加速康复外科应用于胰腺切除围术期安全性和可行性的Meta分析

Safety and feasibility of enhanced recovery after surgery in perioperative management of pancreatectomy：a Meta analysis

目的系统评价加速康复外科（ERAS）应用于胰腺切除围术期的安全性和有效性。方法以快速康复外科、加速康复外科、胰腺切除术、胰十二指肠切除术、惠普而术、ERAS、enhanced recovery、fast track、pancreatic surgery、pancreateetomy、Whipple、pancreatoduodenectomy、pancreatoduodenal resection为检索词，检索中国期刊全文数据库、万方医学数据库、维普数据库、PubMed、Cochrane、Embase。检索时间为1990年1月至2018年3月。纳入ERAS应用于择期胰腺手术或胰十二指肠切除术的回顾性队列研究，患者采用ERAS围术期管理设为研究组，患者采用传统围术期管理设为对照组。由两名研究者独立筛选文献并提取数据，进行质量评价。计数资料采用优势比（OR）及95％可信区间（CI）表示。计量资料，对于同一指标采用相同测量工具获取的结果，则使用加权均数差（WMD）作为合并统计量，而用不同测量工具获取的结果，则使用标准均数差（SMD）作为合并统计量。采用，对异质性进行分析。结果最终纳入符合标准的相关文献19篇。19篇文献均为回顾性队列研究。19篇文献累计样本量3699例患者．其中研究组1823例，对照组1876例。Meta分析结果显示：研究组与对照组患者术后鼻胃管拔除时间、术后进食固态食物时间、术后恢复排便时间、术后总体并发症发生率、术后胃延迟排空发生率，术后腹腔感染发生率、术后住院时间、住院费用比较，差异均有统计学意义（WMD=-1．70，-3．61，-0．86，OR=0．65，0．60，0．70，WMD=-4．64，SMD=-0．48，95％C1：-2．97--0．42，-4．70-2．53，-1．01～-0．71，0．52～0．81，0．45-0．80，0．54～0．91，-5．91--3．38，-0．77--0．18，P〈0．05）。研究组与对照组患者手术时间、术中出血量、术后胰瘘发生率、术后切口感染发生率、再人院率、再手术率、病死率比较，差异均无统计学意义（WMD=-9．73，-14．39，OR=0．85，0．72，1．05，0．81，0．74，95％CI：-34．24-14．78，-116．96～88．17，0．72～1．01，0．46-1．14，0．83～1．32，0．58～1．13，0．53～1．02，P〉0．05）。亚组分析结果显示：数据异质性主要来源于东西方国家。结论加速康复外科应用于胰腺切除围术期安全可行，可促进患者术后康复，降低并发症发生率，减轻患者经济负担。

Objective To systematically evaluate the safety and feasibility of enhanced recovery after surgery （ERAS） in perioperative management of pancreateetomy. Methods Literatures were researched using CNKI, Wa,ffang database, VIP database, PubMed, Cochrane Library, Emhase from January 1990 to March 2018 with the key words including ＂快速康复外科,加速康复外科,胰腺切除术,胰十二指肠切除术,惠普而术, ERAS, enhanced recovery, fast track, pancreatic surgery, pancreatectomy, Whipple, pancreatoduodenectomy, pancreatoduodenal resection＂. The cohort study about ERAS in elective pancreatic surgery or pancreatico- duodenectomy were received and enrolled. The patients using ERAS in perioperative management and using traditional perioperative management were respectively allocated into the ERAS group and control group. Two reviewers independently screened literatures, extracted data and assessed the risk of bias. Count data were described as odds ratio （OR） and 95% confidence interval （CI）. Weighted Mean Difference （WMD） was used as a consolidated statistics for measurement data that were measured using the same tool, and standardized mean difference （SMD） was used as a consolidated statistics for measurement data that were measured using the different tools. The heterogeneity of the studied was analyzed using the 12 test. Results Nineteen retrospective cohort studies were enrolled in the Meta analysis, and total sample size was 3 699 patients, including 1 823 in the ERAS group and 1 876 in the control group. The results of Meta analysis showed that there were statistically significant differences in the time of postoperative nasogastric tube removal, time for postoperative solid diet intake, time of postoperative defecation recovery, incidence of postoperative overall complications, incidence of postoperative delayed gastric emptying, incidence of postoperative intra-abdominal infection, duration of postoperative hospital stay and hospital expenses between ERAS group and control group （ WMD = - 1.70, -3.61, -0. 86, OR = O. 65, 0.60, 0.70, WMD=-4.64, SMD=-0.48, 95%CI：-2. 97--0.42,-4. 70--2. 53,-1.01--0. 71, 0.52-0.81, 0. 45-0. 80, 0. 54-0. 91, -5.91 --3.38, -0. 77--0. 18, P〈0. 05）. There was no statistically significant difference in the operation time, volume of intraoperative blood loss, incidence of postoperative pancreatic fistula, incidence of postoperative wound infection, readmission rate, reoperation rate and mortality between ERAS group andcontrolgroup （WMD=-9.73,-14.39, OR=0.85, 0.72, 1.05, 0.81, 0.74, 95%CI：-34.24-14.78, -116.96-88. 17, 0.72-1.01, 0.46-1.14, 0.83-1.32, 0.58-1.13, 0.53-1.02, P〉0.05）. The results of subgroup analysis showed that heterogeneity of data was from eastern and western countries. Conclusion ERAS in the perioperative management of pancreatectomy is safe and feasible, it can also promote postoperative recovery of patients and reduce incidence of comDhcations and financial burden.