大网膜包裹胰肠吻合口预防胰十二指肠切除术后并发症有效性和安全性的Meta分析

史亚波; 李扬; 刘华兵; 王智聪; 黄长文

doi:10.12449/JCH240122

大网膜包裹胰肠吻合口预防胰十二指肠切除术后并发症有效性和安全性的Meta分析

DOI: 10.12449/JCH240122

史亚波^{1, 2},
李扬^{1, 2},
刘华兵^{1, 2},
王智聪^{1, 2},
黄长文^3, , ,

1.
南昌大学医学院，南昌 330036
2.
江西省人民医院（南昌医学院第一附属医院）肝胆外科，南昌 330036
3.
广州医科大学附属第六医院（清远市人民医院）肝胆外科，广东清远 511500

基金项目:

江西省自然科学基金面上项目 (20202BABL206096)

利益冲突声明：本文不存在任何利益冲突。

作者贡献声明：史亚波、黄长文负责课题设计，资料分析，撰写论文；李扬、刘华兵、王智聪参与收集数据，修改论文；黄长文负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

通信作者:
黄长文， ncdxhcw@163.com （ORCID： 0000-0001-6898-0162）

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出版历程
- 收稿日期: 2023-04-12
- 录用日期: 2023-05-24
- 出版日期: 2024-01-23

Efficacy and safety of omental wrapping technique for pancreaticojejunal anastomosis in preventing complications after pancreaticoduodenectomy： A Meta-analysis

Yabo SHI^{1, 2},
Yang LI^{1, 2},
Huabing LIU^{1, 2},
Zhicong WANG^{1, 2},
Changwen HUANG^{3
, ,
,}

1.
Medical School of Nanchang University，Nanchang 330036，China
2.
Department of Hepatobiliary Surgery，Jiangxi Provincial People’s Hospital，The First Affiliated Hospital of Nanchang Medical College，Nanchang 330036，China
3.
The Sixth Affiliated Hospital of Guangzhou Medical University，Qingyuan People’s Hospital，Qingyuan，Guangdong 511500，China

Research funding:

General Program of National Natural Science Foundation of Jiangxi Province (20202BABL206096)

More Information

Corresponding author: HUANG Changwen， ncdxhcw@163.com （ORCID： 0000-0001-6898-0162）

