加速康复外科与传统康复方案在肝切除术中应用比较的Meta分析
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摘要
目的评价加速康复外科(ERAS)与传统康复方案在肝切除术中的应用效果。方法文献检索到2016年8月,在Pub Med、EBSCO、MEDLINE及Cochrane数据库中检索ERAS与传统康复方案在肝脏外科中应用效果比较的文献,2名单独观察者根据纳入与排除标准进行质量评价与数据提取后,采用Rev Man5.3.5软件进行Meta分析。结果共纳入4篇文献,共524例患者,其中254例为ERAS组,270例为传统治疗组。ERAS组术后住院时间明显优于传统治疗组[加权均数差(WMD)=-2.72,95%可信区间(95%CI):-3.86~-1.57,P<0.000 01];ERAS组功能恢复时间明显早于传统治疗组(WMD=-2.67,95%CI:-3.68~-1.65,P<0.000 01);ERAS组总并发症发生率明显少于传统治疗组[比值比(OR)=0.45,95%CI:0.30~0.67,P<0.000 1],亚组分析1级并发症及2~5级并发症的发生率ERAS组也具有明显优势(OR=0.55,95%CI:0.31~0.98,P<0.05;OR=0.49,95%CI:0.32~0.76,P<0.05);2组再住院率比较无统计学意义(P>0.05);术后1 d及3 d C反应蛋白含量2组比较差异无统计学意义(P值均>0.05),而术后5 d ERAS组C反应蛋白含量明显小于传统治疗组(WMD=-21.68,95%CI:-29.30~-14.05,P<0.000 1);ERAS组术后第1次排气时间明显早于传统治疗组(WMD=-0.93,95%CI:-1.41~-0.46,P=0.000 1)。结论 ERAS在肝脏外科中的应用是安全、有效且可行的。
Objective To investigate the effect of enhanced recovery after surgery(ERAS) versus traditional rehabilitation program in patients undergoing hepatectomy.Methods Pub Med,EBSCO,MEDLINE,and Cochrane Library were searched for the articles on the effect of ERAS versus traditional rehabilitation program in liver surgery published up to August 2016.Two independent observers performed quality assessment and data extraction according to the inclusion and exclusion criteria,and Rev Man 5.3.5 was used for the Meta-analysis.Results A total of 4 articles with 524 patients(254 patients in ERAS group and 270 in traditional treatment group) were included.Compared with the traditional treatment group,the ERAS group had significantly shorter length of postoperative hospital stay(weighted mean difference[WMD]=-2.72,95% confidence interval[CI]:-3.86 to-1.57,P <0.000 01),shorter time to functional recovery(WMD =-2.67,95% CI:-3.68 to-1.65,P < 0.000 01),and lower overall incidence rate of complications(odds ratio [OR]= 0.45,95% CI: 0.30-0.67,P < 0.000 1).The subgroup analysis showed that the ERAS group also had significantly lower incidence rates of grade 1 and grade2-5 complications than the traditional treatment group(grade 1: OR = 0.55,95% CI: 0.31-0.98,P < 0.05; grade 2-5: OR = 0.49,95% CI: 0.32-0.76,P < 0.05).There was no significant difference in rehospitalization rate between the two groups(P > 0.05).As for the level of C-reactive protein,there was no significant difference between the two groups at 1 and 3 days after surgery(P > 0.05),but the ERAS group had a significantly lower level than the traditional treatment group at 5 days after surgery(WMD =-21.68,95% CI:-29.30 to-14.05,P < 0.000 1).The ERAS group also had a significantly shorter time to first flatus than the traditional treatment group(WMD =-0.93,95% CI:-1.41 to-0.46,P = 0.000 1).Conclusion ERAS is safe,effective,and feasible in liver surgery.
Objective To investigate the effect of enhanced recovery after surgery(ERAS) versus traditional rehabilitation program in patients undergoing hepatectomy.Methods Pub Med,EBSCO,MEDLINE,and Cochrane Library were searched for the articles on the effect of ERAS versus traditional rehabilitation program in liver surgery published up to August 2016.Two independent observers performed quality assessment and data extraction according to the inclusion and exclusion criteria,and Rev Man 5.3.5 was used for the Meta-analysis.Results A total of 4 articles with 524 patients(254 patients in ERAS group and 270 in traditional treatment group) were included.Compared with the traditional treatment group,the ERAS group had significantly shorter length of postoperative hospital stay(weighted mean difference[WMD]=-2.72,95% confidence interval[CI]:-3.86 to-1.57,P <0.000 01),shorter time to functional recovery(WMD =-2.67,95% CI:-3.68 to-1.65,P < 0.000 01),and lower overall incidence rate of complications(odds ratio [OR]= 0.45,95% CI: 0.30-0.67,P < 0.000 1).The subgroup analysis showed that the ERAS group also had significantly lower incidence rates of grade 1 and grade2-5 complications than the traditional treatment group(grade 1: OR = 0.55,95% CI: 0.31-0.98,P < 0.05; grade 2-5: OR = 0.49,95% CI: 0.32-0.76,P < 0.05).There was no significant difference in rehospitalization rate between the two groups(P > 0.05).As for the level of C-reactive protein,there was no significant difference between the two groups at 1 and 3 days after surgery(P > 0.05),but the ERAS group had a significantly lower level than the traditional treatment group at 5 days after surgery(WMD =-21.68,95% CI:-29.30 to-14.05,P < 0.000 1).The ERAS group also had a significantly shorter time to first flatus than the traditional treatment group(WMD =-0.93,95% CI:-1.41 to-0.46,P = 0.000 1).Conclusion ERAS is safe,effective,and feasible in liver surgery.
