加速康复外科对消化道肿瘤患者长期生存率影响的Meta分析
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摘要
背景加速康复外科(enhanced recovery after surgery, ERAS)是指在围手术期通过多学科协作模式采取一系列基于循证医学证据的最优化措施,降低围手术期应激反应,加快患者术后各器官功能恢复. ERAS已在多个学科得到推广,并被证实可以提高患者近期预后,而针对患者远期预后的研究正在初步进行.目的评价围手术期应用ERAS对消化道肿瘤患者生存率的影响.方法应用计算机检索1995-01/2018-11万方、CNKI、维普、PubMed、Cochrane Library、EMBASE数据库有关消化道肿瘤患者围手术期应用ERAS的随机对照试验、病例对照研究,由两名研究者分别对符合纳入标准的研究进行质量评价和数据提取,采用Rev Man5.3.5软件进行Meta分析.结果共纳入10篇研究进行Meta分析,共计2477例患者,其中ERAS组751例,对照组(采取传统围手术期管理)1726例.与对照组相比, ERAS组术后3年生存率提高(OR=0.48, 95%CI:0.30-0.78, P<0.05),术后5年生存率提高(OR=0.51, 95%CI:0.40-0.65, P<0.05);两组术后1年生存率差异无统计学意义(OR=1.13, 95%CI:0.63-2.02, P>0.05),术后2年生存率差异无统计学意义(OR=1.19, 95%CI:0.38-3.73, P>0.05).结论消化道肿瘤手术围手术期实施ERAS可以改善预后,3年生存率, 5年生存率.
BACKGROUND Enhanced recovery after surgery(ERAS) programs refer to a series of optimization measures based on evidencebased medical evidence to reduce perioperative stress response and speed up the recovery of organ function after surgery through a multi-disciplinary collaboration model. ERAS has been popularized in many disciplines and proved to improve the short-term prognosis of patients, while the study of long-term prognosis of patients is limited.AIM To evaluate the impact of ERAS programs on the longterm survival among patients undergoing digestive tract tumor surgery.METHODS Computer searches were performed in databases including Wanfang, CNKI, VIP, PubMed, Cochrane Library, and EMBASE for randomized controlled trials or case-control studies describing ERAS programs in patients undergoing digestive tract tumor surgery published between January 1995 and November 2018. Two researchers independently evaluated the quality of studies that met the inclusion criteria and performed a meta-analysis using RevMan5.3.5 software.RESULTS A total of ten studies including 2477 patients were selected for the meta-analysis, including the ERAS group(n = 751) and the control group(n = 1726, undergoing traditional perioperative management). Compared with the control group, the ERAS group had improved 3-year survival(OR = 0.48, 95%CI: 0.30-0.78, P < 0.05) and 5-year survival(OR = 0.51, 95%CI: 0.40-0.65, P < 0.05). However, no significant difference was observed in 1-year survival(OR = 1.13, 95%CI: 0.63-2.02, P > 0.05) or 2-year survival(OR = 1.19, 95%CI: 0.38-3.73, P > 0.05) between the two groups.CONCLUSION Perioperative implementation of ERAS programs can improve outcomes and 3-and 5-year survival among patients undergoing digestive tract tumor surgery.
BACKGROUND Enhanced recovery after surgery(ERAS) programs refer to a series of optimization measures based on evidencebased medical evidence to reduce perioperative stress response and speed up the recovery of organ function after surgery through a multi-disciplinary collaboration model. ERAS has been popularized in many disciplines and proved to improve the short-term prognosis of patients, while the study of long-term prognosis of patients is limited.AIM To evaluate the impact of ERAS programs on the longterm survival among patients undergoing digestive tract tumor surgery.METHODS Computer searches were performed in databases including Wanfang, CNKI, VIP, PubMed, Cochrane Library, and EMBASE for randomized controlled trials or case-control studies describing ERAS programs in patients undergoing digestive tract tumor surgery published between January 1995 and November 2018. Two researchers independently evaluated the quality of studies that met the inclusion criteria and performed a meta-analysis using RevMan5.3.5 software.RESULTS A total of ten studies including 2477 patients were selected for the meta-analysis, including the ERAS group(n = 751) and the control group(n = 1726, undergoing traditional perioperative management). Compared with the control group, the ERAS group had improved 3-year survival(OR = 0.48, 95%CI: 0.30-0.78, P < 0.05) and 5-year survival(OR = 0.51, 95%CI: 0.40-0.65, P < 0.05). However, no significant difference was observed in 1-year survival(OR = 1.13, 95%CI: 0.63-2.02, P > 0.05) or 2-year survival(OR = 1.19, 95%CI: 0.38-3.73, P > 0.05) between the two groups.CONCLUSION Perioperative implementation of ERAS programs can improve outcomes and 3-and 5-year survival among patients undergoing digestive tract tumor surgery.
