四种手术方式治疗痔病的网状Meta分析

目的利用网状Meta分析系统评价传统外剥内扎术（MMH）、吻合器痔上黏膜环切术（PPH）、选择性痔上黏膜切除术（TST）和多普勒超声引导下痔动脉结扎术（DG-HAL）治疗痔病的手术方式的疗效和安全性，为临床提供参考。 方法检索中国知网、万方数据、中国生物医学网，Pubmed、Cochrane Library、Embase数据库，收集建库至2020年12月关于MMH、PPH、TST和DG-HAL治疗痔病的随机对照试验，提取的资料采用GeMTC 0.14.3软件进行网状Meta分析。 结果最终纳入45项研究，包括43篇两臂实验，2篇三臂实验；共5 847例患者，其中MMH组1 777例，PPH组1 971例，TST组1 205例，DG-HAL组894例。与MMH相比，DG-HAL（MD=-4.16，95% CI：-6.49~ -1.82，P<0.05）和PPH（MD=2.28，95% CI：0.64~3.89，P<0.05）可以显著降低术后疼痛程度，差异均有统计学意义；TST术后尿潴留发生率明显低于MMH（OR=2.08，95% CI：1.23~4.09，P<0.05）；相比于MMH（OR=0.01，95% CI：0~0.15，P<0.05）和PPH（OR=0.08，95% CI：0~0.78，P<0.05），DG-HAL术后肛门狭窄发生率低；而PPH（OR=6.56，95% CI：1.20~57.74，P<0.05）和TST（OR=58.25，95% CI：4.37~2 605.94，P<0.05）的术后肛门狭窄发生率均比MMH低，TST优于PPH（OR=8.50，95% CI：1.23~150.91，P<0.05），差异均有统计学意义。术后24 h疼痛评分排序为MMH>PPH>TST>DG-HAL；术后出血发生率排序为MMH>PPH>TST>DA-HAL；尿潴留发生率排序为MMH>PPH>DA-HAL>TST；肛门狭窄发生率排序为MMH>PPH>TST>DG-HAL；复发率排序为DA-HAL>PPH>MMH>TST。 结论四种手术方式治疗痔病的作用机制各有优势，DG-HAL和TST术后疼痛、出血、尿潴留、肛门狭窄等并发症发生率低，术后舒适度和安全性方面有明显优势。术后复发率方面TST最优，DG-HAL最差。

Network Meta-analysis of four surgical methods in the treatment of hemorrhoids

ObjectiveTo compare the milligant-morgant hemorrhoidectomy (MMH), procedure for prolapse and hemorrhoids (PPH), tissue selecting therapy (TST) and Doppler-guided hemorrhoidal artery ligation (DG-HAL) in the treatment of hemorrhoids, and to provide evidence-based reference in clinic. MethodsThe full-text database of CNKI, Wanfang Database, CBMdisc, Pubmed, Cochrane Library and Embase were retrieved from the date of their establishment to December 2020. Randomized controlled trials (RCTs) about MMH, PPH, TST and DG-HAL in the treatmnet of hemorrhoids were collected. Meta-analysis was conducted by using GeMTC 0.14.3 statistical software. ResultsA total of 45 RCTs were included, involving 5 847 patients. Compared with MMH, DG-HAL (MD=-4.16, 95% CI: -6.49, -1.82; P<0.05) and PPH (MD=2.28, 95% CI: 0.64, 3.89; P<0.05) could significantly reduce the degree of postoperative pain, the incidence of urinary retention after TST was significantly lower (OR=2.08, 95% CI: 1.23, 4.09; P<0.05). Compared with MMH (OR=0.01, 95% CI: 0, 0.15; P<0.05) and PPH (OR=0.08, 95% CI: 0, 0.78; P<0.05), the incidence of anal stenosis after DG-HAL was lower. PPH (OR=6.56, 95% CI: 1.20, 57.74; P<0.05) and TST (OR=58.25, 95% CI: 4.37, 2 605.94; P<0.05) had lower anal stenosis rates than MMH, TST was better than PPH (OR=8.50, 95% CI: 1.23, 150.91; P<0.05), with statistical significance. The order of probability were as follows: DA-HAL>TST>PPH>MMH in pain scores 24 hours after operation, MMH>PPH>TST>DA-HAL in postoperative bleeding, MMH>PPH>DA-HAL>TST in urinary retention, MMH>PPH>TST>DA-HAL in anal stenosis, DA-HAL>PPH>MMH>TST in recurrence rate. ConclusionsThe four surgical methods show their own advantages in the treatment of hemorrhoids. DG-HAL and TST have low incidence of postoperative complications such as pain, bleeding, urinary retention, anal stenosis and obvious advantages in postoperative comfort and safety. However, in terms of recurrence rate, TST is the best and DG-HAL is the worst.