腹腔热灌注联合手术及静脉化疗对Ⅱ、Ⅲ期结直肠癌疗效的Meta分析

摘 要：［目的］ 系统评价腹腔热灌注(HIPEC)联合直肠肿瘤根治术（CRR）及静脉化疗治疗Ⅱ、Ⅲ期结直肠癌的临床疗效。［方法］ 检索PubMed、EMbase、Cochrane Library、CBM、CNKI、万方数据,纳入国内外采用腹腔热灌注联合直肠肿瘤根治术及静脉化疗(CHC)对比结直肠肿瘤根治术联合静脉化疗（CC）治疗Ⅱ、Ⅲ期结直肠癌的随机对照试验（RCT）,检索时限均为建库至2017年2月。采用RevMan 5.3 软件对纳入文献的1、2、3、5年生存率及2年局部复发率进行Meta 分析。［结果］ 最终纳入 11 个 RCT,共933例Ⅱ、Ⅲ期结直肠癌患者。CHC组2、3、5年生存率均优于CC组,两组1年生存率差异无统计学意义,其2年生存率OR为3.06（95%CI：1.54～6.11,P=0.001）;3年生存率OR为2.60（95%CI：1.76～3.83,P <0.00001）;5年生存率OR为2.37（95%CI：1.38～4.07,P=0.002）;1年生存率OR为1.51（95%CI：0.56～4.07,P=0.42）;CHC组2年局部复发率低于CC组,OR为0.20（95%CI：0.08～0.47,P=0.0002）。［结论］ 与CC模式相比,CHC模式可以有效提高Ⅱ、Ⅲ期结直肠癌患者的生存率,降低局部复发率。     

腹腔镜与开腹直肠癌术后复发率比较的Meta分析

[目的]评价腹腔镜与开腹直肠癌手术术后复发率的长期肿瘤学效果。[方法]系统检索Medline、Embase、Cochrane中1991年1月至2012年10月间发表的有关腹腔镜与开腹直肠癌手术后复发率比较的随机对照研究(RCT)。由2名评价员独立筛选并提取数据资料,对符合纳入标准的研究使用RevMan5.1软件进行统计分析。[结果]共纳入12个临床随机对照研究,病例总数2259例,其中LRR组1158例,ORR组1101例。腹腔镜直肠癌切除术对比开腹手术治疗直肠癌的术后总体复发率(OR=0.92,95%CI:0.66～1.28,P=0.61)、局部复发率(OR=0.79,95%CI:0.49～1.28,P=0.34)、远处转移率(OR=0.87,95%CI:0.59～1.27,P=0.47)及术后戳孔或切口种植转移率(OR=1.34,95%CI:0.07～24.10,P=0.84)差异均无统计学意义。[结论]腹腔镜直肠切除术对比传统开腹手术治疗直肠癌其术后长期肿瘤学效果相当,并不会导致术后各类复发率明显升高。但其长期生存效果需要更多大样本、高质量的前瞻性多中心的临床随机对照试验来证实。     

术中直肠冲洗对直肠癌局部复发影响的Meta分析

目的探讨术中直肠冲洗对直肠癌术后局部复发率的影响。方法采用Meta分析的方法对国内外已发表的9篇随机对照研究的文献进行定量综合,以直肠癌根治术中行直肠冲洗治疗的患者为冲洗组,以仅施行直肠根治术未行直肠冲洗的患者为对照组(未冲洗组),比较2组术后局部复发率,计算其风险比(RR)及95%可信区间(CI)。结果 9篇文献符合纳入标准,共有5 451例患者参与,其中4 153例接受直肠冲洗,1 298例未接受直肠冲洗。文献纳入研究显示,9项研究评估了直肠冲洗对直肠癌术后复发的影响:总复发率为7.1%(387/5 451),冲洗组直肠癌局部复发率为5.9%(245/4 153),低于未冲洗组的10.9%(142/1 298),差异有统计学意义(RR=0.55,95%CI:0.45～0.69,P<0.01);其中5项研究评估了直肠冲洗可显著降低吻合口复发的风险:冲洗组局部复发率为5.8%低于未冲洗组局部复发率10.1%,差异有统计学意义(RR=0.57,95%CI=0.46～0.71,P<0.00001)。术中直肠冲洗对显著降低吻合口复发率无影响(RR=0.3,95%CI=0.12～0.71,P=0.007)。亚组分析:采用TME术中直肠冲洗对直肠癌术后局部复发的影响,总的复发率6.7%,冲洗组复发率5.8%(230/3 971),低于未冲洗组的复发率10.1%(114/1 127),合并RR值为0.53(95%CI:0.41～0.67),差异有统计学意义(P<0.01)。结论此Meta分析可能合理,建议术中直肠冲洗,并可能降低直肠癌术后局部复发率及吻合口复发。     

