加速康复外科在胰十二指肠切除术围术期疗效和安全性的Meta分析

邵星1; 顾进2; 邹永康2; 曹宇2; 涂奎2; 赵礼金2

doi:10.3760/cma.j.issn.1673-9752.2019.11.012

加速康复外科在胰十二指肠切除术围术期疗效和安全性的Meta分析

Efficacy and safety of enhanced recovery after surgery in perioperative management of pancreatoduo denectomy:a Meta analysis

摘要

摘要: 目的:系统评价加速康复外科(ERAS)在胰十二指肠切除术(PD)围术期的疗效和安全性。
方法:以Enhanced Recovery After Surgery、Fasttrack Surgery、fast track multidisciplinary treatment、Pancreatoduodenectomy、Laparoscopic pancreatoduodenectomy、Whipple Surgery、加速康复外科、快速康复外科、加速康复综合治疗模式、胰十二指肠切除术、腹腔镜胰十二指肠切除术、whipple手术为检索词，检索the Cochrane Library、PubMed、Embase、CNKI、VANFUN数据库、CBM、中文科技期刊数据库。检索时间为1979年6月至2019年6月。纳入PD围术期采用传统模式对比ERAS模式的随机对照试验(RCT)或前瞻性队列研究。ERAS组：PD围术期采用ERAS模式处理；传统组：PD围术期采用传统模式处理。由2名研究者独立筛选文献并提取数据，进行质量评价。计数资料采用相对危险度(RR)及其95%可信区间(95%CI)表示。计量资料采用均数差(MD)及其95%CI表示。采用I²对纳入文献进行异质性分析。纳入研究≥5篇，采用漏斗图检验潜在发表偏倚；纳入研究<5篇，则不检验。
结果:(1)文献检索结果：最终纳入符合标准的相关文献8篇。8篇文献均为RCT。8篇文献累积样本量为1 187例患者，其中ERAS组588例，传统组599例。(2)Meta分析结果：①术后出血发生率，两组患者术后出血发生率比较，差异无统计学意义(RR=0.79，95%CI为0.45～1.37，P>0.05)。8篇文献进行漏斗图分析，其结果显示：漏斗图左右基本对称，表明发表偏倚对Meta分析结果影响较小。②术后胰瘘发生率，两组患者术后胰瘘发生率比较，差异无统计学意义(RR=0.97，95%CI为0.67～1.39，P>0.05)。③术后腹腔感染发生率，两组患者术后腹腔感染发生率比较，差异无统计学意义(RR=0.76，95%CI为0.51～1.12，P>0.05)。5篇文献进行漏斗图分析，其结果显示：漏斗图左右基本对称，表明发表偏倚对Meta分析结果影响较小。④术后胃排空延迟发生率，两组患者术后胃排空延迟发生率比较，差异有统计学意义(RR=0.46，95%CI为0.31～0.67，P<0.05)。5篇文献进行漏斗图分析，其结果显示：漏斗图左右基本对称，表明发表偏倚对Meta分析结果影响较小。⑤术后首次肛门排气时间，两组患者术后首次肛门排气时间比较，差异有统计学意义(MD=-2.06，95%CI为-3.08～ -1.05，P<0.05)。5篇文献进行漏斗图分析，其结果显示：漏斗图左右基本对称，表明发表偏倚对Meta分析结果影响较小。⑥术后住院时间，两组患者术后住院时间比较，差异有统计学意义(MD=-5.12，95%CI为-6.09～ -4.14，P<0.05)。5篇文献进行漏斗图分析，其结果显示：漏斗图左右基本对称，表明发表偏倚对Meta分析结果影响较小。⑦术后总体并发症发生率，两组患者术后总体并发症发生率比较，差异有统计学意义(RR=0.63，95%CI为0.44～0.89，P<0.05)。6篇文献进行漏斗图分析，其结果显示：漏斗图左右基本对称，表明发表偏倚对Meta分析结果影响较小。⑧术后再入院率，两组患者术后再入院率比较，差异无统计学意义(RR=1.07，95%CI为0.62～1.84，P>0.05)。5篇文献进行漏斗图分析，其结果显示：漏斗图左右不对称，表明纳入文献有发表偏倚的可能性。
结论:ERAS用于PD围术期安全、有效，能明显降低术后胃排空延迟发生率，缩短患者术后首次肛门排气时间和住院时间，降低术后总体并发症发生率。

