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

Impact of enhanced recovery after surgery on perioperative inflammatory responses and immune function in colorectal cancer patients:a Meta-analysis

目的:系统评价加速康复外科(ERAS)干预对结直肠癌择期手术患者围术期炎症反应与免疫功能的影响。方法:计算机检索多个国内外数据库中从建库至2018年发表的关于ERAS应用于结直肠癌手术的随机对照试验,检索时限均为从建库至2018年4月。按照Cochrane系统评价方法对纳入研究的进行质量评价和提取资料,采用Rev Man5.3软件进行Meta分析。结果:最终纳入26篇研究,共2420例患者,ERAS组1185例,对照组1235例。描述性分析结果显示,与对照组比较,ERAS组术后炎症因子水平明显降低,恢复时间明显缩短(均P<0.05)。合并分析结果显示,ERAS组较对照组术后1、3、7d的CD4+T细胞百分比(WMD=0.85,95%CI=0.21~1.49;WMD=2.85,95%CI=1.76~3.94;WMD=1.52,95%CI=0.42~2.62)、Ig G水平(WMD=0.54,95%CI=0.11~0.97;WMD=1.26,95%CI=0.79~1.74;WMD=0.63,95%CI=0.27~0.99)明显升高,术后1、3d的CD3+T细胞百分比(WMD=1.46,95%CI=0.62~2.30;WMD=2.78,95%CI=1.82~3.73)、Ig A水平(WMD=0.14,95%CI=0.07~0.22;WMD=0.29,95%CI=0.22~0.36)明显升高,术后3d的Ig M水平(WMD=0.11,95%CI=0.06~0.16)明显升高(均P<0.05),切口感染(OR=0.52,95%CI=0.31~0.85)、肺部感染(OR=0.40,95%CI=0.21~0.73)、泌尿系统感染(OR=0.15,95%CI=0.04~0.54)、术后肠梗阻(OR=0.34,95%CI=0.13~0.87)以及总并发症的发生率(OR=0.40,95%CI=0.28~0.56)均明显降低(均P<0.05)。结论:ERAS可以安全应用于结直肠癌择期手术患者,能够降低结直肠癌患者围术期炎性介质的释放,维护机体的免疫稳定,从而减少并发症发生率,促进术后早期康复。

Objective： To systematically evaluate the impacts of using enhanced recovery after surgery（ERAS） protocols on perioperative inflammatory response and immune function in patients with colorectal cancer undergoing elective surgery.Methods： The randomized controlled trials concerning using ERAS pathways in the setting of surgery for colorectal cancer were searched from several national and international online databases. The retrieval time was from inception of the database to April 2018. Quality assessment and data extraction of the selected studies were performed according to the Cochrane systematic review methods. Meta-analysis was performed by using Rev Man 5.3 software.Results： Twenty-six studies were finally included, involving a total of 2 420 patients, with 1 185 cases in ERAS group and 1 235 cases in control group. The results of descriptive analysis showed that the postoperative levels of inflammatory factors were decreased and the time for postoperative recovery was shortened significantly in ERAS group compared with control group（all P〈0.05）. The results of pooled analysis showed that the percentage of CD4＋T cells（WMD=0.85, 95% CI=0.21–1.49; WMD=2.85, 95% CI=1.76–3.94; WMD=1.52, 95% CI=0.42–2.62） and Ig G levels（WMD=0.54, 95% CI=0.11–0.97; WMD=1.26, 95% CI=0.79–1.74; WMD=0.63, 95% CI=0.27–0.99） at postoperative day（POD） 1, 3 and 7, the percentage of CD3＋ T cells（WMD=1.46, 95% CI=0.62–2.30; WMD=2.78, 95% CI=1.82–3.73） and Ig A levels（WMD=0.14, 95% CI=0.07–0.22; WMD=0.29, 95% CI=0.22–0.36） at POD 1 and 3, and Ig M levels（WMD=0.11, 95% CI=0.06–0.16） at POD 3 in ERAS group were significantly higher than those in control group（P〈0.05）; the incidence of wound infection（OR=0.52, 95% CI=0.31–0.85）, pulmonary infection（OR=0.40, 95% CI=0.21–0.73）, urinary tract infection（OR=0.15, 95% CI=0.04–0.54）, postoperative intestinal obstruction（OR=0.34, 95% CI=0.13–0.87） and the overall complications（OR=0.40, 95% CI=0.28–0.56） in the ERAS group were significantly lower than those in control group（all P〈0.05）.Conclusion： ERAS protocols can be safely used in colorectal cancer patients undergoing elective surgery, which can inhibit the release of inflammatory mediators and help to maintain the stability of immune function during perioperative period, and thereby reduce the complications and promote early postoperative recovery.