引文
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[12]SANTILLAN A,GOVAN L,ZAHURAK ML,et al.Feasibility and economic impact of a clinical pathway for pap test utilization in Gynecologic Oncology practice[J].Gynecol Oncol,2008,109(3):388-393.
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[14]XIONG JJ,SZATMARY P,HUANG W,et al.Enhanced recovery after surgery program in patients undergoing pancreaticoduodenectomy:a PRISMA-compliant systematic review and Meta-analysis[J].Medicine(Baltimore),2016,95(18):e3497.
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[18]HE F,LIN X,XIE F,et al.The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer[J].Clin Transl Oncol,2015,17(9):694-701.
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[21]MAESSEN J,DEJONG C,KESSELS A,et al.Length of stay:an inappropriate readout of the success of enhanced recovery programmes[J].World J Surg,2008,32(6):971-997.
[22]MILLER RJ,SUTHERLAND AG,HUTCHISON JD,et al.C-reactive protein and interleukin 6 receptor in post-traumatic stress disorder:a pilot study[J].Cytokine 2001,13(4):253-255.
[23]VANDREVALA T,SENIOR V,SPRING L,et al.‘Am I really ready to go home?’:a qualitative study of patients’experience of early discharge following an enhanced recovery programme for liver resection surgery[J].Support Care Cancer,2016,24(8):3447-3454.
[24]CORREIA MIT,CAMPOS ACL.Prevalence of hospital malnutrition in Latin America[J].Nutrition,2003,19(10):823-825.
[25]ALVES A,PANIS Y,MATHIEU P,et al.Postoperative mortality and morbidity in French patients undergoing colorectal surgery:results of a prospective multicenter study[J].Arch Surg,2005,140(3):278-283.
[26]PENG PD,van VLEDDER MG,TSAI S,et al.Sarcopenia negatively impacts short-term outcomes in patients undergoing hepatic resection for colorectal liver metastasis[J].HPB(Oxford),2011,13(7):439-446.
[27]MERLI M,NICOLINI G,ANGELONI S,et al.Malnutrition is a risk factor in cirrhotic patients undergoing surgery[J].Nutrition,2002,18(11-12):978-986.
[28]SLIM K,PANIS Y,ALVES A,et al.Predicting postoperative mortality in patients undergoing colorectal surgery[J].World J Surg,2006,30(1):100-106.
[29]ELIA M,van BOKHORST MA,GARVEY J,et al.Enteral(oral or tube administration)nutritional support and eicosapentaenoic acid in patients with cancer:a systematic review[J].Int J Oncol,2006,28(1):5-23.
[30]GRANTCHAROV TP,ROSENBERG J.Vertical compared with transverse incisions in abdominal surgery[J].Eur J Surg,2001,167(4):260-267.
[31]BROWN SR,GOODFELLOW PB.Transverse verses midline incisions for abdominal surgery[J].Cochrane Database Syst Rev,2005,19(4):CD005199.
[32]ISHIDA H,SOBAJMA J,YOKOYAMA M,et al.Comparison between transverse mini-incision and longitudinal mini-incision for the resection of locally advanced colonic cancer[J].Int Surg,2014,99(3):216-222.
[33]BROWN SR,GOODFELLOW PB.Transverse verses midline incisions for abdominal surgery[J].Cochrance Database Syst Rev,2005,4:CD005199.
[34]DIENER MK,VOSS S,JENSEN K,et al.Elective midline laparotomy closure:the INLINE systematic review and metaanalysis[J].Ann Surg,2010,251(5):843-856.
[35]MUYSOMA FE,ANTONIOU SA,BURY K,et al.European Hernia Society guidelines on the closure of abdominal wall incisions[J].Hernia,2015,19(1):1-24.