引文
1 Kehlet H.Multimodal approach to control postoperative pathophysiology and rehabilitation.Br J Anaesth 1997;78:606-617[PMID:9175983]
2黎介寿,江志伟.加速康复外科的临床意义不仅仅是缩短住院日.中华消化外科杂志2015;1:22-24[DOI:10.3760/cma.j.issn.1673-9752.2015.01.005]
3 Snyder GL,Greenberg S.Effect of anaesthetic technique and other perioperative factors on cancer recurrence.Br J Anaesth2010;105:106-115[PMID:20627881 DOI:10.1093/bja/aeq164]
4叶松.ERAS对青中年胃癌手术治疗近远期疗效的影响分析.实用癌症杂志2017;9:1511-1514[DOI:10.3969/j.issn.1001-5930.2017.09.034]
5张威庆,张花花.腹腔镜辅助下D2根治术联合快速康复理念对进展期胃癌患者近期预后的影响.中国内镜杂志2018;24:67-72[DOI:10.3969/j.issn.1007-1989.2018.08.011]
6 Oakley B,Lamb C,Vohra R,Catton J.Achieving long term survival in oesophagectomy patients aged over 75.Ann Med Surg(Lond)2016;9:15-21[PMID:27358728 DOI:10.1016/j.amsu.2016.05.016]
7方法,于涛,王海江.腹腔镜局部进展期胃窦癌根治术后加速康复外科对血浆VEGF水平的影响及临床意义.腹腔镜外科杂志2016;1:19-23[DOI:10.13499/j.cnki.fqjwkzz.2016.01.019]
8 Gustafsson UO,Oppelstrup H,Thorell A,Nygren J,Ljungqvist O.Adherence to the ERAS protocol is Associated with 5-Year Survival After Colorectal Cancer Surgery:ARetrospective Cohort Study.World J Surg 2016;40:1741-1747[PMID:26913728 DOI:10.1007/s00268-016-3460-y]
9林威,龚瑾,方丁玲,包真.加速康复外科理念在完全腹腔镜右半结肠切除术中的应用研究.消化肿瘤杂志(电子版)2017;3:173-177[DOI:10.3969/j.issn.1674-7402.2017.03.005]
10 Asklid D,Segelman J,Gedda C,Hjern F,Pekkari K,Gustafsson UO.The impact of perioperative fluid therapy on short-term outcomes and 5-year survival among patients undergoing colorectal cancer surgery-A prospective cohort study within an ERAS protocol.Eur J Surg Oncol 2017;43:1433-1439[PMID:28528188 DOI:10.1016/j.ejso.2017.04.003]
11许国定,孙兴,刘锦新,黄海,冯关荣.快速康复治疗在胃肠道恶性肿瘤中的应用.微创医学2017;1:57-60[DOI:10.11864/j.issn.1673.2017.01.17]
12陈诚,唐成武.加速康复外科对Ⅱ~Ⅲ期结直肠癌患者术后长期生存的影响.中国现代医生2018;56:42-45
13刘刚,蔡安庆,朱振飞,戚玉龙,花京文.加速康复理念在胃癌根治术中的应用效果及对生存期的影响研究.中华肿瘤防治杂志2018;25:101-102[DOI:10.16073/j.cnki.cjcpt.20181102.020]
14江志伟,黎介寿.快速康复外科--优化的临床路径.中华胃肠外科杂志2012;15:12-13[DOI:10.3760/cma.j.issn.1671-0274.2012.01.005]
15 Zhu S,Qian W,Jiang C,Ye C,Chen X.Enhanced recovery after surgery for hip and knee arthroplasty:a systematic review and meta-analysis.Postgrad Med J 2017;93:736-742[PMID:28751437 DOI:10.1136/postgradmedj-2017-134991]
16 Li MZ,Wu WH,Li L,Zhou XF,Zhu HL,Li JF,He YL.Is ERAS effective and safe in laparoscopic gastrectomy for gastric carcinoma?A meta-analysis.World J Surg Oncol 2018;16:17[PMID:29373978 DOI:10.1186/s12957-018-1309-6]
