胃上部腺癌全胃切除术与近端胃切除术安全性及有效性比较的Meta分析

摘要

目的 比较胃上部腺癌行近端胃切除及全胃切除术后的安全性及有效性,并确定胃上部肿瘤最为合适的手术切除方式.方法 检索Pubmed、Embase、the Cochrane Library及Web of Science数据库,收集关于胃上部肿瘤行近端胃切除和全胃切除的英文文献,由两名研究者按照纳入与排除标准筛选符合条件的文献.其中回顾性研究文献采用卡斯尔?渥太华(NOS)量表评估,前瞻性随机对照临床试验(RCT)文献采用Jadad量表评估.提取文献基本信息及相关临床指标,主要结局指标包括:术后5年总体生存率和肿瘤复发率;次要结局指标包括手术时间、术中出血量、术后并发症发生率、吻合口狭窄发生率及反流性食管炎发生率等.考虑到肿瘤分期可能对胃癌切除术后临床病理特征及预后的影响,在统计分析时,分别对纳入病例为早期胃癌的文献,以及肿瘤分期包括Ⅰ~Ⅳ期胃癌患者的文献进行分组分析.统计分析采用Revman 5.3软件以及R软件(V3.2.4)中的"metafor"和"meta"软件包.结果 最终纳入25篇文献,共计3 667例患者,24篇回顾性研究文献评分均在5分以上,1篇RCT为3分,均为高质量文献.研究病例为早期胃癌的文献共18篇,共2 516例患者,其中近端胃切除组1 027例,全胃切除组1 489例.研究中纳入肿瘤分期为Ⅰ~Ⅳ期病例的文献共7篇,1 151例患者,其中近端胃切除组456例,全胃切除组695例.在术后5年生存率方面,早期胃癌近端胃切除组与全胃切除组比较,差异无统计学意义(OR=1.16,95% CI :0.72~1.86,P=0.54);Ⅰ~Ⅳ期胃癌组患者近端胃切除组与全胃切除组比较,差异也无统计学意义(OR=1.19,95% CI :0.92~1.53,P=0.18).早期胃癌近端胃切除组与全胃切除组间肿瘤复发率比较,差异无统计学意义(OR=0.40,95% CI :0.05~3.16,P=0.39);但Ⅰ~Ⅳ期胃癌患者近端胃切除组复发率高于全胃切除组(OR=1.55,95% CI:1.09~2.19,P<0.01),差异有统计学意义.无论早期胃癌还是Ⅰ~Ⅳ期胃癌,近端胃切除组与全胃切除组的术后并发症发生率比较,差异均无统计学意义(均P>0.05).早期胃癌近端胃切除组术后吻合口狭窄发生率(OR=3.57,95% CI :1.82~6.99,P<0.01)及反流性食管炎发生率(OR=2.83, 95% CI:1.23~6.54,P=0.01)均显著高于全胃切除组.结论 对于胃上部肿瘤,全胃切除与近端胃切除术后远期生存结局指标无明显差异,但全胃切除术后吻合口狭窄以及反流性食管炎发生率低于近端胃切除,并且肿瘤复发率也显著低于近端胃切除术.故对于进展期胃上部肿瘤仍建议首选全胃切除.%Objective To compare the safety and efficacy between proximal gastrectomy and total gastrectomy and to ascertain the optimized procedure for patients with upper third gastric cancer through meta?analysis. Methods The English literatures about proximal gastrectomy and total gastrectomy for upper third gastric cancer were searched from PubMed, EMBASE, the Cochrane Library and the Web of Science database and then collected. The quality of enrolled studies was independently assessed by two researchers according to the Newcastle?Ottawa Scale for retrospective studies and Jadad scale for RCT studies. The basic information of the literature and related clinical indicators were extracted. The primary endpoints were 5?year overall survival rate and recurrence rate. The secondary endpoints were operative time, intraoperative blood loss, morbidity of postoperative complication, incidence of anastomotic stenosis and incidence of reflux esophagitis. Considering the influence of tumor staging on postoperative clinicopathological features and prognosis, a subgroup analysis was performed on the literatures including cases of early gastric cancer and those including cases of tumor stage I to IV. Statistical analyses were carried out by the"metafor"and"meta"software packages from RevMan 5.3 software and R software (V3.2.4). Results Twenty?five literatures involving 3667 patients (proximal gastrectomy for 1483, total gastrectomy for 2184) were finally enrolled for analysis, including 24 retrospective studies with≥5 points and 1 RCT with 3 points, and all the literatures were of high quality. A total of 2516 cases of early gastric cancer were enrolled in 18 articles, including 1027 with proximal gastrectomy and 1489 with total gastrectomy. A total of 1151 cases with stage I to IV were enrolled in 7 articles, including 456 in proximal gastrectomy group and 695 in total gastrectomy group. Five?year survival rate was not significantly different for patients with early gastric cancer between the proximal gastrectomy group and total gastrectomy group ( OR=1.16, 95% CI : 0.72 to 1.86, P=0.54). Similarly, there was no significant difference for patients with stage I to IV between the proximal gastrectomy group and the total gastrectomy group ( OR=1.19, 95% CI :0.92 to 1.53, P=0.18). Recurrence rate of early gastric cancer patients was not significantly different between the proximal gastrectomy group and the total gastrectomy group (OR=0.40, 95% CI: 0.05 to 3.16, P=0.39).However, the recurrence rate of the proximal gastrectomy group was higher than that of the total gastrectomy group in patients with stage I to IV ( OR=1.55, 95% CI : 1.09 to 2.19, P<0.01), whose difference was statistically significant. There was no significant differences in postoperative complication between the groups, both in patients with early gastric cancer, and in those with stage I to IV (both P>0.05). The incidences of postoperative anastomotic stenosis ( OR=3.57, 95% CI : 1.82 to 6.99, P<0.01) and reflux esophagitis ( OR=2.83, 95% CI : 1.23 to 6.54, P=0.01) in the proximal gastrectomy group were significantly higher than those in the total gastrectomy group in patients with early gastric cancer. Conclusions There is no significant difference in long?term survival outcomes between total gastrectomy and proximal gastrectomy for upper gastric tumors. However,incidence of anastomotic stenosis and reflux esophagitis, and tumor recurrence rate after total gastrectomy are significantly lower. The total gastrectomy is recommended as the first choice for advanced upper gastric tumor.