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標題: | 術後加速康復療程對接受胃切除術病人之成效探討:系統性文獻回顧、統合分析與臨床試驗計劃書 Efficacy of enhanced recovery after surgery in gastric cancer patients undergoing gastrectomy: a systematic review, meta-analysis and clinical trial protocol |
作者: | 張芳瑜 Fang-Yu Zhang |
指導教授: | 陳祈玲 Chi-Ling Chen |
關鍵字: | 術後加速康復療程,胃癌,胃切除術,系統性文獻回顧,統合分析, Enhanced recovery after surgery,gastric cancer,gastrectomy,systematic review,meta-analysis, |
出版年 : | 2023 |
學位: | 碩士 |
摘要: | 背景
術後加速康復 (Enhanced recovery after surgery, ERAS) 療程目的在於減輕手術壓力反應,並加速手術後的功能康復。ERAS療程包括一系列以實證醫學證據為基礎的圍術期介入措施,包括術前諮詢、縮短術前禁食時間、減少手術侵襲性、早期進食、保持體液平衡、減少常規管路置放或早期移除管路、術後多模式疼痛管理、營養支持和早期康復。ERAS療程已成功適用於結腸癌手術,並逐漸推廣至許多手術專科的臨床實踐中使用。如腹部手術、關節置換手術、乳房手術等。本系統性文獻回顧與統合分析,旨在評估術後加速康復療程與常規照護在接受胃切除術的胃癌患者中,其治療成效與可行性。 方法 我們對接受胃切除術的胃癌患者進行了涉及術後加速康復隨機對照試驗的統合分析。檢索了截至2022年9月的PubMed, clinicaltrials.gov, EMBASE和Cochrane Library,以獲取所有可用的在胃切除術中比較ERAS療程和常規照護的隨機對照試驗。主要終點是住院時間。次要終點包含術後併發症、腸道功能恢復與首次進食時間、行走時間、再入院率和死亡率。所有統計分析均使用統計軟體Review Manager 版本5.4.1進行,使用加權平均差(WMD)分析連續變項、風險比(RR)分析二元變項、 I2統計評估研究的異質性,本統合分析使用隨機效果模式呈現,P值 小於 0.05被認為具有統計學意義。 結果 有12項隨機對照試驗符合統合分析的條件。一共有1,356名受試者被納入此次的統合分析。與常規照護組相比,ERAS組術後的住院時間較短(WMD −1.71 days, 95% CI −2.16至−1.26, P < 0.00001)、首次排氣時間較早(WMD −0.65 days, 95% CI −0.89至−0.42,P < 0.00001)、首次排便時間較早(WMD −0.95 days, 95% CI−1.44至−0.46, P = 0.0001 ),首次進食時間較早(WMD −1.32 days, 95% CI −1.84 to −0.80, P < 0.00001)、以及更早下床行走(WMD −1.02 days, 95% CI −1.63至−0.41, P = 0.001)。而關於術後併發症、再入院率及死亡率,ERAS組與常規照護組之間未觀察到顯著的差異(RR 0.77, 95% CI 0.54至1.09, P = 0.14;RR 1.24, 95% CI 0.56至2.71, P = 0.60;RR 0.33, 95% CI 0.01至8.04, P = 0.50)。 結論 本統合分析比較了術後加速康復療程與常規護理在接受胃切除手術的胃癌患者中的有效性和可行性,共納入了1,356名受試者。統合分析結果顯示,ERAS組在術後住院時間較短,並在首次排氣時間、首次排便時間、首次進食時間和早期下床行走的時間等方面,與常規組相比恢復速度更快。然而,在術後併發症、再入院率和死亡率方面,兩組之間並無統計上的顯著差異。這些分析結果有助於我們對於術後加速康復療程在胃癌患者中的重要性,有更深入的了解,並與其他研究者發表的期刊論文研究結果一致,進一步支持在這類患者中實施術後加速康復療程的價值。然而,需要更進一步的研究來驗證這些發現,並解決異質性和方法學上的問題。未來的研究應該著重於擴展和優化術後加速康復療程的內容,尤其是在圍術期中的營養照護策略以及納入Sugammadex是一種新型的肌肉鬆弛藥物拮抗劑,可帶來逆轉神經肌肉阻滯劑的效果。它的使用已被證明可以減少麻醉過程中的不良事件,同時也有助於患者的快速恢復,以及在麻醉後監測治療室中應用高流量鼻導管供氧等輔助治療方面。這樣可以引導臨床實踐,改善接受胃切除術之胃癌患者的護理和康復過程,從而提高患者的生活質量和預後。 Background Enhanced recovery after surgery (ERAS) intends to alleviate surgical stress and expedite postoperative functional recovery. ERAS protocol comprises a series of evidence-based perioperative interventions, encompassing preoperative counselling, shortening of preoperative fasting time, reducing surgical invasiveness, early postoperative oral intake, maintaining body fluid balance, early removal of catheters, postoperative multimodal analgesia management, nutritional support, and early rehabilitation. ERAS protocol has been successfully merged into the perioperative management of various cancer surgeries, such as colorectal cancer. Due to compelling evidence and recommendations