Comparison Of Laparoscopic And Lateral Lymph Node Dissection In Open Rectal Cancer:A Meta-analysis

Rectal cancer is one of the most common malignant tumors in humans,and its incidence and mortality are currently the third highest in the world.The proportion of colorectal cancer in China is about 60%.Rectal cancer is still treated with a comprehensive surgical approach,while traditional total mesorectal excision(TME)is the "gold standard" for rectal cancer surgery,but local recurrence still occurs in a few And chemoradiotherapy cannot completely solve it.Studies by Japanese scholars have shown that patients with lateral lymph node metastasis(lymph nodes from the obturator artery to the medial border of the internal and external iliac arteries)of low rectal cancer account for 10%-25% of rectal cancer.Certain limitations.The lymph nodes other than the mesentery(including total lymph nodes in the iliac crest,intra-iliac lymph nodes,and obturator lymph nodes)have not been completely removed.Based on the main spread of rectal cancer,lymph node metastasis is proposed.On the basis of surgery,lateral lymph node dissection was performed.And in 1970,Japan began to implement expanded radical resection of rectal cancer,mainly based on lateral lymph node dissection(LLND).It believes that radical resection of rectal cancer combined with LLND can effectively control regional recurrence of tumors and increase the number of patients.Survival rate is particularly important for patients with lateral lymph node metastasis below the peritoneal reflex.JCOG0212 multi-center study of Japanese reported that the positive rate of lateral lymph node metastasis in the group receiving TME plus lateral lymph node dissection was 7%,and the postoperative complications were not significantly different from those in the TME group alone.There was no statistically significant difference in the TME group,but the local recurrence rate was significantly reduced(7.4% vs.12.6%),especially the lateral recurrence.With the publication of the results of this study,scholars in China have also begun to approve lateral lymph node dissection for low-to-medium rectal cancer in stages T3 to T4.However,traditional lateral lymph node dissection is still based on open surgery.It has been widely used,but because the rectal cancer lateral lymph node dissection is a difficult operation,laparoscopic rectal cancer lateral lymph node dissection has not been widely carried out in China.At present,domestic and foreign scholars are still controversial whether laparoscopic radical rectal cancer combined with lateral lymph node dissection is better than open surgery for rectal cancer.This study performed a meta-analysis of the effects of laparoscopic and open rectal cancer lateral lymph node dissection on the clinical application of laparoscopic and lateral lymph node dissection in the treatment of rectal cancer.Objective:Comparison of intraoperative time,intraoperative blood loss,postoperative complication rate,postoperative hospital stay,3-year survival rate,and urinary function during laparoscopic radical rectal cancer combined with lateral lymph node dissection and open surgery for rectal cancer Obstacles and other indicators,systematic evaluation of the surgical effects of laparoscopic rectal cancer lateral lymph node dissection and open rectal cancer lateral lymph node dissection is expected to provide guidance for clinical treatment.Methods:Search for Pub Med,Embase,Cochrane Library,Wan Fang database using the terms "rectal cancer","lateral lymph node dissection","laparoscopy","rectal tumor","pelvic lateral lymph node dissection","rectal tumor",etc.Databases and electronic databases such as the CNKI database.The search method is a combination of synonyms,free words,and Me SH words.The search period is set from January 2001 to March 2019.Randomized controlled trials(RCT)or non-RCTs for laparoscopic radical rectal cancer combined with LLND and open-surgery for rectal cancer were selected.Statistical analysis was performed using Review Manager(Rev Man)5.3 software.Apply binary classification data to calculate Odds Ratio(OR)combined count data,apply continuity data to calculate Mean Difference(MD)or standard mean difference(SMD)combined measurement data,and combine the two values It is expressed as a 95% confidence interval(CI).I~2 test was used to test the heterogeneity of the included literature: when P ≥0.1 or I~2 ≤50%,there was no statistical heterogeneity between the studies,and a fixed effect model analysis was performed.In contrast,when P<0.1 or I~2> 50%,there was statistical heterogeneity between studies and analysis using a random effects model.Finally,literature publication bias assessments were performed by using a funnel plot representation.The above steps are performed independently by two reviewers,and in case of disagreement,a third reviewer participates in the discussion and resolution.Results:Nine published clinical comparative studies were included,376 patients with rectal cancer treated with laparoscopic LLND;594 patients with rectal cancer treated with open surgery;The average intraoperative blood loss in the laparoscopic LLND group(MD=-1.63,95%Cl=-1.85～-1.40,P<0.05)was lower than that in the open group;The postoperative complication rate in the laparoscopic LLND group(OR=0.76,95%Cl=0.56～1.03,P=0.009)was lower than that in the open group;The average postoperative hospital stay in the laparoscopic LLND group(MD=-3.89,95%Cl=-4.80～-2.98,P=0.0005)was lower than that in the open group;The operation time in the laparoscopic LLND group(MD=34.18,95%Cl=17.34～51.03,P=0.01)was higher than that in the open group;There were no significant differences in the 3-year survival rate(OR=2.06,95 % Cl=1.54 ～ 2.76,P=0.12)and the incidence of urinary dysfunction(OR=1.43,95%Cl=0.78～2.63,P=0.41)between the two groups.The funnel graph shows that the inclusion indicators are basically located in the funnel graph,and are roughly symmetrically distributed on both sides of the vertical axis,suggesting that the risk of literature publication deviation is small.ConclusionLaparoscopic rectal cancer lateral lymph node dissection is valuable for radical rectal cancer with lateral lymph node metastasis below the peritoneal reflex.Laparoscopic lateral lymph node dissection for rectal cancer is difficult and longer than open surgery.The incidence of urinary dysfunction and 3-year survival after surgery are not significantly different from open surgery,but it can significantly reduce blood loss during surgery,post-complications and shortened hospital stay after surgery.It is hoped that with the application of laparoscopy and robotics,it is expected to reduce the difficulty of this technology and further promote its application in clinical practice.