保存或左结肠动脉Nonpreservation的临床疗效在全直肠系膜切除腹腔镜下的Meta分析

Abstract

Background and Aims。探讨腹腔镜下保留或全直肠系膜切除（TME）左结肠动脉（LCA）的nonpreservation的临床效果。方法。词语，如“直肠癌”，“左结肠动脉，”和“腹腔镜检查，”被用作检索项，并且关键字检索方法获得通过。检索时间从2013年1月1设置为，2018年6月1日，我们搜索的数据库，包括考研，科学网和中国国家知识基础设施（CNKI）收集的随机对照试验相比，其保存或nonpreservation的影响的腹腔镜下在TME的LCA。两位研究者独立进行筛选文献，数据提取和文献质量评价;审查经理5.3用于荟萃分析。Results。七个研究，包括1467箱子，确定了荟萃分析。作为显示由元分析，与LCA nonpreservation组相比，LCA保存组已显著降低吻合口瘘的发生率（ , , )和postoperative urinary and sexual dysfunction ( , , )和significantly shorter time for intestinal function recovery ( , , ）。该re were no significant differences between the two groups in the duration of surgery, blood loss, number of dissected lymph nodes, or postoperative hospital stay.Conclusions。从结果来看，LCA保存组似乎实现了与可接受的安全成果相媲美的成功。因此，可以在临床实践中被推荐这种手术方法。

1. Introduction

Colorectal cancer is the third most common malignancy that causes significant morbidity and mortality in the world. More than 1.3 million people are diagnosed with colorectal cancer each year, and more than 600,000 patients die from colorectal cancer or related complications [1,2]。目前，手术治疗仍然是直肠癌的治疗中的主要方法。1908年，迈尔斯教授首次提出低结扎，也就是直肠癌切除与左结肠动脉（LCA）。同年，莫伊尼汉教授提出高位结扎的概念，这是在肠系膜下动脉远端结扎线结扎肠系膜下动脉[3]。In recent years, with the development of the TME concept and the development of laparoscopic surgery, the surgical treatment of rectal cancer has undergone tremendous changes. In laparoscopic rectal cancer TME, the treatment of IMA and its branches mainly includes “high ligation and low ligation.” According to the American Association of Colorectal Surgeons guidelines, high ligation is ligation at the root of the IMA and does not retain LCA. Ligation at the lower site is ligation over the LCA branch of the IMA and retains the LCA [4,5]。肠系膜下动脉（IMA）的分支机构应当在手术过程中可以清楚地解剖，但有一个争论是否LCA应保留[6]。在这方面，国外的研究主要集中在住院病例。这些案件进行手术，术中出血量，清扫淋巴结数目，术后吻合口瘘发生率，时间，肠功能恢复，术后排尿及性功能障碍，而复发后两年时间进行比较。收集的发病率和总生存率统计。在这些独立的研究，收集病例数相对较少，这导致的结论可靠性降低。因此，根据现有的研究，我们从2013年1月1日进行了公开发表的文献的荟萃分析，到2018年6月1日，调查LCA的保存直肠癌的治疗腹腔镜TME过程中的作用。动脉的临床影响提供的接受直肠癌的治疗腹腔镜TME的患者术后恢复了可靠的科学依据。

2. Data and Methods

2.1. Literature Retrieval Strategy

我们寻找腹腔镜直肠癌手术（TME使用带有或不带有LCA的保护）相关的，从2013年1月1日发表文章，到2018年6月1日，从数据库，包括CNKI，PubMed和科学网。关键词检索是腹腔镜，直肠癌，左半结肠动脉，直肠，腹腔镜，和左结肠动脉。

2.2。纳入标准

入选标准如下：（1）直肠癌和直肠癌症的治疗腹腔镜TME的诊断的文献研究;（2）与文献积分的分析数据和独立的研究，包括带有一致目的至少一个控制组;（3）保存或LCA作为实验组和对照组之间的唯一区别的nonpreservation;（4）类似的文献研究方法;和（5）组合的结果表示由对应的统计指标。

2.3。排除标准

排除标准有以下几种：（1）重复或大约相同的研究中，这可能导致内容偏压多篇文章;（2）摘要，研究方案，信件，社论，评论，指导和病例报告;（3）和非对照研究。

2.4。研究筛选

两位研究人员使用统一的检索策略根据入选和排除标准，独立的屏幕和提取数据。如果有差异，决定应通过讨论或咨询第三研究者提出。在这项研究中，获得了37的相关文章，其中最终被纳入符合纳入标准的7篇。

