快速康复外科理念在前列腺癌根治术围手术期中应用的meta分析
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摘要
目的:评价快速康复外科(ERAS)方案相比传统围手术期方案应用于前列腺癌根治术(RP)围手术期的有效性及安全性。方法:计算机检索PubMed、TheCochraneLibrary、EMBASE、中国知网、万方、维普数据库,查找快速康复外科(enhancedrecoveryaftersurgery,ERAS)应用于前列腺癌根治术围手术期的随机对照试验(randomizedcontrolled trial,RCT),检索时限为建库至2018年10月30日;依照文献纳入及排除标准,由2名研究者独立进行文献筛选、质量评价、提取资料,采用Revman 5.3软件进行meta分析。结果:共纳入6篇文献,含665例患者,ERAS组308例,对照组357例。Meta分析显示:与对照组比较,ERAS组术后住院时间明显缩短(WMD=-1.59,95%CI:-2.70～-0.49)、术后整体并发症发生率显著降低(RR=0.55,95%CI:0.38～0.80);按不同手术方式进行亚组分析,开放组(RRP)、腹腔镜组(LP)行ERAS术后住院时间明显缩短(WMD=-1.00,95%CI:-1.37～-0.63),(WMD=-2.80,95%CI:-3.35～-2.24),而机器人组(RALP)无统计学差异(WMD=0.24,95%CI:-2.21～2.69)。腹腔镜组行ERAS术后并发症总发生率显著缩短(RR=0.40,95%CI:0.27～0.61),而开放组及机器人组无统计学差异(RR=1.16,95%CI:0.23～5.87),(RR=0.99,95%CI:0.52～1.90)。腹腔镜组行ERAS术后出血发生率显著降低(RR=0.24,95%CI:0.08～0.66),而机器人组无统计学差异(RR=0.33,95%CI:0.02～6.71)。腹腔镜组及机器人组行ERAS术后首次排便时间均显著降低(WMD=-0.33,95%CI:-0.63～-0.02)、(WMD=-0.40,95%CI:-0.62～-0.18),开放组未报道术后出血率及首次排便时间。结论:ERAS应用于前列腺癌根治术中安全有效,尤其在腹腔镜下前列腺癌根治术中,其能明显缩短术后住院时间并降低并发症发生。
Objective: To perform a systematic review and meta-analysis to evaluate efficacy and safety of enhanced recovery after surgery(ERAS) after radical prostatectomy.Methods:We performed a systematic electronic literature search of PubMed,The Cochrane Library, EMBASE, CNKI, WANFANG database, VIP and Chinese biomedical literature database. All randomized controlled trials(RCTs) exploring the effectiveness of ERAS on improving perioperative outcomes including length of hospital stay, rates of overall complication, the time of first defecation and readmission after mainstream surgery methods of radical prostatectomy were collected. Literaturescreening, data extraction and quality assessment were independently performed by two reviewers according to the defined eligibility criteria. Metaanalysis was performed using RevMan 5.3 software.Result:A total of six studies, including 665 patients, met the eligibility criteria, in which 308 and 357 patients were divided into the ERAS and standard care group, respectively. According to the different surgery methods, meta-analysis indicated a significantly shorter length of hospital stay in RRP(radical retropubic prostatectomy)(WMD=-1.00,95%CI:-1.37～-0.63) and LP(laparoscopic radical prostatectomy)(WMD=-2.80,95%CI:-3.35～-2.24), but RALP(Robot-Assisted Laparoscopic Radical Prostatectomy)(WMD=0.24,95%CI:-2.21～2.69). According to the different surgery methods, A significantly lower rate of overall complications in LP(RR=0.40,95%CI:0.27～0.61) was demonstrated, but no significant difference in RALP(RR=0.99,95%CI:0.52～1.90) and RRP(RR=1.16,95%CI:0.23～5.87)was observed. Meta-analysis showed a significantly lower rate of postoperative bleeding in LP(RR=0.24,95%CI:0.08～0.66), but no significant difference in RALP(RR=0.33,95%CI:0.02～6.71)was observed, and shorter time of first defection in both LP(WMD=-0.33,95%CI:-0.63～-0.02) and RALP(WMD=-0.40,95%CI:-0.62～-0.18). However, there were no significant difference between two groups in rates of bowel obstruction(RR=1.46,95%CI:0.43～4.89).Conclusions: ERAS protocols are safe and effective for males after laparoscopic radical prostatectomy. It can significantly reduce the length of hospital stay and decrease rate of complications in laparoscopic radical prostatectomy.