保留盆腔自主神经的全直肠系膜切除术在男性直肠癌保肛术中的应用研究

背景与目的:中低位直肠癌根治术术后常出现严重的与自主神经损害有关的泌尿生殖功能障碍,全直肠系膜切除术(total mesorectal excision,TME)可使上述问题得到一定程度的改善,但排尿功能障碍和性功能障碍仍是术后比较常见的问题.本文旨在探讨保留盆腔自主神经(pelvic autonomic nerve preservation,PANP)的全直肠系膜切除术在男性直肠癌患者低位保肛术中的应用.方法:通过分析保留盆腔自主神经的全直肠系膜切除(TME+PANP组)和不保留自主神经的全直肠系膜切除(TME组)在男性直肠癌患者保肛手术中的应用,对两组患者术后的性功能、排尿功能、局部复发率和5年生存率进行比较.结果:TME组和TME+PANP组的局部复发率、5年生存率差异无统计学意义(P>0.05),PANP+TME组的性功能、排尿功能优于TME组,PANP手术分型与性功能、排尿功能呈正相关(P<0.05).结论:TME+PANP的直肠癌根治术既保证根治,又降低了排尿障碍和性功能障碍的发生率,PANP手术保留神经越完整,手术后排尿障碍、性功能障碍的发生率越低.     

基于TME的直肠癌保留植物神经根治术及其效果分析

目的:探讨基于全直肠系膜切除(TME)的中下段直肠癌保留植物神经根治术对局部复发率、生存率和术后生存质量的影响.方法:回顾性分析125例基于TME的中下段直肠癌保留植物神经根治术与60例未保留植物神经的根治术患者的5年生存率和局部复发率,及排尿功能和性功能.结果:无手术死亡病例.A组排尿功能障碍13例(占10.4%),性功能障碍20例(占16.0%);B组分别为35例(占58.3%)和41例(占68.3%);两组比较,P＜0.005.局部复发率:A组为8.8%(11/125),B组为16.7%(10/60),两组比较,P＞0.05.5年生存率:A组60.8%(76/125),B组46.7%(28/60).结论:保留植物神经的直肠癌全直肠系膜切除术,在不增加局部复发率和降低5年生存率的同时,可以减少病人排尿功能和性功能障碍的发生,提高病人术后的生存质量.     

围手术期化疗对结直肠癌患者预后的影响——附82例报告

背景与目的:近年来有学者主张对结直肠癌患者行围手术期化疗,本研究旨在探讨围手术期化疗对结直肠癌预后的影响.方法:选择2001年8月至2003年8月在我院胃肠外科行根治术的167例Dukes'B、C期结直肠癌患者,电脑抽取随机数方法随机分为对照组和试验组,两组均行根治性手术,试验组采用5-FU进行围手术期化疗,两组术后均采用5-FU/CF方案进行全身化疗.比较两组的不良反应、术后复发转移率和生存率.结果:两组的不良反应发生率和程度比较差异无统计学意义.全组总的术后复发转移率为42.5%,对照组为49.4%,试验组为34.6%,两组比较差异有统计学意义(P=0.038).全组总的术后1、3、4年生存率分别为97.6%、74.7%、61.8%,对照组分别为95.3%、67.1%、54.8%,试验组分别为100%、82.7%、69.1%,两组比较差异有统计学意义(P=0.046).结论:围手术期化疗能改善结直肠癌患者的预后.     