17 Ji HB,Zhu WT,Wei Q,Wang XX,Wang HB,Chen QP.Impact of enhanced recovery after surgery programs on pancreatic surgery:A meta-analysis.World J Gastroenterol 2018;24:1666-1678[PMID:29686474 DOI:10.3748/wjg.v24.i15.1666]
18 de Groot JJ,Ament SM,Maessen JM,Dejong CH,Kleijnen JM,Slangen BF.Enhanced recovery pathways in abdominal gynecologic surgery:a systematic review and meta-analysis.Acta Obstet Gynecol Scand 2016;95:382-395[PMID:26613531DOI:10.1111/aogs.12831]
19严莲,宋美璇,李飞,李显蓉.加速康复外科对结直肠癌患者围术期炎症反应与免疫功能影响的Meta分析.中国普通外科杂志2018;4:474-487[DOI:10.3978/j.issn.1005-6947.2018.04.013]
20宫为一,鲍峰,吴宗阳,夏禹,许瑞.ERAS理念对食管癌围术期患者血清免疫、肿瘤指标的变化及其生理功能恢复的影响分析.东南大学学报(医学版)2018;1:142-145[DOI:10.3969/j.issn.1671-6264.2018.01.031]
21 Martínez AB,Longás J,Ramírez JM.A model for lymphocyte activation in open versus laparoscopic surgery in colorectal cancer patients in enhanced recovery after surgery(ERAS)protocols.Int J Colorectal Dis 2017;32:913-916[PMID:27900463 DOI:10.1007/s00384-016-2731-2]
22陈强谱,冀海斌,魏强.加速康复外科理念下围手术期营养管理.中华普通外科学文献(电子版)2018;12:289-291[DOI:10.3877/cma.j.issn.1674-0793.2018.05.001]
23 Hur H,Si Y,Kang WK,Kim W,Jeon HM.Effects of early oral feeding on surgical outcomes and recovery after curative surgery for gastric cancer:pilot study results.World J Surg 2009;33:1454-1458[PMID:19399550 DOI:10.1007/s00268-009-0009-3]
24 Marano L,Porfidia R,Pezzella M,Grassia M,Petrillo M,Esposito G,Braccio B,Gallo P,Boccardi V,Cosenza A,Izzo G,Di Martino N.Clinical and immunological impact of early postoperative enteral immunonutrition after total gastrectomy in gastric cancer patients:a prospective randomized study.Ann Surg Oncol 2013;20:3912-3918[PMID:23838912 DOI:10.1245/s10434-013-3088-1]
25 Valdés-Ramos R,Benítez-Arciniega AD.Nutrition and immunity in cancer.Br J Nutr 2007;98 Suppl 1:S127-S132[PMID:17922950 DOI:10.1017/S0007114507833009]
26李成付,夏瑞,朱斌.术前饮水与加速康复外科实践.中国现代普通外科进展2017;11:876-880[DOI:10.3969/j.issn.1009-9905.2017.11.011]
27陈光,陈亚红,赵文军,张锐利,邱振明.早期肠内营养支持对结肠癌患者术后免疫功能的影响.现代实用医学2013;2:201-202[DOI:10.3969/j.issn.1671-0800.2013.02.048]
28 Berg J,Gebhardt MC,Rand WM.Effect of timing of postoperative chemotherapy on survival of dogs with osteosarcoma.Cancer 1997;79:1343-1350[PMID:9083156]
29 Biagi JJ,Raphael MJ,Mackillop WJ,Kong W,King WD,Booth CM.Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer:a systematic review and meta-analysis.JAMA 2011;305:2335-2342[PMID:21642686 DOI:10.1001/jama.2011.749]
30茅晔,莫晓东,徐健,姚豪杰,董旭,贺祥昆,吴国忠.加速康复外科理念下结直肠癌患者术后早期行XELOX方案辅助化疗的安全性评价.中国肿瘤外科杂志2018;3:160-163[DOI:10.3969/j.issn.1674-4136.2018.03.007]
