D2淋巴结清扫术与D3淋巴结清扫术治疗胃癌的Meta分析

D2 lymphadenectomy and D3 lymphadenectomy for gastric cancer：a Meta-analysis

摘要:

目的：系统评价D2淋巴结清扫术式和D3淋巴结清扫术式（后简称D2术式和D３术式）在胃癌根治术中的安全性和有效性。方法：计算机检索PubMed、Cochrane Library、中国生物医学文献数据库、中文科技期刊数据库、中国期刊全文数据、万方数据库，此外，手工检索了本领域的相关杂志，全面检索D2术式和D3术式治疗胃癌的随机对照试验（randomized controlled trials，RCTs）。对纳入文献进行方法学质量评价，用RevMan 5.1软件进行统计分析。结果：共纳入6篇RCTs，Meta分析结果显示：D2术式和D3术式治疗胃癌在围手术期病死率[优势比（odds ratio，OR）=1.01，95％可信区间（confidence interval，CI）＝0.44~2.32]、术后总并发症的发生率（OR=1.53，95%CI=0.81~2.89）、5年生存率（OR=1.08，95%CI＝0.81～1.44）、术后复发率（OR=0.89，95%CI＝0.67~1.81）方面差异无统计学意义（P=0.980、0.190、0.590、0.410）。D3术式淋巴瘘（OR=0.66，95%CI＝0.01～0.50）和顽固性腹泻（OR=0.11，95%CI＝0.01～0.90）的发生率高，而D2术式肺部感染发生率高（OR=3.71，95%CI=1.43~9.61），差异均有统计学意义（P=0.009、0.040、0.007）。２种术式在术后吻合口瘘、胰瘘、腹腔脓肿、术后出血、伤口感染、二次手术发生率、肠梗阻等发生率差异无统计学意义（P=0.240、0.500、0.080、0.400、0.710、0.570、0.960）。D3术式手术时间长[加权均数差（weighted mean differ－ence，WMD）=-154.86 min，95%CI=1.04~4.18]、术中失血量大（WMD=301 ml，95％CI=151.55~450.45），差异有统计学意义（P=0.008、0.000）；但在术后平均住院天数（WMD=1.77 d，95%CI=-1.65~5.15）和术中平均输血量（WMD=-138.47 ml，95%CI=-379.96 ~ -103.01）方面差异均无统计学意义（P=0.310，0.260）。结论：当前证据表明与D2术式相比，D3术式不能使胃癌患者生存受益且手术风险高，不推荐常规应用。

Abstract:

Objective：To evaluate the safety and effectiveness of D2 lymphadenectomy and D3 lymphadenectomy in the treatment of gastric cancer. Methods：PubMed，Cochrane Library，Chinese biomedicine literature database，Chinese journal full-text database and Chinese scientific journal full-text database were searched to identify randomized controlled trials（RCTs） comparing D2 with D3 lym－phadenectomy for gastric cancer. We also hand-searched related key Chinese journals to identify potential studies. Quality of the included studies was assessed and Meta analysis was performed using RevMan 5.1 software. Results：Six RCTs were included. Meta analysis showed that there was no significant difference between D2 group and D3 group in terms of postoperative mortality（odds ratio（OR）=1.01，95％confidence interval（95％CI）=0.44 to 2.32），incidence of overall postoperative complications（OR=1.53，95%CI=0.81 to 2.89），five-year overall survival rate（OR=1.08，95%CI=0.81 to 1.44） and recurrence rate（OR=0.89，95%CI=0.67 to 1.81）（P=0.980，0.190，0.590，0.410）. D3 group had higher incidence of postoperative lymphatic fistula（OR=0.66，95%CI=0.01 to 0.50）and in－tractable diarrhea（OR=0.11，95%CI=0.01 to 0.90），but D2 group had higher pulmonary infection rate（OR=3.71，95%CI=1.43 to 9.61） when doing comparison with statistical differences（P=0.009，0.040，0.007）. No difference was found between two groups regarding incidence of anastomotic leakage，pancreatic fistula，abdominal abscess，upper gastrointestinal bleeding，wound infection，reoperation rate and intestinal obstruction（P=0.240，0.500，0.080，0.400，0.710，0.570，0.960）. D3 group had longer operation time（weighted mean difference（WMD）=-154.86，95%CI=1.04 to 4.18） and more intraoperative blood loss voulme（WMD=301 ml，95％CI=151.55 to 450.45） compared with those of D2 group（P=0.008，0.000）. No statistically significant difference was existed in mean intraoperative blood transfusion volume（WMD=-138.47 ml，95%CI=-379.96 to -103.01） and hospitalization time（WMD=1.77 d，95%CI=-1.65 to 5.15）between groups（P=0.31，0.26）. Conclusions：Current evidence suggests that D3 lymphadenectomy has no survival advantage and has higher operation risk when compared with D2 lym－phadenectomy，therefore is not recommend for routine use.