胸腔镜肺叶切除术中肺动、静...疗效与安全性影响的系统评价_白向豆.pdf

肿瘤防治研究2023年第50卷第1期 Cancer Res Prev Treat,2023,Vol.50,No.169doi:10.3971/j.issn.1000-8578.2023.22.0593胸腔镜肺叶切除术中肺动、静脉切断顺序对非小细胞肺癌患者手术疗效与安全性 影响的系统评价白向豆1，洪子强1，崔百强1，杨宁1，贺晓阳1，金大成2，苟云久1,2Effect of Sequence of Pulmonary Artery and Vein Transection in Thoracoscopic Lobectomy on Efficacy and Safety of Patients with Non-small Cell Lung Cancer:A Systematic EvaluationBAI Xiangdou1,HONG Ziqiang1,CUI Baiqiang1,YANG Ning1,HE Xiaoyang1,JIN Dacheng2,GOU Yunjiu1,21.The First Clinical Medical College of Gansu University of Chinese Medicine,Lanzhou 730000,China;2.Department of Thoracic Surgery,Gansu Provincial Hospital,Lanzhou 730000,ChinaCorresponding Author:GOU Yunjiu,E-mail:Abstract:Objective To systematically evaluate the effect of sequence of pulmonary artery and vein transection in thoracoscopic lobectomy on the efficacy and safety of patients with non-small cell lung cancer.Methods PubMed,EMbase,Web of Science,The Cochrane Library,CNKI,Wanfang,VIP and CBM databases were searched for the researches on The post-operative efficacy of pulmonary arteriovenous and pulmonary vein resection sequence in thoracoscopic lobectomy for non-small cell lung cancer.The retrieval time is from the database construction to May 2022.Meta-analysis was performed using RevMan 5.4 software.Results Eight articles were included,including 3 randomized controlled studies and 5 cohort studies,with a total of 1810 patients.Meta-analysis results showed that:The operative time(MD=13.34,95%CI(7.36,19.32),P0.0001)and intraoperative blood loss(MD=45.29,95%CI(40.24,50.35),P0.0001)in the group with priority pulmonary vein resection were significantly higher than those in the group with priority pulmonary vein resection.The difference was statistically significant.However,the benefits of OS(HR=1.34,95%CI(1.12,1.60),P=0.001)and DFS(HR=1.44,95%CI(1.18,1.76),P=0.0003)in the group of priority pulmonary vein transection were significantly better than those in the group of priority pulmonary artery transection,with statistically significant differences.Conclusion Priority pulmonary vein transection during thoracoscopic lobectomy effectively improved patients OS and DFS,resulting in higher survival benefit for patients with non-small cell lung cancer,but intraoperative bleeding and operation time are more than those with priority pulmonary artery transection.Key words:Non-small cell lung cancer;Lobectomy;Pulmonary artery;Pulmonary vein;Detachment sequence;Comparison of curative effects;Systematic reviewFunding:Gansu Provincial Peoples Hospital National scientific research project training program general project(No.19SYPYB-28);Gansu Province Health Industry Research Plan Project(No.GSWSKY2017-56);Gansu Provincial Science and Technology Planning Project(No.20JR10RA388)Competing interests:The authors declare that they have no competing interests.摘 要：目的 系统评价胸腔镜下肺叶切除术中肺动、静脉切断顺序对非小细胞肺癌患者手术的疗收稿日期：2022-05-31；修回日期：2022-08-29基金项目：甘肃省人民医院国家级科研项目培育计划一般项目（19SYPYB-28）；甘肃省卫生行业科研计划项目（GSWSKY2017-56）；甘肃省科技计划项目（20JR10RA388）作者单位：1.730000 兰州，甘肃中医药大学第一临床医学院；2.730000 兰州，甘肃省人民医院胸外一科通信作者：苟云久（1974-），男，博士，主任医师，主要从事胸部肿瘤的微创手术治疗，E-mail:作者简介：白向豆（1996-），男，硕士在读，主要从事胸部肿瘤的治疗临床研究效与安全性。方法 检索PubMed、EMbase、Web of Science、The Cochrane Library、中国知网、万方、维普和CBM数据库，搜索关于胸腔镜下肺叶切除术中肺动、静脉切断顺序对非小细胞肺癌手术后疗效的研究，检索时限均为建库至2022年5月。采用RevMan 5.4软件进行Meta分析。结果 最终纳入8篇文献，其中包括3篇随机对照研究、5篇队列研究，总共包含1 810例患者。肿瘤防治研究2023年第50卷第1期 Cancer Res Prev Treat,2023,Vol.50,No.170Meta分析结果显示：术中优先离断肺静脉组在手术时间（MD=13.34,95%CI（7.36,19.32）,P0.0001）、术中出血量（MD=45.29,95%CI（40.24,50.35）,P50%）时，采用随机效应模型；否则采用固定效应模型。敏感度分析检验结果的稳定性，根据漏斗图来判断发表偏倚。2 结果2.1 纳入研究及其基本特征最终纳入8篇文献，其中包括3篇随机对照研究（RCT）、5篇队列研究，总共包含1 810例病例，纳入研究的基本信息及队列研究质量评价见表1，肿瘤防治研究2023年第50卷第1期 Cancer Res Prev Treat,2023,Vol.50,No.171RCT研究质量评价见表2，文献筛查流程，见图1。2.2 Meta分析结果Meta分析结果显示，术中优先离断肺静脉组在手术时间（MD=13.34,95%CI（7.36,19.32），P0.0001）、术中出血量（MD=45.29,95%CI（40.24,50.35）,P0.0001）方面均显著高于优先离断肺动脉组，差异均具有统计学意义。但是优先离断肺静脉组患者的OS（HR=1.34,95%CI（1.12,1.60）,P=0.001）和DFS（HR=1.44,95%CI（1.18,1.76）,P=0.0003）均显著优于肺动脉组，差异均有统计学意义，见表3、图23。2.3 敏感度分析对各指标进行分析时，将纳入的各个研究在RevMan软件中逐一剔除后再进行合并分析，发现结果变化不明显，说明纳入研究的文章异质性较低，研究结论可靠。2.4 发表偏倚我们以OS获益分析为例绘制了漏斗图，发现各项研究均匀分布在漏斗图的两侧，并且没有一项研究分布在漏斗图外面，说明本研究的发表偏倚较小，见图4。3 讨论肺叶切除术作为A期非小细胞肺癌的经典外科手术已在临床实践中使用了数十年21。相比于传统开胸手术，胸腔镜手术以其创伤小、出血少、术后恢复快等优点已被广泛应用于临床22-23。受限于有限的操作空间，胸腔镜下肺叶切除术中每一个手术动作都力求简洁有效，随着NSCLC患者的增加，为改善患者预后，降低手术表1 纳入文献一般资料Table 1 General information of the included literatureStudyYearNationVein groupArtery groupStudy typeNOS scoreTimeHe HH122019China 33 27 Cohort study82012-2013Kozak A132013Poland170215RCT-1999-2003Li FW142015China174 93Cohort study82006-2013Sumitomo R152018Japan104 83Cohort study72007-2013Wei SY182019China210210RCT-2016-2018Jiang GC192014China152 76Cohort study72006-2012Jiao M162019China 89 84Cohort study82016-2018Bai HP202016China 45 45RCT-2012-2015RCT:randomized controlled trial.表2 RCT研究质量评价表Table 2 RCT study quality evaluation tableStudyRandom sequence generationAllocation concealmentBlinding of participants and personnelBlinding of outcome assessmentIncomplete outcome dataSelective