[36]MARTYAK SN,CURTIS LE.Abdominal incision and closure.A systems approach[J].Am J Surg,1976,131(4):476-480.
[37]ZHANG J,ZHANG HK,ZHU HY,et al.Mass Continuous suture versus layered interrupted suture in transverse abdominal incision closure after liver resection[J].World J Surg,2016,40(9):2237-2244.
[38]MARSMAN HA,GRAAF W,HEGER M,et al.Hepatic regeneration and functional recovery following partial liver resection in an experimental model of hepatic steatosis treated with omega-3 fatty acids[J].Br J Surg,2013,100(5):674-683.
[39]GONG Y,LIU Z,LIAO Y,et al.Effectiveness ofω-3 polyunsaturated fatty acids based lipid emulsions for treatment of patients after hepatectomy:a prospective clinical trial[J].Nutrients,2016,8(6):357.
[2]ZHANG Y,REN JS,SHI JF,et al.International trends in primary liver cancer incidence from 1973 to 2007[J].BMC Cancer,2015,15(4):94.
[3]LAU WY.Management of hepatocellular carcinoma[J].J R Coll Surg Edinb,2002,47(1):389-399.
[4]PALAVECINO M,KISHI Y,CHUN Y,et al.Two-surgeon technique of parenchymal transection contributes to reduced transfusion rate in patients undergoing major hepatectomy:analysis of 1557 consecutive liver resections[J].Surgery,2010,147(1):40-48.
[5]VIRANI S,MICHAELSON J,HUTTER M,et al.Morbidity and mortality after liver resections:results of the patient safety in surgery study[J].J Am Coll Surg,2007,204(6):1248-1292.
[6]BARDRAM L,FUNCH-JENSEN P,JENSEN P,et al.Recovery after laparoscopic colonic surgery with epidural analgesia,and early oral nutrition and mobilization[J].Lancet,1995,345(3):763-764.
[7]CHENG Y,JIA WD,XU GL,et al.Application of the concept of enhanced recovery after surgery in the perioperative period of hepatectomy for hepatocellular carcinoma[J/CD].Chin J Hepatic Surg:Electronic Edition,2017,6(3):187-191.程亚,荚卫东,许戈良,等.加速康复外科理念在肝细胞癌肝切除围手术期中的应用[J/CD].中华肝脏外科手术学电子杂志,2017,6(3):187-191.
[8]VARADHAN KK,NEAL KR,DEJONG CH,et al.The enhanced recovery after surgery(ERAS)pathway for patients undergoing major elective open colorectal surgery:a meta-analysis of randomized controlled trials[J].Clin Nutr,2010,29(4):434-440.
[9]KIM JW,KIM WS,CHEONG JH,et al.Safety and efficacy of fast-track surgery in laparoscopic distal gastrectomy for gastric cancer:a randomized clinical trial[J].World J Surg,2012,36(12):2879-2887.
[10]MUEHLING B,SCHELZIG H,STEFFEN P,et al.A prospective randomized trial comparing traditional and fast-track patient care in elective open infrarenal aneurysm repair[J].World J Surg,2009,33(3):577-585.
[11]KIRSH EJ,WORWAG EM,SINNER M,et al.Using outcome data and patient satisfaction surveys to develop policies regarding minimum length of hospitalization after radical prostatectomy[J].Urology,2000,56(1):101-106.
[12]SANTILLAN A,GOVAN L,ZAHURAK ML,et al.Feasibility and economic impact of a clinical pathway for pap test utilization in Gynecologic Oncology practice[J].Gynecol Oncol,2008,109(3):388-393.
[13]JONES EL,WAINWRIGHT TW,FOSTER JD,et al.A systematic review of patient reported outcomes and patient experience in enhanced recovery after orthopaedic surgery[J].Ann R Coll Surg Engl,2014,96(2):89-94.
[14]XIONG JJ,SZATMARY P,HUANG W,et al.Enhanced recovery after surgery program in patients undergoing pancreaticoduodenectomy:a PRISMA-compliant systematic review and Meta-analysis[J].Medicine(Baltimore),2016,95(18):e3497.
[15]Chinese Research Hospital Association,Society for Hepatopancreatobiliary Surgery.Expert consensus for enhanced recovery after hepatobiliary&pancreatic surgery(2015 edition)[J].J Clin Hepatol,2016,32(6):1040-1045.(in Chinese)中国研究型医院学会肝胆胰外科专业委员会.肝胆胰外科术后加速康复专家共识(2015版)[J].临床肝胆病杂志,2016,32(6):1040-1045.
[16]HOZO SP,DJULBEGOVIC B,HOZO I.Estimating the mean and variance from the median,range,and the size of a sample[J].BMC Med Res Methodol,2005,5(4):13.
