經肛門內窺鏡下微創手術與傳統根治術治療直腸癌療效與安全性的系統評價_《中國循證醫學雜志》

作者：

郭瀟繁 ^1,3 , 許海楠 ^1,3 ,  王振寧 ^1,2

1. 中國醫科大學附屬第一醫院腫瘤外科（沈陽?110001）；2. 中國醫科大學附屬第一醫院普通外科教研室胃腸腫瘤外科（沈陽?110001）；3. 中國醫科大學臨床醫學七年制（沈陽?110001）;

關鍵詞：

經肛門內窺鏡下微創手術根治術直腸惡性腫瘤系統評價

DOI：

10.7507/1672-2531.20110013

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目的　系統評價經肛門內窺鏡下微創手術（TEM）與傳統根治術（RS）治療直腸癌的療效及安全性，為進一步的臨床研究與實踐提供參考。
方法　計算機檢索Cochrane 圖書館臨床對照試驗資料庫、PubMed、OVID、SpringerLink和中國生物醫學文獻數據庫、中國期刊全文數據庫。檢索范圍均為建庫至2010年4月，并手工檢索《中華外科雜志》等相關期刊。收集TEM與RS比較治療直腸惡性腫瘤的隨機對照試驗和臨床對照試驗。由兩名研究者按Cochrane 系統評價方法，篩選試驗、評價質量、提取資料，并用RevMan 5.0軟件進行Meta 分析。
結果　納入1個隨機對照試驗，4個非隨機對照試驗，共929例受試對象。質量評價結果表明，納入研究質量不高，發生偏倚的可能性較大。Meta分析結果顯示：① 3個研究報道了T1期患者的術后局部復發率，TEM與RS比較，兩組差異有統計學意義［OR=12.61，95%CI（2.59，61.29），P=0.002］；② 2個研究報道了T1期患者的術后無病生存率，結果顯示兩組差異無統計學意義［OR=1.12，95%CI（0.31，4.12），P=0.86］；③ 3個研究報道了T1期患者的術后總生存率，結果顯示兩組差異無統計學意義［OR=1.09，95%CI（0.57，2.08），P=0.80］；④ 3個研究報道了T1期患者術后并發癥情況，結果顯示兩組差異有統計學意義［OR=0.05，95%CI（0.02，0.10），P lt;0.000 01］。
結論　對于T1期患者，TEM具有創傷小，術中出血量較少，住院時間短，術后并發癥發生率低等優點，其總生存率和無病生存率與根治術無差別，但TEM的局部復發率目前仍不夠滿意。TEM對于T2期患者的療效目前尚無定論。因本系統評價納入研究的方法學質量不高，且納入了非隨機對照試驗，無法確定偏倚對結論可靠性的影響程度。因此上述結論尚需多中心、大樣本的隨機對照研究來進一步驗證。

引用本文： 郭瀟繁,許海楠,王振寧. 經肛門內窺鏡下微創手術與傳統根治術治療直腸癌療效與安全性的系統評價. 中國循證醫學雜志, 2011, 11(1): 70-75. doi: 10.7507/1672-2531.20110013 復制

1.	Buess G, Hutterer F, Theiss J, et al. A system for a transanal endoscopic rectum operation. Chirurg, 1984, 55(10): 677-680.
2.	Nakagoe T, Ishikawa H, Sawai T, et al. Surgical technique and outcome of gasless video endoscopic transanal rectal tumor excision. Br J Surg, 2002, 89(6): 769-774.
3.	Dafnis G, Pahlman L, Raab Y, et al. Transanal endoscopic microsurgery: clinical and functional results. Colorectal Dis, 2004, 6 (5): 336-342.
4.	劉建平. 非隨機研究的系統評價方法(一). 中國循證醫學, 2001, 1(4): 239-243.
5.	Lezoche G, Baldarelli M, Guerrieri M, et al. A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc, 2008, 22(2): 352-358.
6.	Palma P, Horisberger K, Joos A, et al. Local excision of early rectal cancer: is transanal endoscopic microsurgery an alternative to radical surgery? Rev Esp Enferm Dig, 2009, 101(3): 172-178.
7.	Ptok H, Marusch F, Meyer F, et al. Oncological outcome of local vs radical resection of low-risk pT1 rectal cancer. Arch Surg, 2007, 142(7): 649-655.
8.	Lee W, Lee D, Choi S, et al. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surg Endosc, 2003, 17(8): 1283-1287.
9.	De Graaf EJ, Doornebosch PG, Tollenaar RA, et al. Transanal endoscopic microsurgery versus total mesorectal excision of T1 rectal adenocarcinomas with curative intention. Eur J Surg Oncol, 2009, 35(12): 1280-1285.
10.	Buess G. Review: transanal endoscopic microsurgery (TEM). J R Coll Surg Edinb, 1993, 38: 239-245.
11.	Borschitz T, Heintz A, Junginger T. The influence of histopathologic criteria on the long-term prognosis of locally excised pT1 rectal carcinomas: results of local excision (transanal endoscopic microsurgery) and immediate reoperation. Dis Colon Rectum, 2006, 49: 1492-1506.
12.	Stipa F, Burza A, Lucandri G, et al. Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: a 5-year follow-up study. Surg Endosc, 2006, 20: 541-545.
13.	Farmer KC, Wale R, Winnett J, et al. Transanal endoscopic microsurgery: the first 50 cases. ANZ J Surg, 2002, 72: 854-856.
14.	Mihai R, Borley N. Transanal endoscopic microsurgery – impact on the practice of a colorectal surgeon in a district general hospital. Ann R Coll Surg Engl, 2005, 87: 432-436.
15.	Platell C, Denholm E, Makin G. Efficacy of transanal endoscopic microsurgery in the management of rectal polyps. J Gastroenterol Hepatol, 2004, 19: 767-772.
16.	Maslekar S, Pillinger SH, Sharma A, et al. Cost analysis of transanal endoscopic microsurgery for rectal tumours. Colorectal Dis, 2007, 9(3): 229-234.
17.	Gavagan JA, Whiteford MH, Swanstrom LL. Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications. Am J Surg, 2004, 187(5): 630-634.
18.	Guerrieri M, Feliciotti F, Baldarelli M, et al. Sphincter-saving surgery in patients with rectal cancer treated by radiotherapy and transanal endoscopic microsurgery: 10 years’ experience. Dig Liver Dis, 2003, 35(12): 876-880.
19.	Kreissler-Haag D, Schuld J, Lindemann W, et al. Complications after transanal endoscopic microsurgical resection correlate with location of rectal neoplasms. Surg Endosc, 2008, 22(3): 612-616.
20.	Lee WY, Lee WS, Yun SH, et al. Decision for salvage treatment after transanal endoscopic microsurgery. Surg Endosc, 2007, 21(6): 975-979.

