P=0.18）、术中出血量（RR=2.34，P=0.81）、术后并发症发生（RR=1.05，P=0.72）、住院时间（RR=-0.91，P=0.14）、肿瘤大小（RR=0.04，P=0.55）、淋巴结清扫数目（RR=-0.71，P=0.17）、肿瘤切缘与肛门距离（RR=-1.26，P=0.20）和CRM阳性率（RR=0.77，P=0.53）差异无统计学意义。结论 TaTME具有与LaTME同等的手术安全性。当DRM存在风险时，TaTME可能是低位、超低位直肠癌的良好选择。

关键词: 直肠癌, 经肛门全直肠系膜切除术, 腹腔镜全直肠系膜切除术, 荟萃分析

Abstract: Objective To compare the safety and efficacy of transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME) for middle and low rectal cancer. Methods This study searched the clinical studies systematically comparing the short-term efficacy of TaTME and LaTME published in PubMed, Web of Science, CNKI, China Biology Medicine disc and Wanfang medical database. Systematic reviews and meta-analysis were conducted to base on the Preferred Reporting Items for Systematic Evaluation and Meta-Analysis. Fixed-effects model or random-effects model was used for evaluation of data. Parameters of outcome evaluation included operation time, intraoperative blood loss, tumor size, conversion rate, length of hospital stay, number of lymph node dissection, distance of rectal lesion from anal verge, positive rate of distal resection margin(DRM), positive rate of circumferential resection margin(CRM), and postoperative complications. Results Nine studies with 1 of randomized controlled trial and 8 of prospective study were included to compare the outcomes of 451 TaTME and 438 LaTME in middle and low rectal cancer. TaTME had a significantly lower rate of conversion to open surgery (RR=0.13, P=0.002) and a lower DRM positive rate(RR=0.17, P<0.03) when compared to LaTME. There was no significant difference between two groups in operative time(RR=15.48, P=0.18), intraoperative blood loss (RR=2.34, P=0.81), postoperative complications (RR=1.05, P=0.72), length of hospital stay (RR=-0.91, P=0.14), tumor size (RR=0.04, P=0.55), number of lymph nodes dissection(RR=-0.71, P=0.17), distance of rectal lesion from anal verge(RR=-1.26, P=0.20) and positive rate of CRM(RR=0.77, P=0.53). Conclusions TaTME has the surgical safety same as LaTME. When the distal resection margin is at risk, TaTME may be a good choice for low and ultra-low rectal cancer.

Key words: Rectal cancer, Transanal total mesorectal excision, Laparoscopic total mesorectal excision, Meta-analysis

中图分类号:

R735.37

秦伟, 胡延岩, 徐玺谟, 蔡正昊, 李健文, 龚昆梅, 冯波. 中低位直肠癌经肛门与腹腔镜全直肠系膜切除术后近期疗效荟萃分析[J]. 外科理论与实践, 2022, 27(05): 435-442.

QIN Wei, HU Yanyan, XU Ximo, CAI Zhenghao, LI Jianwen, GONG Kunmei, FENG Bo. Short-term outcomes after total mesorectal excision for middle and low rectal cancer: transanal versus laparoscopic approach—a meta analysis[J]. Journal of Surgery Concepts & Practice, 2022, 27(05): 435-442.

