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ORIGINAL ARTICLE
Year : 2014  |  Volume : 10  |  Issue : 8  |  Page : 272-275

Is the incidence of postoperative anastomotic leakage different between laparoscopic and open total mesorectal excision in patients with rectal cancer? A meta-analysis based on randomized controlled trials and controlled clinical trials


Department of General Surgery, Huaihe Hospital of Henan University, Kaifeng 475000, China

Date of Web Publication17-Feb-2015

Correspondence Address:
Wanli Ma
Department of General Surgery, Huaihe Hospital of Henan University, Kaifeng 475000
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.151491

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 > Abstract 

Objective: The purpose of this meta-analysis was to assess whether the incidence of postoperative anastomotic leakage (PAL) was different between laparoscopic and open total mesorectal excision (TME) in patients with rectal cancer.
Materials and Methods: The PubMed, Medline, Cochrane Library, Wanfang and China National Knowledge Infrastructure databases were searched for selecting the randomized controlled trials (RCTs) and controlled clinical trials (CCT) on the incidence of PAL between laparoscopic and open TME for rectal cancer. The incidence rate of PAL was extracted from each of the individual study and pooled by the STATA-11.0 statistical software.
Results: Six RCTs and 19 CCTs were included in this meta-analysis. The pooled results indicated that no statistical difference of PAL rate was found between aparoscopic and open TME in patients with rectal cancer (odds ratio [OR] =0.81, 95% confidence interval [CI]: 0.61-1.07, [P > 0.05]); The sub-group analysis when pooling the RCTs and CCTs respectively also indicated that there was no statistical difference of PAL rate between the laparoscopic and open TME (OR = 0.70, 95% CI: 0.35-1.39, [P > 0.05] for RCTs and OR = 0.84, 95% CI: 0.61-1.14, [P > 0.05]).
Conclusion: Based on present studies, laparoscopic TME does not increase the risk of PAL.

Keywords: Meta-analysis, postoperative anastomotic leakage, rectal cancer, total mesorectal excision


How to cite this article:
Hua L, Wang C, Yao K, Zhang J, Chen J, Ma W. Is the incidence of postoperative anastomotic leakage different between laparoscopic and open total mesorectal excision in patients with rectal cancer? A meta-analysis based on randomized controlled trials and controlled clinical trials. J Can Res Ther 2014;10, Suppl S4:272-5

How to cite this URL:
Hua L, Wang C, Yao K, Zhang J, Chen J, Ma W. Is the incidence of postoperative anastomotic leakage different between laparoscopic and open total mesorectal excision in patients with rectal cancer? A meta-analysis based on randomized controlled trials and controlled clinical trials. J Can Res Ther [serial online] 2014 [cited 2020 Dec 4];10:272-5. Available from: https://www.cancerjournal.net/text.asp?2014/10/8/272/151491


 > Introduction Top


Total mesorectal excision (TME) was firstly reported by Heald et al. in 1982. [1] For the following 30 years, the TME procedure was wildly used for the treatment of rectal cancer. The current standard treatment of rectal cancer is based on the modality approach with neoadjuvant chemoradiation in advanced cases and complete surgical removal through total mesorectal excision. [2] Clinical evidence showed that TME can significant decrease the risk of metastases and improve the prognosis in patients with advanced rectal cancer. And now-a-days, neoadjuvant chemoradiation followed by TME surgical procedure is considered as the standard treatment for locally advanced rectal cancer. [3]

At present, the most frequent operative procedure for treatment of rectal cancer is open surgery. But with the development of surgical skill and instrument, the laparoscopic TME is widespread. Postoperative anastomotic leakage (PAL) was one of common and serious complication for rectal cancer patients who received TME. And the incidence rate of PAL between laparoscopic and open TME in patients with rectal cancer was not clear. Thus, we perform this meta-analysis to further evaluate the incidence of PAL between laparoscopic and open TME.


 > Materials and methods Top


Inclusion and exclusion criteria

For inclusion criteria: (1) The study type was randomized controlled trials (RCTs) or controlled clinical trials (CCTs); (2) all the patients in the individual study received TME; (3) language were limited to Chinese or English; (4) all of the included studies provided enough data for calculating the PAL rate. Exclusion criteria: (1) Review or case report; (2) repeat published articles; (3) not enough data for calculation of PAL rate; (4) studies published in other languages other than Chinese or English.

Search strategy

We performed systematic electronic searches of the PubMed, Medline and Cochrane Library, Wanfang and China National Knowledge Infrastructure databases to identify all published studies reporting he incidence of PAL rate between laparoscopic and open TME in patients with rectal cancer. The reference lists of all retrieved articles and those of relevant review articles were also cross-referenced. The searching strategy was based on Cochrane handbook. The search terms were: "Rectal cancer", "Rectal carcinoma", "Rectal neoplasm", "Laparoscopy", "Anastomotic leakage", "Complication".

