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中华结直肠疾病电子杂志

中华结直肠疾病电子杂志 ›› 2021, Vol. 10 ›› Issue (04) : 371 -378. doi: 10.3877/cma.j.issn.2095-3224.2021.04.007

论著

端侧吻合与端端吻合改善低位前切除术后排粪功能的安全性和有效性的Meta分析
侯森1, 赵世栋1, 刘凡2, 叶颖江1,†()   
  1. 1. 100044　北京大学人民医院胃肠外科；100044　北京大学人民医院外科肿瘤实验室；100044　北京市结直肠癌诊疗研究重点实验室
    2. 100044　北京大学人民医院胃肠外科
  • 收稿日期:2021-02-14 出版日期:2021-08-30
  • 通信作者: 叶颖江
  • 基金资助:
    国家自然科学基金(81871962)

Safety and efficiency of side-to-end anastomosis versus straight colorectal anastomosis in low anterior resections

Sen Hou1, Shidong Zhao1, Fan Liu2, Yingjiang Ye1,†()   

  1. 1. Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing 100044, China; Laboratory of Surgical Oncology, Peking University People's Hospital, Beijing 100044, China; Beijing Key Laboratory of Colorectal Cancer Diagnosis and Treatment Research, Peking University People's Hospital, Beijing 100044, China
    2. Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing 100044, China
  • Received:2021-02-14 Published:2021-08-30
  • Corresponding author: Yingjiang Ye
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引用本文：

侯森, 赵世栋, 刘凡, 叶颖江. 端侧吻合与端端吻合改善低位前切除术后排粪功能的安全性和有效性的Meta分析[J]. 中华结直肠疾病电子杂志, 2021, 10(04): 371-378.

Sen Hou, Shidong Zhao, Fan Liu, Yingjiang Ye. Safety and efficiency of side-to-end anastomosis versus straight colorectal anastomosis in low anterior resections[J]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2021, 10(04): 371-378.

目的

直肠癌低位前切除术（LAR）中将末端结肠与直肠或肛管使用端侧吻合（SEA）的方法进行重建，是否会增加手术风险以及术后并发症的发生率，是否会带来术后排粪功能的获益，目前尚不明确。本研究旨在分析SEA与端端吻合（SCA）在直肠癌低位前切除肠道重建中安全性和有效性。

方法

计算机检索1997年10月至2021年1月中国知网、万方、维普、PubMed、Embase、Cochrane Library、Web of science数据库关于比较直肠癌低位前切除中SEA比较SCA的随机对照试验（RCT）或临床对照试验（CCT），中文检索词包括“直肠”“癌/恶性肿瘤”“端侧吻合”“端端吻合/直接吻合”；英文检索词包括“rect*”“cancer/tumor/carcinoma/neoplasm”“side to end/end to side/Baker”“end to end/straight colorectal anastomosis”。对符合要求的文献提取相关数据后采用Review Manager 5.4软件进行Meta分析。

结果

共检索出225篇文献，最终纳入7项临床研究。共有552例患者，其中SCA组284例，SEA组268例。安全性指标显示：SEA组盆腔脓肿的发生率较SCA组明显降低（OR=0.18，95%CI：0.05~0.66；P=0.01）、手术时间（OR=1.28，95%CI：-3.75~6.30；P=0.62）、保护性造口率（OR=3.52，95%CI：0.55~22.66；P=0.19）、术后吻合口漏发生率（OR=0.50，95%CI：0.23~1.08；P=0.08）、吻合口出血发生率（OR=1.08，95%CI：0.26~4.44；P=0.92）、切口感染（OR=0.64，95%CI：0.28~1.50；P=0.31）、切口哆开（OR=1.27，95%CI：0.44~3.64；P=0.65）和肺部感染（OR=0.80，95%CI：0.27~2.38；P=0.68）的发生率差异均无统计学意义。在术后排粪功能方面，术后6个月SEA组夜间遗粪的发生率低于SCA组，差异具有统计学意义（OR=0.35，95%CI：0.14~0.85；P=0.02）。使用止泻药（OR=0.79，95%CI：0.34~1.82；P=0.58）、排粪急迫（OR=0.41，95%CI：0.12~1.34；P=0.14）、使用会阴垫（OR=0.59，95%CI：0.24~1.48；P=0.26）、区分排气排粪（OR=0.75，95%CI：0.27~2.12；P=0.59）方面两组差异均无统计学意义。

结论

低位前切除术中，使用SEA进行肠道重建可以降低术后6个月夜间遗粪的发生率、降低术后盆腔脓肿发生率。SEA具有一定的安全性和有效性，可以应用于低位前切除术中的肠道重建。

关键词: 直肠肿瘤, 低位前切除, 端侧吻合, 端端吻合, Meta分析
Objective

It is yet to be clarified whether side to end anastomosis (SEA) for low anterior resections (LAR) will bring the risk of radical tumor resection, whether it will increase the incidence of postoperative complications, and how much is the benefit of the defecation function for patients after surgery. This meta-analysis aims to evaluate the efficacy and safety of SEA for LAR.

Methods

The Chinese and English literatures published between October 1997 and January 2021 about SEA for rectal cancer were searched from PubMed, Embase, The Cochrane Library, Web of Science, CNKI net and Wanfang database. This Meta-analysis was performed using Review Manager 5.4.