腹腔镜直肠全系膜切除治疗中下段直肠癌临床疗效的探讨

目的:探讨腹腔镜直肠全系膜切除(TME)治疗中下段直肠癌的临床疗效.方法:选择我院外科行腹腔镜直肠全系膜切除治疗中下段直肠癌患者61例为腹腔镜TME组,与行开腹手术治疗的中下段直肠癌患者50例进行对照分析.结果:腹腔镜TME组手术时间明显较开腹手术组长(P＜0.05),而切口长度、术中出血量、VSA评分、术后肛门排气时间及围手术期并发症发生率比较,腹腔镜TME组均明显优于开腹手术组(P＜0.05);两组标本的上、下切缘均为阴性,标本长度和清除淋巴结的数目比较差异无统计学意义,P＞0.05;腹腔镜TME组性功能、泌尿功能障碍发生率明显低于开腹手术组(P＜0.05),而两组术后随访死亡、复发和转移比较差异无统计学意义,P＞0.05.结论:腹腔镜直肠全系膜切除治疗中下段直肠癌手术是安全、可行的,不但能到达传统开腹手术相同的肿瘤根治远期疗效,且具有微创优势.     

腹腔镜肛门括约肌间超低位直肠癌根治术与开腹手术疗效的Meta分析

目的 通过Meta分析探讨腹腔镜经括约肌间切除(ISR)与开腹ISR治疗超低位直肠癌的短期疗效.方法 系统检索PubMed、EMBase、Ovid、中国期刊全文数据库(CNKI)、万方医药期刊全文数据库中比较腹腔镜ISR与开腹ISR治疗超低位直肠癌所有病例对照试验,包括发表和未发表的资料及会议论文.由两位研究者独立进行方法学质量评价之后,采用RevMan5.2软件进行Meta分析.结果 共纳入5篇有关的病例对照研究,合计522例患者.Meta分析结果表明,术中出血量[均数差(MD)=-65.42,95％ CI为-93.45～-37.38,Z=4.57,P＜0.000 01]、排气时间(MD=-0.96,95％ CI为-1.45 ～-0.47,Z=3.83,P=0.000 1)及住院时间(MD=-1.69,95％CI为-2.19～-1.19,Z=6.63,P＜O.000 01),腹腔镜组优于开腹组,差异有统计学意义;手术时间(MD =6.61,95％ CI为-21.29～34.51,Z=0.46,P=0.64)、环周切缘阳性率(OR =1.01,95％ CI为0.37 ～ 2.80,Z=0.02,P=0.98)及术后并发症发生率(OR=0.73,95％CI为0.45 ～1.20,Z=1.23,P=0.22)差异无统计学意义;而开腹组在淋巴结清扫数目方面,略优于腹腔镜组(MD=-1.16,95％ CI为-2.14～-0.18,Z=2.31,P=0.02),差异有统计学意义.结论 腹腔镜ISR手术治疗超低位直肠癌在术后短期疗效方面优于开腹手术.     