摘要

摘要: 目的系统评价大网膜包裹胰肠吻合口预防胰十二指肠切除术后并发症的有效性和安全性。方法本研究根据PRISMA指南完成。计算机检索中国知网、万方、维普、中国生物医学文献数据库、Cochrane Library、PubMed、Embase和Web of Science等中英文数据库，从数据库建立至2022年11月有关大网膜包裹胰肠吻合口预防胰十二指肠切除术后并发症的临床研究，采用Stata 16和Review Manager 5.4进行Meta分析。结果纳入15项研究，共1 830例患者。Meta分析结果显示：网膜包裹组术后胰瘘总体发生率较非网膜包裹组更低（OR=0.30，95%CI：0.22～0.41，P<0.001），亚组分析提示网膜包裹组B/C级术后胰瘘发生率较非网膜包裹组更低（OR=0.29，95%CI：0.21～0.39，P<0.001）。网膜包裹组相较于非网膜包裹组，术后胆漏（OR=0.30，95%CI：0.16～0.56，P<0.001）、术后出血（OR=0.35，95%CI：0.24～0.53，P<0.001）、胃排空障碍（OR=0.45，95%CI：0.31～0.64，P<0.001）、腹腔感染（OR=0.55，95%CI：0.40～0.75，P<0.001）、再次手术（OR=0.31，95%CI：0.18～0.54，P<0.001）、术后30天死亡（OR=0.42，95%CI：0.22～0.80，P=0.009）的发生率更低，开放饮食时间更早（MD=-0.98，95%CI：-1.84～-0.11，P=0.03）、术后住院时间更短（MD=-2.44，95%CI：-4.10～-0.77，P=0.004），两组手术方式在手术时间（MD=-13.68，95%CI：-28.31～0.95，P=0.07）及术中出血量（MD=-17.26，95%CI：-57.55～23.03，P=0.40）方面差异无统计学意义。结论网膜包裹可降低术后胰瘘、胆漏、出血、腹腔感染、胃排空障碍等术后并发症的发生率，改善患者预后，缩短住院时间，且不增加手术难度及手术时间。
- 胰十二指肠切除术 /
- 网膜 /
- 外科吻合口 /
- 手术后并发症 /
- Meta分析
Abstract: Objective To systematically evaluate the efficacy and safety of omental wrapping technique for pancreaticojejunal anastomosis in preventing complications after pancreaticoduodenectomy. Methods This study was conducted according to the PRISMA guideline. English and Chinese databases including CNKI， Wanfang Data， VIP， CBM， the Cochrane Library， PubMed， Embase， and Web of Science were searched for clinical studies on omental wrapping technique for pancreaticojejunal anastomosis in preventing complications after pancreaticoduodenectomy published up to November 2022， and Stata 16 and Review Manager 5.4 were used to perform the meta-analysis. Results A total of 15 studies with 1 830 patients were included in this study. The meta-analysis showed that the omental wrapping group had a significantly lower overall incidence rate of postoperative pancreatic fistula （POPF） than the non-omental wrapping group （odds ratio ［OR］=0.30， 95% confidence interval ［CI］： 0.22‍ ‍—‍ ‍0.41， P<0.001）， and the subgroup analysis showed that the omental wrapping group had a significantly lower incidence rate of grade B/C POPF than the non-omental wrapping group （OR=0.29， 95%CI： 0.21‍ ‍—‍ ‍0.39， P<0.001）. Compared with the non-omental wrapping group， the omental wrapping group had significantly lower incidence rates of postoperative bile leakage （OR=0.30， 95%CI： 0.16‍ ‍—‍ ‍0.56， P<0.001）， postoperative hemorrhage （OR=0.35， 95%CI： 0.24‍ ‍—‍ ‍0.53， P<0.001）， delayed gastric emptying （OR=0.45， 95%CI： 0.31‍ ‍—‍ ‍0.64， P<0.001）， abdominal infection （OR=0.55， 95%CI： 0.40‍ ‍—‍ ‍0.75， P<0.001）， reoperation （OR=0.31， 95%CI： 0.18‍ ‍—‍ ‍0.54， P<0.001）， and death within 30 days after surgery （OR=0.42， 95%CI： 0.22‍ ‍—‍ ‍0.80， P=0.009）， a significantly earlier time to diet （mean difference ［MD］=-0.98， 95%CI： -1.84 to -0.11， P=0.03）， and a significantly shorter length of postoperative hospital stay （MD=-2.44， 95%CI： -4.10 to -0.77， P=0.004）. There were no significant differences between the two groups in the time of operation （MD=-13.68， 95%CI： -28.31 to -0.95， P=0.07） and intraoperative blood loss （MD=-17.26， 95%CI： -57.55 to -23.03， P=0.40）. Conclusion Omental wrapping can reduce the incidence rates of postoperative complications such as pancreatic fistula， bile leakage， postoperative hemorrhage， abdominal infection， and delayed gastric emptying， improve the prognosis of patients， and shorten the length of hospital stay， without increasing surgical difficulty or time of operation.
- Pancreaticoduodenectomy /
- Omentum /
- Surgical Stomas /
- Postoperative Complications /
- Meta-Analysis

