腹腔镜腹会阴联合切除术腹膜外结肠造口对比腹膜内造口治疗直肠癌的Meta分析

目的比较直肠癌行腹腔镜腹会阴联合切除术（LAPR）腹膜外结肠造口与腹膜内结肠造口的安全性与有效性，并确定直肠癌永久性结肠造口最为合适的造口方式。 方法检索Pubmed、Embase、The Cochrane Library、Web of Science、中国知网以及万方数据库等中英文数据库，收集2008年10月至2020年3月国内外公开发表的有关比较LAPR腹膜外造口与腹膜内造口治疗直肠癌的临床研究，由两位研究者按照纳入与排除标准筛选符合条件的文献，非随机对照研究采用Newcastle-Ottawa Scale（NOS）量表评价文献质量，评分>5分的研究纳入Meta分析，随机对照研究采用Jadad量表评估。提取文献基本信息及相关结局指标，数据采用RevMan5.3软件进行Meta分析。 结果最终纳入14篇文献，其中9篇临床对照研究，5篇随机对照研究，共计1 210例患者。其中腹膜外造口组594例，腹膜内造口组616例，Meta分析结果显示，与腹腔镜腹膜内造口相比，腹腔镜腹膜外造口组造口旁疝发生率（OR=0.14，95%CI：0.08~0.25；P<0.00001），造口脱垂发生率（OR=0.15，95%CI：0.06~0.37；P<0.0001），造口回缩发生率（OR=0.24，95%CI：0.09~0.63；P=0.004）均明显降低；术后住院时间缩短（MD=-0.82，95%CI：-0.97~-0.68；P<0.00001），术后首次排气时间提前（MD=-0.71，95%CI：-0.88~-0.54；P<0.00001），更容易获得排便感（OR=9.67，95%CI：4.40~21.23；P<0.00001），但造口水肿发生率明显升高（OR=1.81，95%CI：1.13~2.92；P=0.01），而两组造口狭窄发生率（OR=0.62，95%CI：0.25~1.50；P=0.29）、造口感染发生率（OR=0.57，95%CI：0.29~1.12；P=0.10）以及造口时间（MD=-0.94，95%CI：-5.69~3.81；P=0.70）的差异均无统计学意义。 结论LAPR腹膜外造口能明显降低造口相关并发症的发生率，加速患者康复，更容易获得排便感，具有一定的安全性和有效性，建议直肠癌LAPR永久性结肠造口首选腹膜外造口方式。

Laparoscopic abdominoperineal resection with extraperitoneal colostomy versus intraperitoneal colostomy for patients with rectal cancer: a Meta-analysis

ObjectiveTo compare the safety and efficacy between extraperitoneal colostomy and intraperitoneal colostomy in laparoscopic abdominoperineal resection (LAPR) for rectal cancer through meta-analysis, and to determine the most suitable way of permanent colostomy for patients with rectal cancer. MethodsChinese and English databases such as PubMed, EMBASE, the Cochrane Library, Web of Science, CNKI and Wanfang database were searched. The clinical research on the treatment of rectal cancer by LAPR extraperitoneal stoma and intraperitoneal stoma published in China and abroad from October 2008 to March 2020 was collected. The qualified literatures were selected by two researchers according to the inclusion and exclusion criteria, Newcastle-Ottawa Scale (NOS)was used to evaluate the quality of the Non-randomized controlled studies and the score more than 5 points was the inclusion criteria, and the randomized control study (RCT) was evaluated with Jadad scale. The basic information of literature and related outcome indicators were extracted, and the data were brought into meta-analysis by Revman 5.3 software. ResultsA total of 14 studies involving 1 210 patients(594 patients in the extraperitoneal stoma group and 616 patients in the intraperitoneal stoma group), including 9 clinical control studies and 5 randomized control studies, the results of meta-analysis showed that compared with the laparoscopic intraperitoneal stoma, the incidence of extraperitoneal stoma parastomal hernia (OR=0.14, 95% CI: 0.08~0.25; P<0.00001), the incidence of stoma prolapse (OR=0.15, 95% CI: 0.06~0.37; P<0.0001), the incidence of stoma retraction (OR=0.24, 95% CI: 0.09~0.63; P=0.004) were significantly reduced,the postoperative hospital stay was shortened (MD=-0.82, 95% CI: -0.97~-0.68; P<0.00001), and the first exhaust time was advanced (MD=-0.71, 95% CI: -0.88~-0.54; P<0.00001), the sense of defecation was more easily obtained (OR=9.67, 95% CI: 4.40~21.23; P<0.00001), but the incidence of stoma edema was significantly increased (OR=1.81, 95% CI: 1.13~2.92; P=0.01), while the incidence of stoma stenosis (OR=0.62, 95% CI: 0.25~1.50; P=0.29), the incidence of stoma infection (OR=0.57, 95% CI: 0.29~1.12; P=0.10) and the time of stoma (MD=-0.94, 95% CI: -5.69~-3.81; P=0.70), there were no significant differences. ConclusionLaparoscopic abdominoperineal resection combined with extraperitoneal colostomy can significantly reduce the incidence of complications related to colostomy, accelerate the recovery of patients, more easily obtain the sense of defecation, and have a certain degree of safety and effectiveness. It is suggested that extraperitoneal colostomy should be the first choice for LAPR permanent colostomy for rectal cancer.