同期放化疗与同期放化疗后手术治疗中晚期宫颈癌疗效的Meta分析

目的系统评价同期放化疗后再行根治性手术与仅行同期放化疗治疗中晚期宫颈癌的临床疗效。方法检索PubMed、Medline、the Cochrane Library、中国知网、维普等数据库,筛选关于同期放化疗后再行根治性手术和仅行同期放化疗的符合纳入标准的文献,评价纳入文献的方法学质量,提取资料,应用Review Manager 5.3软件进行Meta分析。结果纳入8篇文献,其中6篇为病例对照研究,2篇为随机对照试验,包括1286例患者,其中718 例患者接受了同期放化疗+全子宫双附件联合全盆腔淋巴结扫除术治疗(CCRT+S 组),568 例患者仅接受了同期放化疗治疗(CCRT 组)。Meta 分析结果显示,CCRT+S 组患者的3 年总生存率(OR=1.60,95%CI:1.20~2.14,P﹤0.01)、3 年无进展生存率(OR=1.89,95%CI:1.41~2.55,P﹤0.01)、5 年总生存率(OR=1.91,95%CI:1.36~2.69,P﹤0.01)、5 年无进展生存率(OR=2.27,95%CI:1.62~3.17,P﹤0.01)均高于CCRT 组,复发率低于CCRT 组(OR=0.51,95%CI:0.37~0.70,P﹤0.01)。两组患者的盆腔复发率比较,差异无统计学意义(OR=0.54,95%CI:0.21~1.38,P﹥0.05)。结论同期放化疗后再行根治性手术可以提高中晚期宫颈癌患者的3年总生存率、3年无进展生存率、5 年总生存率、5 年无进展生存率,并可降低复发率,但对盆腔复发率无明显影响。     

Ivor Lewis和Sweet术式治疗食管癌疗效及安全性的Meta分析

目的:探讨食管癌切除术Ivor Lewis和Sweet两种术式的临床治疗效果及心肺保护作用。方法:检索PubMed、Web of Science、The Cochrane Library、EMBASE、CNKI、Wanfang Data、VIP和CBM数据库，最终纳入24篇文献，其中包括21篇病例对照研究、3篇随机对照研究(RCT)，总共包含5 082例患者，其中行Ivor Lewis术式患者2 241例，行Sweet术式患者2 841例。采用RevMan5.3进行Meta分析。结果:术后心血管并发症发生率Meta分析结果得出［OR=0.50，95%CI(0.25,1.01)，P=0.05］，差异有统计学意义。术后肺部并发症发生率Meta分析结果得出［OR=0.69,95%CI(0.48,0.99)，P=0.04］，差异有统计学意义。术后吻合口瘘发生率Meta分析结果得出［OR=0.83,95%CI(0.51,1.35)，P=0.45］，差异无统计学意义。术后喉返神经损伤发生率Meta分析结果得出［OR=1.57，95%CI(0.75,3.27)，P=0.23］，差异无统计学意义。3年生存率Meta分析结果得出［OR=1.91，95%CI(1.29,2.81)，P=0.001］，Ivor Lewis组患者术后3年生存率高于Sweet组，差异有统计学意义。手术时间Meta分析结果得出［MD=30.61,95%CI(14.48,46.74),P=0.000 2］，差异有统计学意义。淋巴结清扫数目Meta分析结果得出［MD=5.81,95%CI(4.63,6.99),P＜0.001］，差异有统计学意义。术中出血量Meta分析结果得出［MD=4.54,95%CI(-4.54，13.63)，P=0.33］，差异无统计学意义。术后住院天数Meta分析结果得出［MD=-0.59,95%CI(-1.80,0.61),P=0.33］，差异无统计学意义。结论:与Sweet手术相比，Ivor Lewis手术在淋巴结清扫、心肺并发症发生率以及生存率方面有较大优势。而在手术时间方面，传统Sweet手术更具优势。     

Combination surgery in radical nephrectomy

In 18 of 487 patients (11 males, 7 females) operated for renal cancer, radical nephrectomy was made simultaneously with cholecystectomy (n = 14) and prosthetic repair of the abdominal aorta (n = 4). A transabdominal approach was used in all the cases. Duration of radical nephrectomies from the transabdominal approach varies from 95 to 180 min while simultaneous operations lasted from 130 to 228 min. Cholecystectomy increased duration of the operations by 25-55, aortic repair--by 60-90 min. Conduction of concomitant operations had no negative effect on the course of postoperative period or on the number of complications. 18 cases of simultaneous operations (radical nephrectomy and cholecystectomy or aortic repair) showed that there was neither increased number of complications nor duration of hospital stay. Cholecystectomy can be made from the same incision as radical nephrectomy whereas aortic repair demands the middle approach which is not convenient for performance of radical nephrectomy.     