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图 1 筛选流程图

Figure 1. Screening flow chart

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图 2 POPF发生率的Meta分析结果

Figure 2. Meta-analysis result of postoperative pancreatic fistula

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图 3 术后胆漏的Meta分析结果

Figure 3. Meta-analysis result of postoperative biliary leakage

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图 4 术后PPH的Meta分析结果

Figure 4. Meta-analysis result of postpancreatectomy hemorrhages

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图 5 术后DGE的Meta分析结果

Figure 5. Meta-analysis result of postoperative gastric emptying disorder

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图 6 术后腹腔感染的Meta分析结果

Figure 6. Meta-analysis result of postoperative abdominal infection

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图 7 再次手术的Meta分析结果

Figure 7. Meta-analysis result of reoperation

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图 8 术后30天病死率的Meta分析结果

Figure 8. Meta-analysis result of 30-day postoperative mortality

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图 9 术后住院时间的Meta分析结果

Figure 9. Meta-analysis result of postoperative hospital stay

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图 10 术后开放饮食时间的Meta分析结果

Figure 10. Meta-analysis result of postoperative open diet time

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图 11 手术时间的Meta分析结果

Figure 11. Meta-analysis result of operation time

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图 12 术中出血量的Meta分析结果

Figure 12. Meta-analysis result of intraoperative blood loss

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图 13 敏感性分析结果

注： a，术后住院时间；b，开放饮食时间；c，手术时间；d，术中出血量。

Figure 13. Sensitivity analysis results

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图 14 漏斗图

注： a， POPF；b，术后PPH；c，术后腹腔感染；d，术后DGE；e，再次手术；f，术后30天死亡；g，术后住院时间；h，手术时间。

Figure 14. Funnel plot

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表 1 纳入研究的基线资料

Table 1. Baseline data included in the study

作者	发表时间	研究类型	国家	研究周期	组别	年龄（岁）	男/女（例）	例数	BMI （kg/m²）	结局指标
Shah^［11］	2015	RCS	印度	2006—2012	T C	61.5 60.2	59/42 27/19	101 46	21.5 20.6	①②③④⑤⑥⑦⑧⑩⑪
Tangtawee^［12］	2021	RCT	泰国	2017—2019	T C	62.0 58.2	17/17 16/18	34 34	22.7 23.2	①③④⑤⑦⑧⑩⑪
Choi^［13］	2012	RCS	韩国	2009—2011	T C	63.9 63.9	19/10 25/14	29 39	23.6 23.6	①③
Deng^［14］	2022	RCS	中国	2015—2020	T C	60.6 57.6	49/37 60/29	86 89	23.0 23.1	①②③④⑤⑥⑧⑨⑩
Kapoor^［15］	2006	RCS	印度	2002—2006	T C	NA NA	NA/NA NA/NA	25 52	NA NA	①③⑦
Zhong^［16］	2018	RCS	中国	2005—2016	T C	59.8 57.8	31/34 31/30	65 61	22.6 22.1	①②③④⑤⑥⑦⑧⑩⑪
Li^［17］	2022	RCS	中国	2015—2019	T C	64.2 62.1	46/23 44/25	69 69	21.9 22.0	①②③④⑤⑥⑦⑨⑩
刘蕾^［18］	2022	RCS	中国	2017—2020	T C	64.3 59.1	17/18 20/23	35 43	NA NA	①③④⑤⑥⑦⑧
孙韶龙^［19］	2016	RCT	中国	2013—2015	T C	65 63	13/5 11/7	35 35	NA NA	①
孟思嘉^［20］	2022	RCS	中国	2015—2021	T C	61.0 61.3	102/69 71/56	171 127	NA NA	①②③④⑤⑥⑦⑧⑩⑪
杜刚^［21］	2018	RCS	中国	2012—2017	T C	53.3 52.8	33/30 34/29	63 63	NA NA	①③④⑤⑥⑩⑪
王宏伟^［22］	2022	RCS	中国	2018—2021	T C	64.6 62.8	22/16 11/8	38 19	21.8 20.8	①③④⑤⑥⑦⑧⑨⑩
许洁如^［23］	2016	RCS	中国	2009—2015	T C	56.3 56.8	38/26 41/43	64 64	NA NA	①③④⑤⑥⑦⑩⑪
邓尧^［24］	2020	RCS	中国	2015—2018	T C	64.8 62.1	79/48 44/25	127 69	21.9 22.0	①②③④⑤⑥⑦⑧⑨
邝乃乐^［25］	2022	RCS	中国	2018—2020	T C	59.6 62.6	22/16 19/21	38 40	NA NA	①②③④⑥⑧⑩⑪
注：T，网膜包裹组；C，非网膜包裹组。结局指标：①POPF；②胆漏；③PPH；④DGE；⑤腹腔感染；⑥再手术；⑦术后30天内病死率；⑧术后住院时间；⑨开放饮食时间；⑩手术时间；⑪术中出血量；NA，未提供。

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表 2 纳入RCS的质量评价

Table 2. Quality evaluation of the included RCS

作者	人群选择（分）	组间可比性（分）	暴露因素（分）	合计（分）
Shah^［11］	3	2	2	7
Choi^［13］	3	1	2	6
Deng^［14］	3	2	2	7
Kapoor^［15］	3	1	2	6
Zhong^［16］	3	2	2	7
Li^［17］	3	2	2	7
刘蕾^［18］	3	2	2	7
孟思嘉^［20］	3	2	2	7
杜刚^［21］	3	2	2	7
王宏伟^［22］	3	2	3	8
许洁如^［23］	3	2	3	8
邓尧^［24］	3	2	2	7
邝乃乐^［25］	3	2	2	7

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表 3 纳入RCT的质量评价

Table 3. Quality evaluation of the included RCT

作者	随机（分）	隐藏（分）	盲法（分）	退出（分）	合计（分）
孙韶龙^［19］	2	1	0	1	4
Tangtawee^［12］	2	2	1	1	6

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表 4 发表偏倚结果

Table 4. Publication bias results

结局指标	例数	Begg’s检验		Egger’s检验
结局指标	例数	Z值	Pr>\|Z\|	t值	P值
POPF	15	1.88	0.060	-2.58	0.023
PPH	14	1.53	0.125	-1.97	0.072
术后腹腔感染	11	2.80	0.005	-5.04	0.001
术后DGE	12	0.34	0.732	-0.27	0.796
再次手术	10	0.36	0.721	-3.10	0.015
术后30天病死率	11	1.67	0.283	-1.65	0.137
术后住院时间	10	0.89	0.371	-0.44	0.671
手术时间	10	0.36	0.721	0.62	0.551

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