Data extraction

The data of the included individual trials were extracted independently by two reviewers (Hua Long and Wang Chenyu). Any disagreements between the two authors were resolved by discussion. The following data were extracted: Study design and period, year of publication, number of patients included in each study, number of PAL in each group.

Statistical analysis

The odds ratio (OR) and its 95% confidence interval (CI) was used to assess the PAL rate between laparoscopic and open TME in patients with rectal cancer. The pooled ORs for the PAL rate were calculated using a fixed-effects model (Mantel-Haenszel method) or a random-effects model (DerSimonian-Laird method). Statistical heterogeneity across the included trials was evaluated by Chi-square-based Q-test (significance level of P < 0.10). And publication bias was calculated by the funnel plot, in which the standard error of log OR of each study was plotted against its log OR. All the statistical analysis was done by STATA-11.0 software (http://www.stata.com; Stata Corporation, College Station, TX).


 > Results Top


General characteristics of included studies

Finally, six RCTs and 19 CCTs were included in this meta-analysis. The publication year range 1999-2012. And the patients included in each individual study ranged from 43 to 402. Twelve studies were published in Chinese, and other 13 trials were published in English. The general characteristics of included studies are demonstrated in [Table 1].
Table 1: The general characteristics of included studies

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Quality of the randomized controlled trials

The quality of the included six RCTs was assessed according to Cochrane handbook. All of the included studies reported the adequate sequence generation, incomplete outcome data address and free of selective reporting. None of the included study reported the blinding. The detailed quality of included six RCTs is demonstrated in [Figure 1].
Figure 1: The quality assessment of included six randomized controlled trials

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Postoperative anastomotic leakage rate

The median anastomotic leakage rate were 5.4% and 5.8% in the laparoscopic and open group respectively, which indicated that there was no statistical difference of postsurgical anastomotic leakage rate between the two groups (P > 0.05), [Figure 2].
Figure 2: The postoperative anastomotic leakage rate between the two groups

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Publication bias

The funnel plot for evaluation the publication bias was almost symmetrical, which indicated that no significant publication was found in this meta-analysis [Figure 3].
Figure 3: The funnel plot for evaluation the publication bias

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 > Meta-analysis results Top


Six RCTs and 19 CCTs were included in this meta-analysis. The pooled results indicated that no statistical difference of PAL rate was found between laparoscopic and open TME in patients with rectal cancer (OR = 0.81, 95% CI: 0.61-1.07, [P > 0.05]); The sub-group analysis when pooling the RCTs and CCTs respectively also indicated that there was no statistical difference of PAL rate between the laparoscopic and open TME (OR = 0.70, 95% CI: 0.35-1.39, [P > 0.05] for RCTs and OR = 0.84, 95% CI: 0.61-1.14, [P > 0.05]), [Figure 4].
Figure 4: The forest plot for evaluation the postoperative anastomotic leakage

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 > Discussion Top


Colorectal cancer is one of the most diagnosed malignant solid carcinomas with an estimated incidence rate of 4290 new cases in year 2012 in the United States (23500 cases of men and 16790 cases of women). And about 51690 cases died of rectal and colon cancer in the same year in the United States. [29] Rectal carcinoma was defined as cancerous lesion located within 12 cm of the anal verger by rigid proctoscopy. In China, rectal cancer accounts for almost half of the colorectal carcinoma. And by introduction of the TME, the obvious advances and improved prognosis have been achieved in the treatment of rectal cancer [30] in the past few decades. At present, the TME procedure was proposed as the standard treatment procedure for rectal cancer that could significant decrease the locally recurrence rate for patients with rectal cancer. [31]

Laparoscopic operation in the treatment of colorectal cancer has been reported for more than 20 years with the initial objective of ameliorating postoperative recovery without compromising oncological adequacy. But laparoscopic operation for treatment of rectal cancer was complex and technically demanding, especially for patients with low rectal cancer. As surgical techniques and equipment have developed, the feasibility and safety of laparoscopic TME have been reported by many institutes. [7] And several clinical trials indicated that the long-term prognosis of TME seems to be comparable to open TME. [32] However, whether the incidence of PAL was different between laparoscopic and open TME in patients with rectal cancer was not clear.

In this meta-analysis, were collected all the published articles reporting the incidences of PAL between laparoscopic and open TME in patients with rectal cancer in order to make it clear. Finally, we included six RCTs and 19 CCTs. The median anastomotic leakage rate were 5.4% and 5.8% in the laparoscopic and open group respectively, which indicated that there was no statistical difference of postsurgical anastomotic leakage rate between the two groups (P > 0.05). The pooled results indicated that no evidence showed that the PAL risk in the laparoscopic group was higher than the open group (P > 0.05). Thus, we propose that based on present studies, laparoscopic TME does not increase the risk of PAL. But with several low-quality individual studies included in this meta-analysis, the conclusion should be drawn with caution.

 
 > References Top

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    Figures

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