Objective: To perform a systematic review and meta-analysis to evaluate efficacy and safety of enhanced recovery after surgery(ERAS) after radical prostatectomy.Methods:We performed a systematic electronic literature search of PubMed,The Cochrane Library, EMBASE, CNKI, WANFANG database, VIP and Chinese biomedical literature database. All randomized controlled trials(RCTs) exploring the effectiveness of ERAS on improving perioperative outcomes including length of hospital stay, rates of overall complication, the time of first defecation and readmission after mainstream surgery methods of radical prostatectomy were collected. Literaturescreening, data extraction and quality assessment were independently performed by two reviewers according to the defined eligibility criteria. Metaanalysis was performed using RevMan 5.3 software.Result:A total of six studies, including 665 patients, met the eligibility criteria, in which 308 and 357 patients were divided into the ERAS and standard care group, respectively. According to the different surgery methods, meta-analysis indicated a significantly shorter length of hospital stay in RRP(radical retropubic prostatectomy)(WMD=-1.00,95%CI:-1.37～-0.63) and LP(laparoscopic radical prostatectomy)(WMD=-2.80,95%CI:-3.35～-2.24), but RALP(Robot-Assisted Laparoscopic Radical Prostatectomy)(WMD=0.24,95%CI:-2.21～2.69). According to the different surgery methods, A significantly lower rate of overall complications in LP(RR=0.40,95%CI:0.27～0.61) was demonstrated, but no significant difference in RALP(RR=0.99,95%CI:0.52～1.90) and RRP(RR=1.16,95%CI:0.23～5.87)was observed. Meta-analysis showed a significantly lower rate of postoperative bleeding in LP(RR=0.24,95%CI:0.08～0.66), but no significant difference in RALP(RR=0.33,95%CI:0.02～6.71)was observed, and shorter time of first defection in both LP(WMD=-0.33,95%CI:-0.63～-0.02) and RALP(WMD=-0.40,95%CI:-0.62～-0.18). However, there were no significant difference between two groups in rates of bowel obstruction(RR=1.46,95%CI:0.43～4.89).Conclusions: ERAS protocols are safe and effective for males after laparoscopic radical prostatectomy. It can significantly reduce the length of hospital stay and decrease rate of complications in laparoscopic radical prostatectomy.
引文
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[14]方长琴.快速康复护理在腹腔镜下前列腺癌根治术围手术其中的应用[J].健康护理,2016,25:169.
[15]杨如美,徐寅,顾美珍,等.快速康复外科理念在经腹腔镜下行前列腺癌根治术患者围手术期护理中的应用效果[J].解放军护理杂志,2016,33(22):46-48.
[16]Stela Pudar Hozo,Benjamin Djulbegovic,Iztok Hozo.Estimating the mean and variance from the median,range,and the size of a sample[J].BMCMedical Research Methodology,2005,5(13):1-10.
[17]周远秀,李雪梅,王永权.快速康复外科理念在高危前列腺增生患者术后护理中的应用[J].第三军医大学学报,2013,15:1647-1649.
[18]Tyson MD,Chang SS.Enhanced Recovery Pathways Versus Standard Care After Cystectomy:A Metaanalysis of the Effect on Perioperative Outcomes[J].Eur Uro,2016,70(6):995-1003.
[19]Feng F,Ji G,Li JP,et al.Fast-track surgery could improve postoperative recovery in radical total gastrectomy patients[J].World J Gastroenterol,2013,19(23):3642-3648.
[20]Liu XX,Jiang ZW,Wang ZM,et al.Multimodal optimization of surgical care shows beneficial outcome in gastrectomy surgery[J].JPEN J Parenter Enteral Nutr,2010,34(3):313-321.