1. Buess G, Hutterer F, Theiss J, et al. A system for a transanal endoscopic rectum operation. Chirurg, 1984, 55(10): 677-680.
2. Nakagoe T, Ishikawa H, Sawai T, et al. Surgical technique and outcome of gasless video endoscopic transanal rectal tumor excision. Br J Surg, 2002, 89(6): 769-774.
3. Dafnis G, Pahlman L, Raab Y, et al. Transanal endoscopic microsurgery: clinical and functional results. Colorectal Dis, 2004, 6 (5): 336-342.
4. 劉建平. 非隨機研究的系統評價方法(一). 中國循證醫學, 2001, 1(4): 239-243.
5. Lezoche G, Baldarelli M, Guerrieri M, et al. A prospective randomized study with a 5-year minimum follow-up evaluation of transanal endoscopic microsurgery versus laparoscopic total mesorectal excision after neoadjuvant therapy. Surg Endosc, 2008, 22(2): 352-358.
6. Palma P, Horisberger K, Joos A, et al. Local excision of early rectal cancer: is transanal endoscopic microsurgery an alternative to radical surgery? Rev Esp Enferm Dig, 2009, 101(3): 172-178.
7. Ptok H, Marusch F, Meyer F, et al. Oncological outcome of local vs radical resection of low-risk pT1 rectal cancer. Arch Surg, 2007, 142(7): 649-655.
8. Lee W, Lee D, Choi S, et al. Transanal endoscopic microsurgery and radical surgery for T1 and T2 rectal cancer. Surg Endosc, 2003, 17(8): 1283-1287.
9. De Graaf EJ, Doornebosch PG, Tollenaar RA, et al. Transanal endoscopic microsurgery versus total mesorectal excision of T1 rectal adenocarcinomas with curative intention. Eur J Surg Oncol, 2009, 35(12): 1280-1285.
10. Buess G. Review: transanal endoscopic microsurgery (TEM). J R Coll Surg Edinb, 1993, 38: 239-245.
11. Borschitz T, Heintz A, Junginger T. The influence of histopathologic criteria on the long-term prognosis of locally excised pT1 rectal carcinomas: results of local excision (transanal endoscopic microsurgery) and immediate reoperation. Dis Colon Rectum, 2006, 49: 1492-1506.
12. Stipa F, Burza A, Lucandri G, et al. Outcomes for early rectal cancer managed with transanal endoscopic microsurgery: a 5-year follow-up study. Surg Endosc, 2006, 20: 541-545.
13. Farmer KC, Wale R, Winnett J, et al. Transanal endoscopic microsurgery: the first 50 cases. ANZ J Surg, 2002, 72: 854-856.
14. Mihai R, Borley N. Transanal endoscopic microsurgery – impact on the practice of a colorectal surgeon in a district general hospital. Ann R Coll Surg Engl, 2005, 87: 432-436.
15. Platell C, Denholm E, Makin G. Efficacy of transanal endoscopic microsurgery in the management of rectal polyps. J Gastroenterol Hepatol, 2004, 19: 767-772.
16. Maslekar S, Pillinger SH, Sharma A, et al. Cost analysis of transanal endoscopic microsurgery for rectal tumours. Colorectal Dis, 2007, 9(3): 229-234.
17. Gavagan JA, Whiteford MH, Swanstrom LL. Full-thickness intraperitoneal excision by transanal endoscopic microsurgery does not increase short-term complications. Am J Surg, 2004, 187(5): 630-634.
18. Guerrieri M, Feliciotti F, Baldarelli M, et al. Sphincter-saving surgery in patients with rectal cancer treated by radiotherapy and transanal endoscopic microsurgery: 10 years’ experience. Dig Liver Dis, 2003, 35(12): 876-880.
19. Kreissler-Haag D, Schuld J, Lindemann W, et al. Complications after transanal endoscopic microsurgical resection correlate with location of rectal neoplasms. Surg Endosc, 2008, 22(3): 612-616.
20. Lee WY, Lee WS, Yun SH, et al. Decision for salvage treatment after transanal endoscopic microsurgery. Surg Endosc, 2007, 21(6): 975-979.

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經肛門內窺鏡下微創手術與傳統根治術治療直腸癌療效與安全性的系統評價

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經肛門內窺鏡下微創手術與傳統根治術治療直腸癌療效與安全性的系統評價

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