| Objective: With the increasing maturity of minimally invasive surgical methods for rectal cancer,there are a growing number of related researches and reports domestic and overseas.In recent years,Transanal total mesorectal excision(Ta TME)has gradually become a focus of colorectal surgery research.Compared with transabdominal laparoscopic total mesorectal excision(Lap TME),it is still controversial in terms of safety and effectiveness of surgery.In this study,we searched the original literature on Ta TME versus Lap TME for rectal cancer published in various databases domestic and overseas in the past decade,and used Meta-analysis to systematically evaluate the differences in safety and effectiveness of Ta TME and Lap TME for rectal cancer.Clinical practice provides some evidence-based evidence.Methods: According to the principles of PICOS research design,the Chinese and English search keywords and search formulas for this study were determined,and scientific and rigorous search strategies were formulated.In order to find RCT and non-RCT about Ta TME versus Lap TME for rectal cancer,we searched Pubmed,Embase,Cochrane Library,Web of science,China Biomedical Literature,CNKI,Wanfang,and Vip Database on the internet.The start date of literature search was January 1,2010 and the deadline was June 30,2019.The relevant literatures were screened according to the original document inclusion criteria and exclusion criteria.The Cochrane Center’s risk assessment form and the Newcastle-Ottawa Scale(NOS)were used to evaluate the quality of the included documents and obtain the final analysis literature.Relevant data included in the analysis literature was extracted,and Revman 5.3 software provided by the Cochrane Library was used for meta-analysis of relevant research data.Results: A total of 1268 original literatures were obtained through preliminary search.Based on the inclusion and exclusion criteria and literature quality evaluation,31 analysis literatures were included which consist of 2 RCT studies and 29 non-RCT studies,also 23 English literatures and 8 Chinese literatures.A total of 3055 patients with rectal cancer were included in the study,1500 in the Ta TME group and 1555 in the Lap TME group.A meta-analysis of the general characteristics of the included analysis literature showed that there was no statistically significant difference in the proportion of male patients,age,BMI,tumor diameter,and proportion of neoadjuvant therapy in the two groups,while there was statistically significant difference when the distance between the tumor and the anal margin was more shorter in the Ta TME group(WMD =-0.34,95% CI:-0.59~0.09,P = 0.007).Analysis of intraoperative results showed that there was statistically significant difference when the rate of conversion in the Ta TME group was lower than that in the Lap TME group(OR = 0.30,95% CI: 0.15 to 0.60,P <0.05),while the difference between the two groups was not statistically significant in the aspect of operation time(WMD = 0.60,95% CI:-18.18 ~ 19.38,P = 0.95),intraoperative blood loss(WMD =-12.42,95% CI:-25.41~0.58,P = 0.06),the rate of intraoperative complications(OR = 1.2,95% CI: 0.76 to 1.89,P = 0.43).Postoperative pathological results showed that the difference is statistically significant when the positive rate of CRM in the Ta TME group was lower(OR = 0.59,95% CI: 0.42-0.83,P = 0.003)and the CRM distance was longer(WMD = 0.93 95% CI: 0.60~1.25,P <0.05)with sensitivity analysis.The difference between the two groups is not statistically significant in the positive rate of DRM(OR = 0.67,95% CI: 0.34-1.32,P = 0.25),the evaluation of the mesorectal integrity of the postoperative specimens(OR = 1.17,95% CI: 0.82~2.17,P = 1.69),number of acquired lymph nodes(WMD = 0.75,95% CI:-0.12~1.63,P = 0.09),DRM distance(WMD = 1.40,95% CI:-0.70~3.51,P = 0.19).Analysis of recent postoperative results: there was no statistical comparison with Lap TME in terms of the overall complication rate(OR = 0.95,95% CI: 0.80~1.12,P = 0.52),the incidence of anastomotic leakage(OR = 0.70,95% CI: 0.73~1.24,P = 0.70),the incidence of postoperative intestinal obstruction and intestinal paralysis(OR = 0.83,95% CI: 0.55~1.24,P = 0.36),the incidence of urinary retention and urinary tract infection(OR = 0.65,95% CI: 0.42~1.00,P = 0.05),bleeding(OR = 1.00,95% CI: 0.36~2.74,P = 1.00),incidence of pelvic abscess(OR = 1.32,95% CI: 0.51~3.41,P = 0.57),reoperation rate(OR = 0.81,95% CI: 0.43~1.53,P = 0.51)and readmission rate(OR = 0.61,95% CI: 0.34~1.53,P = 0.09),but the differences are statistically significant when the incidence of serious postoperative complications(Clavien-Dindo grade ≥ 3)was lower(OR = 0.68,95% CI: 0.49~0.95,P = 0.02)and the postoperative hospital stay was shorter(WMD =-0.92,95% CI:-1.82~-0.02,P = 0.04).Analysis of long-term postoperativeresults: there were all no statistical significance in the aspects of postoperative tumor recurrence rate(OR = 0.72,95% CI: 0.38~1.40,P = 0.34),2-year DFS(OR = 1.01,95% CI: 0.45~2.26,P = 0.99),2-year OS(OR = 2.38,95% CI: 0.68~8.40,P = 0.18).Conclusion: 1.In terms of surgical safety,Ta TME has a lower risk of conversion to open surgery than Lap TME without increasing the operation time,intraoperative blood loss and intraoperative complications.2.In terms of radical surgery,Ta TME can obtain lower postoperative CRM positive rate and better CRM distance than Lap TME.Although the intact with near intact of rectal mesangial,DRM positive rate and distance and the number of lymph node acquisitions were comparable to Lap TME results in gross specimen examination,the final pathological results of Ta TME were better than Lap TME.3.In terms of the incidence of postoperative complications,although there is no difference between the two in terms of the overall postoperative complication rate and the incidence of anastomotic leakage,the incidence of serious postoperative complications of Ta TME is lower than that Lap TME and Ta TME has a shorter hospital stay.As a result,Ta TME is better than Lap TME in terms of postoperative safety and shortened average hospital stay.4.It’s comparable for Ta TME and Lap TME in terms of the curative effect of tumor recurrence,long-term curative effect of 2-year DFS and 2-year OS.5.Due to factors such as the shorter distance between the tumor and the anal margin of the Ta TME group,the results will have a certain bias,and some analysis indicators will be limited by the number and quality of the literature.In the future,there will be more and higher quality multi-center RCT studies included for Ta TME to provide more scientific and rigorous evidence-based medicine. |
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