[17]LIANG X,YING H,WANG H,et al.Enhanced recovery program versus traditional care in laparoscopic hepatectomy[J].Medicine(Baltimore),2016,95(8):e2835.
[18]HE F,LIN X,XIE F,et al.The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer[J].Clin Transl Oncol,2015,17(9):694-701.
[19]JONES C,KELLIHER L,DICKINSON M,et al.Randomized clinical trial on enhanced recovery versus standard care following open liver resection[J].Br J Surg,2013,100(8):1015-1024.
[20]NI CY,YANG Y,CHANG YQ,et al.Fast track surgery improves postoperative recovery in patients undergoing partial hepatectomy for primary liver cancer:a prospective randomized controlled trial[J].Eur J Surg Oncol,2013,39(6):542-547.
[21]MAESSEN J,DEJONG C,KESSELS A,et al.Length of stay:an inappropriate readout of the success of enhanced recovery programmes[J].World J Surg,2008,32(6):971-997.
[22]MILLER RJ,SUTHERLAND AG,HUTCHISON JD,et al.C-reactive protein and interleukin 6 receptor in post-traumatic stress disorder:a pilot study[J].Cytokine 2001,13(4):253-255.
[23]VANDREVALA T,SENIOR V,SPRING L,et al.‘Am I really ready to go home?’:a qualitative study of patients’experience of early discharge following an enhanced recovery programme for liver resection surgery[J].Support Care Cancer,2016,24(8):3447-3454.
[24]CORREIA MIT,CAMPOS ACL.Prevalence of hospital malnutrition in Latin America[J].Nutrition,2003,19(10):823-825.
[25]ALVES A,PANIS Y,MATHIEU P,et al.Postoperative mortality and morbidity in French patients undergoing colorectal surgery:results of a prospective multicenter study[J].Arch Surg,2005,140(3):278-283.
[26]PENG PD,van VLEDDER MG,TSAI S,et al.Sarcopenia negatively impacts short-term outcomes in patients undergoing hepatic resection for colorectal liver metastasis[J].HPB(Oxford),2011,13(7):439-446.
[27]MERLI M,NICOLINI G,ANGELONI S,et al.Malnutrition is a risk factor in cirrhotic patients undergoing surgery[J].Nutrition,2002,18(11-12):978-986.
[28]SLIM K,PANIS Y,ALVES A,et al.Predicting postoperative mortality in patients undergoing colorectal surgery[J].World J Surg,2006,30(1):100-106.
[29]ELIA M,van BOKHORST MA,GARVEY J,et al.Enteral(oral or tube administration)nutritional support and eicosapentaenoic acid in patients with cancer:a systematic review[J].Int J Oncol,2006,28(1):5-23.
[30]GRANTCHAROV TP,ROSENBERG J.Vertical compared with transverse incisions in abdominal surgery[J].Eur J Surg,2001,167(4):260-267.
[31]BROWN SR,GOODFELLOW PB.Transverse verses midline incisions for abdominal surgery[J].Cochrane Database Syst Rev,2005,19(4):CD005199.
[32]ISHIDA H,SOBAJMA J,YOKOYAMA M,et al.Comparison between transverse mini-incision and longitudinal mini-incision for the resection of locally advanced colonic cancer[J].Int Surg,2014,99(3):216-222.
[33]BROWN SR,GOODFELLOW PB.Transverse verses midline incisions for abdominal surgery[J].Cochrance Database Syst Rev,2005,4:CD005199.
[34]DIENER MK,VOSS S,JENSEN K,et al.Elective midline laparotomy closure:the INLINE systematic review and metaanalysis[J].Ann Surg,2010,251(5):843-856.
[35]MUYSOMA FE,ANTONIOU SA,BURY K,et al.European Hernia Society guidelines on the closure of abdominal wall incisions[J].Hernia,2015,19(1):1-24.
[36]MARTYAK SN,CURTIS LE.Abdominal incision and closure.A systems approach[J].Am J Surg,1976,131(4):476-480.
[37]ZHANG J,ZHANG HK,ZHU HY,et al.Mass Continuous suture versus layered interrupted suture in transverse abdominal incision closure after liver resection[J].World J Surg,2016,40(9):2237-2244.
[38]MARSMAN HA,GRAAF W,HEGER M,et al.Hepatic regeneration and functional recovery following partial liver resection in an experimental model of hepatic steatosis treated with omega-3 fatty acids[J].Br J Surg,2013,100(5):674-683.
[39]GONG Y,LIU Z,LIAO Y,et al.Effectiveness ofω-3 polyunsaturated fatty acids based lipid emulsions for treatment of patients after hepatectomy:a prospective clinical trial[J].Nutrients,2016,8(6):357.