Results

A total of 225 literatures were retrieved, and 7 literatures were enrolled finally. A total of 552 patients were enrolled, including 284 in SCA group and 268 in SEA group. The meta-analysis of the safety indicators showed that there was significant differences in pelvic sepsis (OR=0.18, 95%CI: 0.05~0.66; P=0.01), while there were no significant differences in operation time(OR=1.28, 95%CI: -3.75~6.30; P=0.62), protective stoma(OR=3.52, 95%CI: 0.55~22.66; P=0.19), anastomotic leakage(OR=0.50, 95%CI: 0.23~1.08; P=0.08) anastomotic bleeding (OR=1.08, 95%CI: 0.26~4.44; P=0.92), wound infection(OR=0.64, 95%CI: 0.28~1.50; P=0.31), wound dehiscence(OR=1.27, 95%CI: 0.44~3.64; P=0.65)and pneumonia (OR=0.80, 95%CI: 0.27~2.38; P=0.68). The meta-analysis of the efficacy indicators showed that there was significant differences in nocturnal incontinence (OR=0.35, 95%CI: 0.14~0.85; P=0.02) while there were no significant differences in "use of antidiarrheal medicine" (OR=0.79, 95%CI: 0.34~1.82; P=0.58)、"urgency" (OR=0.41, 95%CI: 0.12~1.34; P=0.14)、"need to wear a pad" (OR=0.59, 95%CI: 0.24~1.48; P=0.26)、"differentiation between flatus and feces" (OR=0.75, 95%CI: 0.27~2.12; P=0.59).

Conclusions

In low anterior resections, SEA for reconstruction can reduce the incidence of nocturnal incontinence 6 months after surgery and the incidence of postoperative pelvic abscess. The safety and efficiency of SEA is definite and SEA can be used for bowel reconstruction during low anterior resections.

Key words: Rectal neoplasms, Low anterior resections, Side to end anastomosis, Straight colorectal anastomosis, Meta-analysis
图1 文献筛选流程图
表1 纳入的7篇文献基本资料及质量评估
作者 发表年份 国家 研究类型 SCA组 SEA组 性别（男/女） 平均年龄（岁） 肿瘤高度（cm） 吻合口高度（cm） 质量评分
SCA组 SEA组 SCA组 SEA组 SCA组 SEA组 SCA组 SEA组
Tsunoda等［14］ 2008 日本 RCT 13 17 9/4 11/6 63 62 - - 5.7 4 4
Brisinda等［13］ 2009 意大利 RCT 37 40 20/17 19/21 63.7 67.0 - - - - 4
Zhang等［12］ 2011 中国 CCT 30 15 16/14 8/7 54 53 6 6 - - 7
陈涛等［11］ 2013 中国 CCT 30 30 19/11 18/12 64 62 5.5 5.5 3.4 3.5 7
Rybakov等［10］ 2016 俄罗斯 RCT 40 41 20/20 13/28 63 61 8.5 8.4 5.1 4.8 5
Marti等［9］ 2019 瑞士 RCT 99 95 67/32 62/33 66.3 67.2 5 7 - - 6
Planellas等［8］ 2021 西班牙 RCT 35 30 23/12 17/13 68 64 - - 6.7 6.1 5
图2 端侧吻合（SEA）和端端吻合（SCA）手术时间的比较
图3 端侧吻合（SEA）和端端吻合（SCA）保护性造口发生率的比较
图4 端侧吻合（SEA）和端端吻合（SCA）吻合口漏发生率的比较
图5 端侧吻合（SEA）和端端吻合（SCA）吻合口出血发生率的比较
图6 端侧吻合（SEA）和端端吻合（SCA）术后盆腔脓肿发生率的比较
表2 端侧吻合（SEA）组与端端吻合（SCA）组手术相关并发症的比较
手术并发症 研究数量 纳入人数 统计方法 效应量 P值 异质性
I2 P值
切口感染 2 137 Odds Ratio（M-H，Fixed，95%CI） 0.64（0.28~1.50） 0.31 0% 0.48
切口哆开 2 137 Odds Ratio（M-H，Fixed，95%CI） 1.27（0.44~3.64） 0.65 0% 0.66
肺部感染 2 137 Odds Ratio（M-H，Fixed，95%CI） 0.80（027~2.38） 0.68 0% 0.65
尿潴留 2 158 Odds Ratio（M-H，Fixed，95%CI） 1.20（0.31~4.46） 0.80 0% 0.79
图7 端侧吻合（SEA）和端端吻合（SCA）术后6个月使用止泻药的比较
图8 端侧吻合（SEA）和端端吻合（SCA）术后6个月夜间遗粪的比较
表3 端侧吻合（SEA）组与端端吻合（SCA）组术后6个月排粪功能的比较
排粪功能 研究数量 纳入人数 统计方法 效应量 P值 异质性
I2 P值
排粪急迫 2 109 Odds Ratio（M-H，Fixed，95% CI） 0.41（0.12~1.34） 0.14 0% 0.44
使用会阴垫 2 125 Odds Ratio（M-H，Fixed，95% CI） 0.59（0.24~1.48） 0.26 0% 0.51
区分排气排粪 2 74 Odds Ratio（M-H，Fixed，95% CI） 0.75（0.27~2.12） 0.59 0% 0.68
图9 端侧吻合（SEA）和端端吻合（SCA）术后吻合口漏发生率漏斗图
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