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中华疝和腹壁外科杂志(电子版) ›› 2024, Vol. 18 ›› Issue (03) : 343 -350. doi: 10.3877/cma.j.issn.1674-392X.2024.03.021

循证医学

加速康复外科理念应用于腹壁重建手术的系统评价及Meta分析
王招荐1, 曹桢1, 郭小双2, 靳小雷2, 刘子文1,()   
  1. 1. 100730 中国医学科学院 北京协和医学院 北京协和医院基本外科
    2. 100144 中国医学科学院 北京协和医学院 整形外科医院颅颌面一科
  • 收稿日期:2023-08-31 出版日期:2024-06-18
  • 通信作者: 刘子文
  • 基金资助:
    北京市自然科学基金面上项目(7202164); 中国医学科学院医学与健康科技创新工程经费资助

Enhanced recovery after surgery (ERAS) for abdominal wall reconstruction: A systematic review and meta-analysis

Zhaojian Wang1, Zhen Cao1, Xiaoshuang Guo2, Xiaolei Jin2, Ziwen Liu1,()   

  1. 1. Department of General Surgery, Peking Union Medical College Hospital, CAMS, PUMC, Beijing 100730, China
    2. 1th Department of Craniomaxillofacial Surgery, Plastic Surgery Hospital, CAMS, PUMC, Beijing, 100144, China
  • Received:2023-08-31 Published:2024-06-18
  • Corresponding author: Ziwen Liu
引用本文:

王招荐, 曹桢, 郭小双, 靳小雷, 刘子文. 加速康复外科理念应用于腹壁重建手术的系统评价及Meta分析[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(03): 343-350.

Zhaojian Wang, Zhen Cao, Xiaoshuang Guo, Xiaolei Jin, Ziwen Liu. Enhanced recovery after surgery (ERAS) for abdominal wall reconstruction: A systematic review and meta-analysis[J/OL]. Chinese Journal of Hernia and Abdominal Wall Surgery(Electronic Edition), 2024, 18(03): 343-350.

目的

通过对现有文献进行系统评价和Meta分析,比较加速康复外科护理方案与常规护理方案对腹壁重建手术的影响。

方法

本文作者利用PubMed、EMBASE和Cochrane数据库,查找了与腹壁重建手术ERAS方案相关的研究,检索时限为建库至2020年4月。分析比较ERAS方案与常规护理方法对患者的住院时长、肠道功能恢复、术后并发症以及再入院率的影响。

结果

分析纳入了4项回顾性队列研究,共涉及患者768人(ERAS组345人,常规护理组423人)。相较于常规护理组,ERAS方案缩短了患者的住院时长[平均差(MD)-0.93(-1.83~-0.04),P=0.04)],促进了肠道功能早期恢复[MD -0.86(-1.12~-0.60),P<0.000 1]。ERAS组与常规护理组患者术后并发症以及再入院率相近。

结论

在腹壁重建手术中应用ERAS方案有可能缩短平均住院时长、加快肠道功能恢复。未发现ERAS组和常规护理组患者的并发症发生率和再入院率差异有统计学意义。为证实ERAS方案的优越性,并做进一步优化,需进行大规模随机对照试验。

Objective

To compare the influence of ERAS care on postoperative recovery with that of conventional care in abdominal wall reconstruction, we performed a systematic review and meta-analysis based on current literature.

Methods

PubMed, EMBASE and Cochrane were searched for studies published before April 2020 containing original data on the ERAS program for abdominal wall reconstruction. The effects of ERAS protocols and conventional care on length of stay (LOS), bowel recovery, postoperative complications and readmission were compared.

Results

Four retrospective cohort studies with a total of 768 patients (345 in ERAS and 423 in the conventional care group) were identified. LOS was shorter with ERAS than with conventional care [mean difference (MD) -0.93 (-1.83--0.04), P=0.04]. ERAS patients had an earlier return of bowel function than the control [MD, -0.86 (-1.12--0.60); P<0.000 1]. Postoperative complications and readmission were comparable between the ERAS and conventional care groups.

Conclusion

The application of ERAS protocols in abdominal wall reconstruction surgery may reduce the average length of hospital stay and accelerate the recovery of bowel function. No statistically significant differences were found in the incidence of complications and readmission rates between the ERAS and conventional care groups. To further confirm the advantages of ERAS protocols and optimize them, large-scale randomized controlled trials are needed.

图1 系统评价和Meta分析文献筛选流程图
表1 纳入Meta分析的临床试验的主要特征
表2 纳入Meta分析的临床试验组间特征差异
表3 纳入研究的腹壁重建的加速康复外科方案比较
项目 Majumder 2016[25] Jensen 2019[26] Colvin 2019[27] Harryman 2020[28]
住院前 教育 -
  优化 戒烟;减重咨询;HbA1c<8%;营养支持 戒烟;体重指数<35 kg/m2 - 戒烟;体重指数<40 kg/m2;HbA1c≤8.0%;营养支持
  其他 OSA,MRSA 限制酒精摄入 - -
术前 预防性抗生素 -
  血栓预防 -
  爱维莫潘 12 mg - - 必要时
  疼痛预防 加巴喷丁100~300 mg 术前1 h内:对乙酰氨基酚1000 mg,布洛芬600 mg,加巴喷丁600 mg - -
  其他 - - - 能量补剂
术中 腹横肌平面阻滞 未进行
  目标导向的输液
  其他 - 甲泼尼龙125 mg×1剂 - 体温≥36 ℃
术后 患者自控镇痛 氢吗啡酮,在术后2 d清流质饮食后停止 - 氢吗啡酮,术后2 d戒断,术后3 d停止 -
  硬膜外麻醉 - 布比卡因和吗啡,术后2 d停止 - 氢吗啡酮和布比卡因
  辅助镇痛剂 口服羟考酮、对乙酰氨基酚、加巴喷丁、地西泮等,必要时 口服对乙酰氨基酚、布洛芬、吗啡或羟考酮作为救济性镇痛药 口服对乙酰氨基酚、加巴喷丁、羟考酮,必要时;静脉输注酮咯酸,必要时 羟考酮、酮咯酸,必要时过渡至对乙酰氨基酚、布洛芬,必要时
  预防性止吐药物 - -
  鼻胃管
  早下地活动 -
  即刻早期经口进食
  胃肠道功能 爱维莫潘12 mg日2次 氧化镁乳剂,嚼口香糖,如术后2 d无肠功能则灌肠 镁乳剂和多库酯钠 爱维莫潘,日2次,至肠功能恢复
  审慎的静脉输液策略 -
  导尿管 - 术后1 d移除 术后2 d移除 术后2 d移除
  出院标准 - # -
  其他 普通肝素,必要时 腹带;补氧,必要时;肺功能锻炼 - 胰岛素、肝素,必要时
图2 ERAS组与常规护理组住院时长的森林图
图3 ERAS组与常规护理组肠道功能恢复时间的森林图
表4 纳入研究ERAS组与常规护理组的住院时长和术后并发症发生率
表5 加速康复外科方案对腹壁重建患者住院时长的影响
表6 加速康复外科方案对腹壁重建患者肠道功能恢复的影响
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