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参考文献 25

[26]	Birbeck KF, Macklin CP, Tiffin NJ, et al. Rates of circumferential resection margin involvement vary between surgeons and predict outcomes in rectal cancer surgery[J]. Ann Surg, 2002, 235(4):449-457.
[27]	Ma B, Gao P, Song Y, et al. Transanal total mesorectal excision(TaTME) for rectal cancer: a systematic review and meta-analysis of oncological and perioperative outcomes compared with laparoscopic total mesorectal excision[J]. BMC Cancer, 2016, 16:380.
[28]	Xu W, Xu Z, Cheng H, et al. Comparison of short-term clinical outcomes between transanal and laparoscopic total mesorectal excision for the treatment of mid and low rectal cancer: a meta-analysis[J]. Eur J Surg Oncol, 2016, 42(12):1841-1850.
[29]	Rubinkiewicz M, Czerwińska A, Zarzycki P, et al. Comparison of short-term clinical and pathological outcomes after transanal versus laparoscopic total mesorectal excision for low anterior rectal resection due to rectal cancer: a systematic review with meta-analysis[J]. J Clin Med, 2018, 7(11):448.
[30]	Lin D, Yu Z, Chen W, et al. Transanal versus laparoscopic total mesorectal excision for mid and low rectal cancer: a meta-analysis of short-term outcomes[J]. Wideochir Inne Tech Maloinwazyjne, 2019, 14(3):353-365.
[31]	Jiang HP, Li YS, Wang B, et al. Pathological outcomes of transanal versus laparoscopic total mesorectal excision for rectal cancer: a systematic review with meta-analysis[J]. Surg Endosc, 2018, 32(6):2632-2642.
[32]	Aubert M, Mege D, Panis Y. Total mesorectal excision for low and middle rectal cancer: laparoscopic versus transanal approach-a meta-analysis[J]. Surg Endosc, 2020, 34(9):3908-3919.
[33]	Veltcamp Helbach M, Koedam TWA, Knol JJ, et al. Residual mesorectum on postoperative magnetic resonance imaging following transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LapTME) in rectal cancer[J]. Surg Endosc, 2019, 33(1):94-102.
[1]	Heald RJ, Ryall RD. Recurrence and survival after total mesorectal excision for rectal cancer[J]. Lancet, 1986, 1(8496):1479-1482.
[2]	Kang L, Zeng Z, Luo S, et al. Transanal vs. laparoscopic total mesorectal excision for rectal cancer: a multicenter randomized phase Ⅲ clinical trial (TaLaR trial) protocol[J]. Gastroenterol Rep (Oxf), 2020, 9:71-76.
[3]	Kang SB, Park JW, Jeong SY, et al. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial[J]. Lancet Oncol, 2010, 11(7):637-645.
[4]	Sylla P, Rattner DW, Delgado S, et al. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance[J]. Surg Endosc, 2010, 24(5):1205-1210.
[5]	Francis N, Penna M, Mackenzie H, et al. Consensus on structured training curriculum for transanal total mesorectal excision (TaTME)[J]. Surg Endosc, 2017, 31(7):2711-2719.
[6]	Adamina M, Buchs NC, Penna M, et al. St. Gallen consensus on safe implementation of transanal total mesorectal excision[J]. Surg Endosc, 2018, 32(3):1091-1103.
[7]	Lau S, Kong J, Bell S, et al. Transanal mesorectal excision: early outcomes in Australia and New Zealand[J]. Br J Surg, 2021, 108(2):214-219.
[8]	Larsen SG, Pfeffer F, Kørner H, et al. Norwegian moratorium on transanal total mesorectal excision[J]. Br J Surg, 2019, 106(9):1120-1121.
[9]	Fearnhead NS, Acheson AG, Brown SR, et al. The ACPGBI recommends pause for reflection on transanal total mesorectal excision[J]. Colorectal Dis, 2020, 22(7):745-748.
[10]	Veltcamp Helbach M, van Oostendorp SE, Koedam TWA, et al. Structured training pathway and proctoring; multicenter results of the implementation of transanal total mesorectal excision (TaTME) in the Netherlands[J]. Surg Endosc, 2020, 34(1):192-201.
[11]	Abbott SC, Stevenson ARL, Bell SW, et al. An assessment of an Australasian pathway for the introduction of transanal total mesorectal excision (TaTME)[J]. Colorectal Dis, 2018, 20(1):O1-O6.
[12]	Roodbeen SX, Penna M, Arnold S, et al. A nationwide study on the adoption and short-term outcomes of transanal total mesorectal excision in the UK[J]. Minerva Chir, 2019, 74(4):279-288.
[13]	Atallah SB, DuBose AC, Burke JP, et al. Uptake of transanal total mesorectal excision in North America: initial assessment of a structured training program and the experience of delegate surgeons[J]. Dis Colon Rectum, 2017, 60(10):1023-1031.
[14]	中国医师协会外科医师分会经肛门全直肠系膜切除术专业委员会, 中国医师协会外科医师分会结直肠外科医师委员会, 中国经肛腔镜外科学院. 中国经肛腔镜手术专家共识(2019版)[J]. 中华胃肠外科杂志, 2019, 22(6):501-506.
[15]	Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses[J]. BMJ, 2003, 327(7414):557-560.
[16]	Li Y, Bai X, Niu B, et al. A prospective study of health related quality of life, bowel and sexual function after TaTME and conventional laparoscopic TME for mid and low rectal cancer[J]. Tech Coloproctol, 2021, 25(4):449-459.
[17]	Di Candido F, Carvello M, Keller DS, et al. A comparative cost analysis of transanal and laparoscopic total mesorectal excision for rectal cancer[J]. Updates Surg, 2021, 73(1):85-91.
[18]	Zuhdy M, Elmore U, Shams N, et al. Transanal versus laparoscopic total mesorectal excision: a comparative prospective clinical trial from two centers[J]. J Laparoendosc Adv Surg Tech A, 2020, 30(7):769-776.
[19]	Zeng Z, Luo S, Chen J, et al. Comparison of pathological outcomes after transanal versus laparoscopic total mesorectal excision: a prospective study using data from randomized control trial[J]. Surg Endosc, 2020, 34(9):3956-3962.
[20]	Rubinkiewicz M, Zarzycki P, Witowski J, et al. Functio-nal outcomes after resections for low rectal tumors: comparison of transanal with laparoscopic total mesorectal excision[J]. BMC Surg, 2019, 19(1):79.
[21]	Sparreboom CL, Komen N, Rizopoulos D, et al. Transanal total mesorectal excision: how are we doing so far?[J]. Colorectal Dis, 2019, 21(7):767-774.
[22]	Roodbeen SX, Penna M, Mackenzie H, et al. Transanal total mesorectal excision(TaTME) versus laparoscopic TME for MRI-defined low rectal cancer: a propensity score-matched analysis of oncological outcomes[J]. Surg Endosc, 2019, 33(8):2459-2467.
[23]	Ren J, Liu S, Luo H, et al. Comparison of short-term efficacy of transanal total mesorectal excision and laparoscopic total mesorectal excision in low rectal cancer[J]. Asian J Surg, 2021, 44(1):181-185.
[24]	顾永兴, 张杰. 两种全直肠系膜切除术治疗中低位直肠癌的效果与安全性比较[J]. 中国现代普通外科进展, 2019, 22(9):691-693.
[25]	Vennix S, Pelzers L, Bouvy N, et al. Laparoscopic versus open total mesorectal excision for rectal cancer[J]. Cochrane Database Syst Rev, 2014, 4:CD005200

