转移灶不可切除的转移性结直肠癌原发灶切除术疗效的Meta分析

摘要

目的 系统评价转移灶不可切除的转移性结直肠癌行原发灶切除术的疗效及安全性.方法 以asymptomatic、primary、resection、metastatic、stageⅣ、cancer、colon、colorectal、rectal、无症状性、原发灶切除、转移性、4期(Ⅳ期)、结直肠癌、结肠癌、直肠癌为检索词,检索PubMed、Cochrane Library、CNKI、中国生物医学文献数据库、万方数据库,检索期限为从建库至2015年8月.纳入比较转移灶不可切除的无症状性转移性结直肠癌患者初始行原发灶切除术与初始行全身治疗的病例对照文献,由2位研究者独立行文献筛选和数据提取,并进行文献质量评价.将初始行原发灶切除术的患者设为初始行原发灶切除术组,将初始行全身治疗的患者设为初始行全身治疗组.比较两组患者总体生存率及中位生存时间,进一步评估初始行原发灶切除术组患者的围术期并发症发生率和病死率,以及初始行全身治疗组患者的肠梗阻发生率和急诊手术率.总体生存率采用优势比(OR)及95％可信区间(95％CI)表示.单个率资料采用率(r)及95％ CI表示,r=OR值×100％.中位生存时间采用均数差(MD)及95％ CI表示.采用I2对异质性进行分析.结果 最终共10篇文献纳入研究,均为回顾性病例对照研究,累计样本量为1 434例,其中初始行原发灶切除术组770例,初始行全身治疗组664例.Meta分析结果显示:初始行原发灶切除术组患者总体生存率优于初始行全身治疗组(OR=1.35,95％CI:1.01～ 1.79,P＜0.05);初始行原发灶切除术组患者中位生存时间比初始行全身治疗组延长3.8个月(MD=3.78,95％CI:3.60～3.97,P＜0.05).初始行原发灶切除术组患者围术期总并发症发生率为22％ (95％ CI:0.13 ～0.30),病死率为1％(95％CI:0.00～0.03).初始行全身治疗组患者肠梗阻发生率为18％ (95％ CI:0.14 ～0.21),急诊手术率为11％(95％CI:0.06 ～0.16).结论 对于转移灶不可切除,且原发灶无症状的转移性结直肠癌患者,初始行原发灶切除术是安全可行的,可改善患者的总体生存率,延长中位生存时间.初始无症状性患者如未行原发灶切除术,其肠梗阻发生率较高.%Objective To evaluate the efficacy and safety of primary tumor resection for metastatic colorectal cancer with unresectable metastases.Methods Database including PubMed,Cochrane Library,China National Knowledge Infrastructure (CNKI),China Biomedicine and Wanfang Database were searched with the key words of asymptomatic,primary,resection,metastatic,stage Ⅳ,cancer,colon,colorectal,rectal,无症状性,原发灶切除,转移性,4期(Ⅳ期),结直肠癌,结肠癌,直肠癌between the database establishment and August 2015.Literatures about primary tumor resection or systemic treatment as first-line treatment for asymptomatic patients with unresectable metastatic colorectal cancer were retrieved,and data were extracted and evaluated by 2 independent researchers.Patients with primary tumor resection as first-line treatment were allocated to the primary tumor resection group and patients with systemic treatment as first-line treatment were allocated into the systemic treatment group.The overall survival rate and median survival time were compared between the 2 groups.The incidence of perioperative complications and mortality in the primary tumor resection group as well as the incidences of intestinal obstruction and emergency operation in the systemic treatment group were evaluated.Survival data were presented by the odds ratio (OR) and 95％ confidence interval (CI).Single rate data were presented as rate (r) and 95％CI.The median survival time was analyzed using the mean difference (MD) and 95 ％ CI.Heterogeneity of the publication was analyzed using the I2 test.Results Ten retrospective control studies including 1 434 patients were retrieved.There were 770 patients in the primary tumor resection group and 664 patients in the systemic treatment group.The results of Meta analysis showed that overall survival rate of patients in the primary tumor resection group was better than that in the systemic treatment group (OR =1.35,95 ％ CI:1.01-1.79,P ＜0.05),and there was a longer median survival time of 3.8 months in the primary tumor resection group (MD =3.78,95％ CI:3.60-3.97,P ＜ 0.05).The incidence of perioperative complications and mortality in the primary tumor resection group were 22％ (95％ CI:0.13-0.30) and 1％ (95％ CI:0.00-0.03),respectively.The incidences of intestinal obstruction and emergency surgery were 18％ (95％ CI:0.14-0.21)and 11％ (95％CI:0.06-0.16) in the systemic treatment group,respectively.Conclusions For asymptomatic patients with unresectable metastatic colorectal cancer,resection of the primary tumor is safe and feasible,and it can improve the overall survival rate of patients and median survival time.The incidence of intestinal obstruction is higher among asymptomatic patients who do not receive primary tumor resection.