Exclusive radical surgery for esophageal adenocarcinoma

BACKGROUND: Because very poor survival rates were reported after exclusive nonradical surgery, the current opinion in the medical community is that very few esophageal adenocarcinoma patients can anticipate long-term survival after esophagectomy. In the current study the ability of exclusive radical surgery including very extended lymph node dissection to provide a substantial percentage of patients with long-term survival was examined. METHODS: Radical esophagectomy (including removal of the esophageal tube, excision of the potentially involved locoregional lymph nodes, and skeletization of the nonresectable vital organs in the mediastinum and upper abdomen) was attempted in 183 consecutive patients with either Barrett (n = 77) or non-Barrett (n = 106) adenocarcinoma of the esophagus or cardia. Esophagectomy was subtotal (neck anastomosis) or distal (chest anastomosis) in 103 patients and 80 patients, respectively. RESULTS: Radical esophagectomy (Ro resection) was feasible in 137 patients (75%) whereas 46 patients (25%) in whom a part of the neoplastic process was not resectable (R1 or R2 resection) underwent a palliative esophagectomy. The 5-year survival, including in-hospital deaths (4.3%), was 35.3% for the whole series, 48% after Ro resection, and 0% after R1 or R2 resection. The 5-year survival rate after any R resection was 57.2% in patients with Barrett adenocarcinoma compared with 20% in patients with non-Barrett adenocarcinoma (P < 0.0001) because of a higher prevalence of nontransmural tumors (Tis through T2, N0) in the former group (56.5%) compared with the latter group (6.6%) (P < 0.0001). The 5-year survival was related closely to the magnitude of both wall penetration and extraesophageal neoplastic spread (Ro, Tis-T1-T2, N0 = 83.5% vs. Ro, T3, N0 = 44.4% vs. Ro, any T, N1 < 5 metastatic lymph nodes = 37% vs. Ro, any T, N1 > or = 5 metastastic lymph nodes = 6.8% vs. R1, R2 = 0%; P < 0.0001). CONCLUSIONS: Exclusive radical esophagectomy provides a chance of long-term survival in 35% of esophageal adenocarcinoma patients in whom it is attempted and nearly 50% of those patients in whom it is feasible. The presence of a small number of metastatic lymph nodes does not appear to preclude a long-term favorable outcome.     

Lateral lymph node dissection with radical surgery versus single radical surgery for rectal cancer: a meta-analysis

Objectives: To assess the value of lateral lymph node dissection( LLND) in the radical surgery of rectal cancer. Methods: The published Chinese and English literature was retrieved. A total of 15 papers fitted the selection criteria, including 4,858 patients. Among them 2,401 were in the LLND group and 2,457 in the non-LLND (NLLND) group. Evaluation parameters included 5-year survival rate recurrence rate, peri-operative outcomes, postoperative urinary and sexual functions. Results: The operating time was significantly shorter in the NLLND group than that in the LLND group (weighted mean difference (WMD)=109 min, 95 confidence interval(CI):90-129, P <0.001). Intra-operative blood loss was greater in the LLND group, but the difference was not significant (WMD=429 mL, 95 CI:325-854, P = 0.05).The frequency of peri-operative morbidity(OR, 1.57 95 CI:1.06-2.33, P = 0.02) was also significantly higher in the LLND group. There were no significant differences in 5-year survival rateand recurrence rate between the two groups. Data from individual studies(three)showed that the frequency of male urinary dysfunction (OR=5.12, 95CI 2.15-12.19, P=0.0002) and sexual dysfunction (P < 0.05) were greatly lower in the NLLND group. Conclusion: Meta analysis showed that LLND did not have specific advantage in decreasing postoperative recurrence and prolonging survival time. Furthermore it was associated with prolonged operation time, increased blood loss and elevated incidence of peri-operative complications and urinary and sexual dysfunction.