作者	年份	国家	研究类型	年龄（岁）		BMI（kg/m²）		文献质量评分（分）
作者	年份	国家	研究类型	TaTME	LaTME	TaTME	LaTME	文献质量评分（分）
顾永兴等^[24]	2019	中国	前瞻性	58.1±15.0	57.7±11.8	NA	NA	8
Li等^[16]	2021	中国	前瞻性	NA	NA	27.88±2.03	23.03±2.08	8
Di Candido等^[17]	2021	意大利	前瞻性	60.50±12.81	64.32±11.37	24.94±3.58	25.40±3.55	9
Ren等^[23]	2021	中国	前瞻性	65.78±12.37	67.16±10.03	22.87±2.66	23.05±2.70	8
Zuhdy等^[18]	2020	埃及	前瞻性	53.89±13.99	53.40±11.38	30.74±7.79	25.99±4.68	9
Zeng等^[19]	2020	中国	RCT	56.1±11.2	56.1±10.9	22.5±3.1	22.2±2.9	8
Rubinkiewicz等^[20]	2019	波兰	前瞻性	59.50±4.00	63.25±2.25	26.13±1.73	26.85±1.70	8
Sparreboom等^[21]	2019	荷兰	前瞻性	61.75±1.83	66.13±2.25	26.65±1.00	25.58±0.92	8
Roodbeen等^[22]	2019	荷兰	前瞻性	62.5±10.7	66.0±9.2	26.7±1.9	26.1±4.0	8