[21]江志伟,李宁,黎介寿.快速康复外科的概念及临床意义[J].中国实用外科杂志,2007,27(2):131-133.
[2]江志伟,黎介寿.规范化开展加速康复外科几个关键问题[J].中国实用外科学杂志,2016,36(1):44-46.
[3]Hemmerling TM,Le N,Olivier JF,et al.Immediate extubation after aortic valve surgery using high thoracic epidural analgesia or opioidbased analgesia[J].J Cardiothorac Vasc Anesth,2005,19(2):176-181.
[4]Kehlet H,Wilmore DW.Evidence-based surgical care and the evolution of fast-track surgery[J].Ann Surg,2008,248(2):189-198.
[5]Bianco FJ Jr,Riedel ER,Begg CB,et al.Variations among high volume surgeons in the rate of complications after radical prostatectomy:further evidence that technique matters[J].J Urol,2005,173(6):2099-2103.
[6]Shea RA,Brooks JA,DayhoV NE,et al.Pain intensity and postoperative pulmonary complications among the elderly after abdominal surgery[J].Heart Lung,2002,31(6):440-444.
[7]Gralla 0,Haas F,Knoll N,et al.Fast-track surgery in laparoscopic radical prostatectomy:Basic principles[J].World J Urol,2007,25(2):185-191.
[8]Pierorazio PM,Mullins JK,Ross AE,et al.Trends in immediate perioperative morbidity and delay in discharge after open and minimally invasive radical prostatectomy(RP):a 20-year institutional experience[J].BJU Int,2013,112(1):45-53.
[9]Wilmore DW,Kehlet H.Management of patients in fast track surgery[J].BMJ,2001,322(7284):473-476.
[10]Higgins JPT,Green S.(2011)Cochrane Handbook for Systematic Reviews of Interventions,version 5.1.0[updated March 2011].The Cochrane Colloboration.
[11]Hiba Abou-Haidar,MDf Samuel Abourbih,Samuel Abourbih,et al.Enhanced recovery pathway for radical prostatectomy:Implementation and evaluation in a universal healthcare system.[J].Can Urol Assoc J,2014,11-12(8):418-423.
[12]Motohiko Sugi,Tadashi Matsuda,Takashi Yoshida,et al.Introduction of an Enhanced Recovery after Surgery Protocol for Robot-Assisted Laparoscopic Radical Prostatectomy[J].Urol Int,2017,99(2):194-200.
[13]任建,王翔,耿凛,等.快速康复外科在腹腔镜性前列腺癌根治术中的应用[J].北京医学,2014,36(4):289-291.
[14]方长琴.快速康复护理在腹腔镜下前列腺癌根治术围手术其中的应用[J].健康护理,2016,25:169.
[15]杨如美,徐寅,顾美珍,等.快速康复外科理念在经腹腔镜下行前列腺癌根治术患者围手术期护理中的应用效果[J].解放军护理杂志,2016,33(22):46-48.
[16]Stela Pudar Hozo,Benjamin Djulbegovic,Iztok Hozo.Estimating the mean and variance from the median,range,and the size of a sample[J].BMCMedical Research Methodology,2005,5(13):1-10.
[17]周远秀,李雪梅,王永权.快速康复外科理念在高危前列腺增生患者术后护理中的应用[J].第三军医大学学报,2013,15:1647-1649.
[18]Tyson MD,Chang SS.Enhanced Recovery Pathways Versus Standard Care After Cystectomy:A Metaanalysis of the Effect on Perioperative Outcomes[J].Eur Uro,2016,70(6):995-1003.
[19]Feng F,Ji G,Li JP,et al.Fast-track surgery could improve postoperative recovery in radical total gastrectomy patients[J].World J Gastroenterol,2013,19(23):3642-3648.
[20]Liu XX,Jiang ZW,Wang ZM,et al.Multimodal optimization of surgical care shows beneficial outcome in gastrectomy surgery[J].JPEN J Parenter Enteral Nutr,2010,34(3):313-321.
[21]江志伟,李宁,黎介寿.快速康复外科的概念及临床意义[J].中国实用外科杂志,2007,27(2):131-133.