2.5。统计分析

A statistical analysis was performed on the retrieved domestic and foreign literature for the following: duration of surgery, blood loss, number of dissected lymph nodes, postoperative anastomotic leakage, time for intestinal function recovery, postoperative urinary and sexual dysfunction, two-year recurrence rate, and overall survival. The data from each article was compiled in a table and entered into a computer. The meta-analysis software Review Manager 5.3 was used to calculate and analyze the data. Weighted mean difference (WMD) and binary data were calculated for continuous variables. Odds ratio (OR) and combined values were expressed in 95% confidence interval (CI); the heterogeneity test of对所包含的文献进行：在不存在统计异质性（使用固定效应模型 , ）;除此以外 （ , ）使用随机效应模型。该 -测试用于测试的组合效果。的差异，在被认为有统计学意义 而在巨大的统计学意义 。与此同时，漏斗图表构建评估偏压的存在。

3.结果

在纳入研究共1467例，其中872了LCA的保存和595并没有参与其中。

3.1。数据提取和质量评价

的文献检索和筛选过程在图中所示1。All quality evaluations were conducted using the Cochrane risk-of-bias tool for the assessment of the randomization method, allocation concealment, blinding, completeness of outcome data, selective reporting, and other biases. The final literature quality evaluation is shown in Table1和Figure2。

3.2。主元分析的结果（主要成果）

3.2.1。手术时间

荟萃分析的结果显示在图图3（a）和图3（b）。该results of duration of surgery in patients with or without preservation of LCA were significantly heterogeneous (heterogeneity test: , ）;当与使用WMD随机效应模型相结合，WMD的组合效果是3.27（ , ,和 ）这不是明显不同。基于results of the analysis, it can be concluded that there is no significant difference in the WMD in the duration of surgery between LCA-preserved patients and LCA-nonpreserved ones. Therefore, whether the LCA is preserved during the laparoscopic rectal cancer resection does not affect the duration of surgery. The funnel plot shows a symmetrical shape, indicating that there is no bias.

3.2.2。术中出血

荟萃分析的结果显示在图图4（a）和4(b)。在患者有无LCA的保存失血的结果没有显著异质性（异质性检验： , ）;当与使用WMD固定效应模型相结合，WMD的组合效果是0.16（ , ,和 ）这不是明显不同。基于results of the analysis, it can be concluded that there is no significant difference in the WMD in the intraoperative blood loss between LCA-preserved patients and LCA-nonpreserved ones. Therefore, whether the LCA is preserved during the laparoscopic rectal cancer resection does not affect the amount of blood loss. The funnel plot shows a symmetrical shape, indicating that there is no bias.

3.2.3。清扫淋巴结数

荟萃分析的结果显示在图5(a)和图5（b）。患者具有或不具有LCA的保存清扫淋巴结的数目，结果为显著异质的（异质性检验： , ）;when combined with WMD using the random effects model, the combined effect of WMD is -1.07 ( , ,和 ）这不是明显不同。根据分析结果，可以得出结论认为，在LCA保存完好的患者和LCA-无防腐剂者之间清扫淋巴结数目的大规模杀伤性武器无显著差异。因此，LCA是否腹腔镜直肠癌切除期间保持不影响清扫淋巴结的数目。漏斗图显示了一个对称的形状，这表明不存在偏差。

3.2.4。吻合口漏

荟萃分析的结果显示在图6(一)和6(b)。吻合口瘘的患者具有或不具有LCA的保存结果并不显著异质的（异质性检验： , ）;当结合或使用固定效应模型，OR的组合效果是0.44（ , ,和 ）这是显著不同。根据分析结果，可以得出结论，在LCA保存完好的患者和LCA-无防腐剂的人之间的吻合口瘘的或显著差异。“钻石”代表共同影响降到无效线的左侧。与LCA保存的患者吻合口瘘比没有LCA保存的发病率较低。因此，LCA的保存可以减少吻合口漏的发生率。与此同时，漏斗图示出了对称的形状，这表明不存在偏差。

3.3。次要终点

3.3.1。时间肠功能恢复

荟萃分析的结果显示在图7(a)和图7（b）。该results of time for intestinal function recovery in patients with or without preservation of the LCA were not significantly heterogeneous (heterogeneity test: , ）;当与使用WMD固定效应模型相结合，WMD的组合效果是-0.26（ , ,和 ）这是显著不同。基于results of the analysis, it can be concluded that there is a significant difference in the WMD of time for intestinal function recovery between LCA-preserved patients and LCA-nonpreserved ones. The “diamond” representing the combined effect falls to the left of the ineffective line. The patients with preservation of the LCA had shorter time for intestinal function recovery than those without preservation of the LCA. Therefore, preservation of the LCA can help patients in terms of time for intestinal function recovery. At the same time, the funnel plot shows a symmetrical shape, indicating that there is no bias.