2黎介寿,江志伟.加速康复外科的临床意义不仅仅是缩短住院日.中华消化外科杂志2015;1:22-24[DOI:10.3760/cma.j.issn.1673-9752.2015.01.005]
3 Snyder GL,Greenberg S.Effect of anaesthetic technique and other perioperative factors on cancer recurrence.Br J Anaesth2010;105:106-115[PMID:20627881 DOI:10.1093/bja/aeq164]
4叶松.ERAS对青中年胃癌手术治疗近远期疗效的影响分析.实用癌症杂志2017;9:1511-1514[DOI:10.3969/j.issn.1001-5930.2017.09.034]
5张威庆,张花花.腹腔镜辅助下D2根治术联合快速康复理念对进展期胃癌患者近期预后的影响.中国内镜杂志2018;24:67-72[DOI:10.3969/j.issn.1007-1989.2018.08.011]
6 Oakley B,Lamb C,Vohra R,Catton J.Achieving long term survival in oesophagectomy patients aged over 75.Ann Med Surg(Lond)2016;9:15-21[PMID:27358728 DOI:10.1016/j.amsu.2016.05.016]
7方法,于涛,王海江.腹腔镜局部进展期胃窦癌根治术后加速康复外科对血浆VEGF水平的影响及临床意义.腹腔镜外科杂志2016;1:19-23[DOI:10.13499/j.cnki.fqjwkzz.2016.01.019]
8 Gustafsson UO,Oppelstrup H,Thorell A,Nygren J,Ljungqvist O.Adherence to the ERAS protocol is Associated with 5-Year Survival After Colorectal Cancer Surgery:ARetrospective Cohort Study.World J Surg 2016;40:1741-1747[PMID:26913728 DOI:10.1007/s00268-016-3460-y]
9林威,龚瑾,方丁玲,包真.加速康复外科理念在完全腹腔镜右半结肠切除术中的应用研究.消化肿瘤杂志(电子版)2017;3:173-177[DOI:10.3969/j.issn.1674-7402.2017.03.005]
10 Asklid D,Segelman J,Gedda C,Hjern F,Pekkari K,Gustafsson UO.The impact of perioperative fluid therapy on short-term outcomes and 5-year survival among patients undergoing colorectal cancer surgery-A prospective cohort study within an ERAS protocol.Eur J Surg Oncol 2017;43:1433-1439[PMID:28528188 DOI:10.1016/j.ejso.2017.04.003]
11许国定,孙兴,刘锦新,黄海,冯关荣.快速康复治疗在胃肠道恶性肿瘤中的应用.微创医学2017;1:57-60[DOI:10.11864/j.issn.1673.2017.01.17]
12陈诚,唐成武.加速康复外科对Ⅱ~Ⅲ期结直肠癌患者术后长期生存的影响.中国现代医生2018;56:42-45
13刘刚,蔡安庆,朱振飞,戚玉龙,花京文.加速康复理念在胃癌根治术中的应用效果及对生存期的影响研究.中华肿瘤防治杂志2018;25:101-102[DOI:10.16073/j.cnki.cjcpt.20181102.020]
14江志伟,黎介寿.快速康复外科--优化的临床路径.中华胃肠外科杂志2012;15:12-13[DOI:10.3760/cma.j.issn.1671-0274.2012.01.005]
15 Zhu S,Qian W,Jiang C,Ye C,Chen X.Enhanced recovery after surgery for hip and knee arthroplasty:a systematic review and meta-analysis.Postgrad Med J 2017;93:736-742[PMID:28751437 DOI:10.1136/postgradmedj-2017-134991]
16 Li MZ,Wu WH,Li L,Zhou XF,Zhu HL,Li JF,He YL.Is ERAS effective and safe in laparoscopic gastrectomy for gastric carcinoma?A meta-analysis.World J Surg Oncol 2018;16:17[PMID:29373978 DOI:10.1186/s12957-018-1309-6]
17 Ji HB,Zhu WT,Wei Q,Wang XX,Wang HB,Chen QP.Impact of enhanced recovery after surgery programs on pancreatic surgery:A meta-analysis.World J Gastroenterol 2018;24:1666-1678[PMID:29686474 DOI:10.3748/wjg.v24.i15.1666]
