肝切除术围术期行免疫营养支持治疗临床疗效的Meta分析

Clinical efficacy of immunonutrition support in perioperative period of hepatectomy:a Meta analysis

目的:系统评价肝切除术围术期行免疫营养支持治疗的临床疗效。方法:以肝切除术、免疫营养、hepatectomy、hepatic resection、immunonutrition、immunoenhanced nutrition为检索词,检索中国期刊全文数据库(CNKI)、中国生物医学文献数据库(CBM)、万方数据库、维普数据库、PubMed(Medline)、Embase、Web of Science、Science Direct、Cochrane Center。检索时间为1996年1月至2018年3月。纳入比较肝切除术围术期行免疫营养和常规营养支持治疗临床疗效的随机对照试验(RCT)。免疫营养组患者行肝切除术围术期予免疫营养支持治疗,常规营养组患者行肝切除术围术期予常规营养支持治疗。结局指标:术后总体并发症发生率、术后感染性并发症发生率、术后肝衰竭发生率、围术期病死率、住院时间、住院费用。由两名研究者独立筛选文献和提取数据,并进行文献质量评价。计数资料采用相对危险度(RR)及95%可信区间(95%CI)表示,计量资料采用均数差(MD)或加权均数差(WMD)及95%CI表示。采用I2分析纳入文献异质性。纳入研究≥10篇,采用漏斗图检验潜在发表偏倚;纳入研究<10篇,则对纳入研究最多的结局指标纳入文献进行检验。结果:(1)文献检索结果:最终纳入符合标准的相关研究共12篇,均为RCT;累计样本量1 136例,其中免疫营养组和常规营养组各568例。(2)Meta分析结果:免疫营养组行肝切除术患者术后总体并发症发生率、术后感染性并发症发生率、术后肝衰竭发生率、住院时间均显著低于常规营养组,差异均有统计学意义(RR=0.57,0.49,0.30,MD=-3.28,95%CI:0.46~0.71,0.37~0.65,0.12~0.74,-4.45^-2.11,P<0.05);住院费用显著高于常规营养组,差异有统计学意义(MD=11.86,95%CI:10.96~12.77,P<0.05)。两组患者围术期病死率比较,差异无统计学意义(RR=0.26,95%CI:0.07~1.05,P>0.05)。对免疫营养组与常规营养组行肝切除术患者术后感染性并发症发生率比较的Meta分析9篇纳入文献进行漏斗图分析,其结果显示:漏斗图左右对称,表明发表偏倚对Meta分析结果影响较小。结论:肝切除术患者围术期予免疫营养支持治疗安全、可行,与常规营养支持治疗比较,不增加围术期病死率,可显著降低患者术后总体并发症发生率、术后感染性并发症发生率、术后肝衰竭发生率,且缩短住院时间。

Objective:To systematically evaluate the clinical efficacy of immunonutrition support in perioperative period of hepatectomy. Methods:Literatures were researched using CNKI, CBM, Wanfang database, VIP databases, PubMed (Medline), Embase, Web of science, Science Direct, Cochrane Center from January 1996 to March 2018 with the key words including “肝切除术,免疫营养, hepatectomy, hepatic resection, immunonutrition, immunoenhanced nutrition”. The randomized controlled trials (RCTs) on comparison of efficacy of immunonutrition support versus routine nutritional support in perioperative period of hepatectomy. Patients in the immunonutrition group received immunonutrition support in perioperative period of hepatectomy, and patients in the routine nutrition group received routine nutritional support in perioperative period of hepatectomy. Outcome measures: overall incidence of postoperative complications, incidence of postoperative infectious complications, incidence of postoperative liver failure, perioperative mortality, hospital stay, and hospitalization expenses. Literatures screening, data extraction and quality assessment of methodology were conducted by two researchers separately. Count data were represented as risk ratio (RR) and 95% confidence interval (CI). Measurement data were represented as mean difference (MD) or weighted mean difference (WMD) and 95%CI. Heterogeneity of the included studies was analyzed with I2. Funnel plot was used to test potential publication bias if the number of studies included ≥ 10, and funnel plot was used to test potential publication bias for the outcome measures with the maximum number of studies if the number of studies included <10. Results:(1) Document retrival: 12 RCTs were enrolled in the Meta analysis, and the total sample size was 1 136 patients, including 568 patients in the immunonutrition group and in the routine nutrition group, respectively.(2) Results of Meta-analysis: the that immunonutrition group had lower overall incidence of postoperative complications, incidence of postoperative infectious complications, incidence of postoperative liver failure, and hospital stay (RR=0.57, 0.49, 0.30, MD=-3.28, 95%CI: 0.46-0.71, 0.37-0.65, 0.12-0.74,-4.45 to -2.11, P<0.05), and higher hospital expenses (MD=11.86, 95%CI: 10.96-12.77, P<0.05) compared with the routine nutrition group. There was no significant difference in the perioperative mortality between the two groups (RR=0.26, 95%CI: 0.07-1.05, P>0.05). The bilateral symmetry was presented in the funnel plot based on the 9 studies comparing incidence of postoperative infectious complications between the immunonutrition group and routine nutrition group, suggesting that publication bias had little influence on results of Meta-analysis. Conclusions: Perioperative immunonutrition support for hepatectomy is safe and feasible. Compared with routine nutritional support, immunonutrition support can significantly reduce overall incidence of postoperative complications, incidence of postoperative infectious complications, incidence of postoperative liver failure, and shorten the hospital stay without increasing postoperative mortality.