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目的探讨食管癌切除术中不同的胸导管处理方式预防术后乳糜胸的效果及对患者术后转归的影响。方法计算机检索Pub Med、The Cochrane Library(2016年4期)、CBM、CNKI、VIP及Wan Fang Data,搜集关于食管癌术中不同方式处理胸导管预防乳糜胸的随机对照试验(RCT)、队列研究及病例-对照研究,检索时限均为建库至2016年5月。由2名研究者独立进行文献筛、资料提取并评价纳入研究的质量,然后采用Rev Man 5.2软件进行Meta分析。结果共纳入23篇文献,包括4个RCT、4个队列研究和15个病例-对照研究。Meta分析结果显示:(1)食管癌术中胸导管结扎组的术后乳糜胸发生率明显低于未结扎组[RCT:OR=0.20,95%CI(0.09,0.47),P=0.000 2;队列/病例-对照:OR=0.20,95%CI(0.14,0.28),P<0.000 01]。(2)食管癌切除术中,结扎与不结扎胸导管在患者围手术期死亡率、其余并发症发生率及术后第2、3、5年生存率上无差别(P均>0.05);(3)结扎组并发乳糜胸的患者再手术率明显低于未结扎组[RCT:OR=0.13,95%CI(0.03,0.59),P=0.008;队列/病例-对照:OR=0.18,95%CI(0.11,0.32),P<0.000 01],其保守治疗治愈率高于未结扎组[OR=0.14,95%CI(0.04,0.54),P=0.004]。(4)胸导管集束结扎组术后乳糜胸发生率明显低于胸导管单根结扎组[OR=3.67,95%CI(1.43,9.43),P=0.007)]。结论食管癌切除术中预防性结扎胸导管可有效降低术后乳糜胸发生率,并有利于降低并发乳糜胸患者的再手术率,胸导管集束整块结扎预防乳糜胸效果优于单根胸导管游离结扎。
Objective To investigate the effects of different methods of thoracic ductal management in preventing postoperative chylothorax in esophageal cancer resection and the prognosis of patients after operation. Methods We searched PubMed, The Cochrane Library (2016 issue 4), CBM, CNKI, VIP and Wan Fang Data to collect randomized controlled trials (RCTs) on different ways of intrathoracic esophagectomy for the prevention of chylothorax. And case-control study, the search time limit was established until May 2016. Two researchers independently screened the literature, extracted the data and evaluated the quality of the included studies, then used Meta-analysis with Rev Man 5.2 software. Results A total of 23 articles were included, including 4 RCTs, 4 cohort studies and 15 case-control studies. Meta analysis showed that: (1) The incidence of postoperative chylothorax in esophagectomy group was significantly lower than that in non - ligation group [RCT: OR = 0.20,95% CI (0.09,0.47, P = 0.0002; Cohort / Case-Control: OR = 0.20, 95% CI (0.14, 0.28), P <0.000 01]. (2) During the resection of esophageal cancer, the perioperative mortality rate, the incidence of the other complication and the second, third and fifth year survival rates were the same in both groups (P> 0.05). (3) The rate of reoperation in patients with ligation of chylothorax was significantly lower than that of patients without ligation (RCT: OR = 0.13, 95% CI 0.03, 0.59, P = 0.008; % CI (0.11,0.32), P <0.000 01]. The cure rate of conservative treatment was higher than that of non-ligated group [OR = 0.14,95% CI (0.04,0.54), P = 0.004]. (4) The incidence of postoperative chylothorax in thoracic duct bundle group was significantly lower than that in single thoracic duct ligation group [OR = 3.67,95% CI (1.43,9.43), P = 0.007). Conclusions The prophylactic ligation of the thoracic duct during esophageal cancer resection can effectively reduce the incidence of postoperative chylothorax and reduce the reoperation rate of the patients with chylothorax. The thoracic duct ligation blockade is superior to the single thoracic duct Free ligation.