18 de Groot JJ,Ament SM,Maessen JM,Dejong CH,Kleijnen JM,Slangen BF.Enhanced recovery pathways in abdominal gynecologic surgery:a systematic review and meta-analysis.Acta Obstet Gynecol Scand 2016;95:382-395[PMID:26613531DOI:10.1111/aogs.12831]
19严莲,宋美璇,李飞,李显蓉.加速康复外科对结直肠癌患者围术期炎症反应与免疫功能影响的Meta分析.中国普通外科杂志2018;4:474-487[DOI:10.3978/j.issn.1005-6947.2018.04.013]
20宫为一,鲍峰,吴宗阳,夏禹,许瑞.ERAS理念对食管癌围术期患者血清免疫、肿瘤指标的变化及其生理功能恢复的影响分析.东南大学学报(医学版)2018;1:142-145[DOI:10.3969/j.issn.1671-6264.2018.01.031]
21 Martínez AB,Longás J,Ramírez JM.A model for lymphocyte activation in open versus laparoscopic surgery in colorectal cancer patients in enhanced recovery after surgery(ERAS)protocols.Int J Colorectal Dis 2017;32:913-916[PMID:27900463 DOI:10.1007/s00384-016-2731-2]
22陈强谱,冀海斌,魏强.加速康复外科理念下围手术期营养管理.中华普通外科学文献(电子版)2018;12:289-291[DOI:10.3877/cma.j.issn.1674-0793.2018.05.001]
23 Hur H,Si Y,Kang WK,Kim W,Jeon HM.Effects of early oral feeding on surgical outcomes and recovery after curative surgery for gastric cancer:pilot study results.World J Surg 2009;33:1454-1458[PMID:19399550 DOI:10.1007/s00268-009-0009-3]
24 Marano L,Porfidia R,Pezzella M,Grassia M,Petrillo M,Esposito G,Braccio B,Gallo P,Boccardi V,Cosenza A,Izzo G,Di Martino N.Clinical and immunological impact of early postoperative enteral immunonutrition after total gastrectomy in gastric cancer patients:a prospective randomized study.Ann Surg Oncol 2013;20:3912-3918[PMID:23838912 DOI:10.1245/s10434-013-3088-1]
25 Valdés-Ramos R,Benítez-Arciniega AD.Nutrition and immunity in cancer.Br J Nutr 2007;98 Suppl 1:S127-S132[PMID:17922950 DOI:10.1017/S0007114507833009]
26李成付,夏瑞,朱斌.术前饮水与加速康复外科实践.中国现代普通外科进展2017;11:876-880[DOI:10.3969/j.issn.1009-9905.2017.11.011]
27陈光,陈亚红,赵文军,张锐利,邱振明.早期肠内营养支持对结肠癌患者术后免疫功能的影响.现代实用医学2013;2:201-202[DOI:10.3969/j.issn.1671-0800.2013.02.048]
28 Berg J,Gebhardt MC,Rand WM.Effect of timing of postoperative chemotherapy on survival of dogs with osteosarcoma.Cancer 1997;79:1343-1350[PMID:9083156]
29 Biagi JJ,Raphael MJ,Mackillop WJ,Kong W,King WD,Booth CM.Association between time to initiation of adjuvant chemotherapy and survival in colorectal cancer:a systematic review and meta-analysis.JAMA 2011;305:2335-2342[PMID:21642686 DOI:10.1001/jama.2011.749]
30茅晔,莫晓东,徐健,姚豪杰,董旭,贺祥昆,吴国忠.加速康复外科理念下结直肠癌患者术后早期行XELOX方案辅助化疗的安全性评价.中国肿瘤外科杂志2018;3:160-163[DOI:10.3969/j.issn.1674-4136.2018.03.007]