3.3.2。术后排尿和性功能障碍

荟萃分析的结果显示在图图8（a）和图8（b）。该results of urinary and sexual dysfunction in patients with or without preservation of the LCA were not significantly heterogeneous (heterogeneity test: , ）;当结合或使用固定效应模型，OR的组合效果是0.26（ , ,和 ）这是显著不同。根据分析结果，可以得出的结论是在LCA保存完好的患者和LCA-无防腐剂者之间术后排尿和性功能障碍或显著差异。“钻石”代表共同影响降到无效线的左侧。与LCA保存的患者术后排尿和性功能障碍比那些没有LCA保存的发病率较低。因此，LCA的保存可减少尿及性功能障碍的可能性。与此同时，漏斗图示出了对称的形状，这表明不存在偏差。

3.3。3. Postoperative Hospital Stay

荟萃分析的结果显示在图图9（a）和图9（b）。该results of postoperative hospital stay in patients with or without preservation of the LCA were significantly heterogeneous (heterogeneity test: , ）;当与使用WMD随机效应模型相结合，WMD的组合效果是-1.69（ , ,和 ）这不是明显不同。基于results of the analysis, it can be concluded that there is no significant difference in the WMD of postoperative hospital stay between LCA-preserved patients and LCA-nonpreserved ones. Therefore, whether the LCA is preserved during the laparoscopic rectal cancer resection does not affect the postoperative hospital stay. The funnel plot shows a symmetrical shape, indicating that there is no bias.

4。讨论

该re has been a long debate about whether to preserve the left colonic artery in TME under laparoscopy. So far, there is no clear consensus. Anastomotic leakage is one of the most serious complications after rectal cancer surgery. Anastomotic blood supply and tension are two important factors affecting the incidence of anastomotic leakage. Theoretically, preservation of the LCA can improve the blood supply to the colon [14,15]。有研究通过在手术过程中使用的仪器来检测边缘动脉的压力[16]。它的结论是，LCA的保护可以提高结肠的血液灌注。在此荟萃分析，全面的临床数据显示，LCA的保存可减少术后吻合口漏。有学者认为，肠系膜下动脉高位结扎术可能会增加盆腔自主神经损伤的几率，从而导致泌尿生殖功能障碍[17,18]，但其他学者提出的间隙精确定位可以减少盆腔自主神经损伤的概率。还有就是动脉盆腔自主神经损伤及结扎水平之间没有显著的关系[19]。In the present study, statistical data showed that the patients with preservation of the LCA had a lower incidence of urinary and sexual dysfunction and shorter time to venting than those without preservation of the LCA. However, since the sample size of this study was only 319, it may be deduced that preserving the LCA can reduce the risk of pelvic autonomic nerve injury, while further study is necessary to justify the conclusion.

5. Conclusions

该evidence from the current study suggests that preservation of the LCA during laparoscopic rectal cancer resection shows a significant effect on reducing the incidence of anastomotic leakage and postoperative urinary and sexual dysfunction, as well as the time for intestinal function recovery, but the effect on reducing duration of surgery, amount of blood loss, number of dissected lymph nodes, and postoperative hospital stay was not significant. Therefore, this surgical method can be recommended in the clinical practice. However, our conclusion still needs to be tested by more data in the future studies.

数据可用性

该retrospective data used to support the findings of this study are included within the article.

Disclosure

这份手稿是基于本文由作者。

利益冲突

作者宣称，他们没有利益冲突。

致谢

该authors would like to thank Yujing Gong who is the original author of the Chinese version of this article which has not been published in other magazines now. This work was supported by the Hunan Province Natural Science Foundation (Project No.: 2018jj6125): new model of colorectal cancer screening and prevention based on medical association and multidisciplinary cooperation.

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