Abstract: Objective:To systematically evaluate the efficacy and safety of enhanced recovery after surgery (ERAS) in perioperative management of pancreatoduodenectomy.
Methods:Literatures were researched using the Cochrane Library, PubMed, Embase, CNKI, VANFUN database, CBM, China Science and Technology Journal Database from June 1979 to June 2019 with the key words including “enhanced recovery after surgery, fasttrack surgery, fast track multidisciplinary treatment, pancreatoduodenectomy, laparoscopic pancreatoduodenectomy, whipple surgery, 加速康复外科, 快速康复外科, 加速康复综合治疗模式, 胰十二指肠切除术, 腹腔镜胰十二指肠切除术, whipple手术”. The randomized controlled trial or prospective cohort study about traditional perioperative management versus ERAS in perioperative management of pancreaticoduodenectomy were received and enrolled. The patients receiving ERAS in perioperative management and traditional perioperative management were respectively allocated into ERAS group and control group. Two reviewers independently screened literatures, extracted data and assessed the risk of bias. Count data were described as risk ratio (RR) and 95% confidence interval (CI). Measurement data were represented as mean difference (MD) and 95%CI. The heterogeneity of the studies was analyzed using the I² test. Funnel plot was used to test potential publication bias if the studies included ≥ 5, and no test was needed if the studies included < 5.
Results:(1) Document retrieval: a total of 8 randomized controlled trials were included. There were 1 187 patients, including 588 in the ERAS group and 599 in the control group. (2) Results of Meta analysis. ① There was no significant difference in the incidence of postoperative hemorrhage between the two groups (RR=0.79, 95%CI: 0.45-1.37, P>0.05). The bilateral symmetry was presented in the funnel plot based on the 8 studies, suggesting that publication bias had little influence on results of Meta analysis. ② There was no significant difference in the incidence of postoperative pancreatic fistula between the two groups (RR=0.97, 95%CI: 0.67-1.39, P>0.05). ③ There was no significant difference in the incidence of postoperative intraabdominal infection between the two groups (RR=0.76, 95%CI: 0.51-1.12, P>0.05). The bilateral symmetry was presented in the funnel plot based on the 5 studies, suggesting that publication bias had little influence on results of Meta analysis. ④ There was a significant difference in the incidence of postoperative delayed gastric emptying between the two groups (RR=0.46, 95%CI: 0.31-0.67，P<0.05). The bilateral symmetry was presented in the funnel plot based on the 5 studies, suggesting that publication bias had little influence on results of Meta analysis. ⑤ There was a significant difference in the time to postoperative first flatus between the two groups (MD=-2.06, 95%CI: -3.08 to -1.05, P<0.05). The bilateral symmetry was presented in the funnel plot based on the 5 studies, suggesting that publication bias had little influence on results of Meta analysis. ⑥ There was a significant difference in the duration of postoperative hospital stay between the two groups (MD=-5.12, 95%CI: -6.09 to -4.14, P<0.05). The bilateral symmetry was presented in the funnel plot based on the 5 studies, suggesting that publication bias had little influence on results of Meta analysis. ⑦ There was a significant difference in the incidence of postoperative complications between the two groups (RR=0.63, 95%CI: 0.44-0.89, P<0.05). The bilateral symmetry was presented in the funnel plot based on the 6 studies, suggesting that publication bias had little influence on results of Meta analysis. ⑧ There was no significant difference in the postoperative readmission rate between the two groups (RR=1.07, 95%CI: 0.62-1.84, P>0.05). The leftright asymmetry was presented in the funnel plot based on the 5 studies, suggesting that publication bias may exist in the included studies.
Conclusion:ERAS in the perioperative management of pancreatoduodenectomy is safe and effective, which can reduce the incidence of postoperative delayed gastric emptying, shorten the time to postoperative first flatus and duration of hospital stay, and reduce the incidence of postoperative overall complications.

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