内镜下黏膜切除术与内镜黏膜下剥离术治疗结直肠癌临床疗效的Meta分析*

Clinical efficacy of endoscopic mucosal resection versus endoscopic submucosal dissection for patients with colorectal cancer: a Meta-analysis*

摘要:

系统性评价内镜下黏膜切除术（EMR）与内镜黏膜下剥离术（ESD）治疗结直肠癌的疗效。方法 计算机检索PubMed、The Cochrane Library、EMbase、CNKI、CBM和WanFang数据库，查找所有比较EMR与ESD治疗结直肠癌的随机对照试验（RCT），检索时限为从建库至2018年12月16日。同时手动检索纳入研究的参考文献，按照纳入和排除标准筛选文献、提取资料，评价纳入研究的方法质量学，数据采用RevMan 5.3软件进行Meta分析。结果 最终纳入18个RCT，共1 764例患者。Meta分析结果显示：①有效性方面：ESD整块切除率高（OR=0.16，95%CI：0.09～0.27，P =0.000），组织治愈性切除率高（OR=0.32，95%CI：0.11～0.90，P =0.030），复发率低（OR=6.15，95%CI：3.42～11.06，P =0.000）；②安全性方面：ESD手术时间长（MD =-25.53，95%CI：-33.37～-17.69，P =0.000），术中穿孔率较高（OR=0.22，95%CI：0.10～0.47，P =0.000），术中出血率和感染率差异均无统计学意义（OR=0.67，95%CI：0.43～1.05，P =0.080；OR=0.57，95%CI：0.22～1.49，P =0.250）。结论 现有证据表明，ESD较EMR对结直肠癌病变患者的治疗有效性高且复发率低，但手术时间较长、穿孔率高。受纳入研究质量和数目所限，以上结论尚需进一步开展更多大样本、高质量及多中心的RCT加以定论。

Abstract:

To review the clinical efficacy of Endoscopic Mucosal Resection (EMR) vs Endoscopic Submucosal Dissection (ESD) for patients with colorectal cancer. Methods Randomized controlled trials (RCTs) about EMR vs ESD for colorectal cancer were searched in PubMed, the Cochrane Library, EMbase, CNKI, CBM and WanFang Databases from the date of their establishment to Dec 16th, 2018. Other relevant journals and references of included studies were also searched manually. Reviewers independently screened literatures according to the inclusion and exclusion criteria, extracted data and assessed methodological quality of included studies. Meta-analysis was then conducted using RevMan 5.3 software. Results 18 RCTs involving 1 764 patients were enrolled. The results of meta-analysis indicated that: effectiveness, ESD groups had higher endoscopic complete resection rate (OR = 0.16, 95%CI: 0.09 ~ 0.27, P = 0.000), higher histological complete resection rate (OR = 0.32, 95%CI: 0.11 ~ 0.90, P = 0.030) and less recurrence rate than EMR groups (OR = 6.15, 95%CI: 3.42 ~ 11.06, P = 0.000); Safety, ESD groups had longer procedure time (MD = -25.53, 95%CI: -33.37 ~ -17.69, P = 0.000) as well as higher perforation rate than EMR groups (OR = 0.22, 95%CI: 0.10 ~ 0.47, P = 0.000). However, there seemed to be no statistical difference between ESD groups and EMR groups in the bleeding and infection rate (OR = 0.67, 95%CI: 0.43 ~ 1.05, P = 0.080; OR = 0.57, 95%CI: 0.22 ~ 1.49, P = 0.250, respectively). Conclusion Current evidence indicates that ESD is more effectiveness, but it needs longer procedure time and may cause higher perforation rate than EMR for colorectal cancer. Due to the limited quantity and quality of the included studies, more larger sample, multicenter and high quality RCTs are needed to verify the above conclusion.