regarding colorectal cancer, ERAS concepts have gained broad recognition and are progressively to in clinical practice across numerous surgical specialties. This systematic review and meta-analysis were aimed to evaluate the efficacy and feasibility of comparing ERAS protocol and conventional care in gastric cancer patients undergoing gastrectomy. Methods We performed a meta-analysis of randomized controlled trials involving ERAS for patients underwent gastrectomy. PubMed, clinicaltrials.gov, EMBASE, and Cochrane Library were searched up to Sep 2022 for all available randomized controlled trials comparing ERAS protocol and conventional care in gastrectomy. Primary endpoint was the length of hospital stay. Secondary endpoints included postoperative complications, time to return of gut function, first food intake, ambulation time, readmission, and mortality. All statistical analysis were conducted using the software Review Manager 5.4.1. The pooled results were expressed as the mean difference (MD) with 95% confidence interval (CI). Continuous variables were assessed using weighted mean difference (WMD). Dichotomous variables were analyzed using risk ratio (RR). Heterogeneity was evaluated using the I2 statistics. The random-effects model was used in this meta-analysis. P value less than 0.05 was considered to be statistically significant. Results There were twelve randomized controlled trials eligible for meta-analysis. A total of 1,356 subjects were included in this analysis. Compared with conventional group, ERAS group related to shorter length of postoperative hospital stay (WMD −1.71 days, 95% CI −2.16 to −1.26, P < 0.00001), shorter time to first flatus (WMD −0.65 days, 95% CI −0.89 to −0.42, P < 0.00001), first defecation (WMD −0.95 days, 95% CI −1.44 to −0.46, P = 0.0001), first liquid diet (WMD −1.32 days, 95% CI −1.84 to −0.80, P < 0.00001), shorter time to ambulation (WMD −1.02 days, 95% CI −1.63 to −0.41, P = 0.001). Regarding postoperative complications, readmission rate and mortality, no significant differences were observed between ERAS group and conventional group (RR 0.77, 95% CI 0.54 to 1.09, P = 0.14; RR 1.24, 95% CI 0.56 to 2.71, P = 0.60; RR 0.33, 95% CI 0.01 to 8.04, P = 0.50). Conclusions In conclusion, our meta-analysis comparing the effectiveness and feasibility of the ERAS protocol with conventional care in gastric cancer patients undergoing gastrectomy included 1,356 subjects. The findings showed that the ERAS group had significant advantages over the conventional group, including a shorter length of postoperative hospital stay and faster recovery in terms of time to first flatus, defecation, liquid diet intake, and ambulation. However, there were no significant differences between the two groups in terms of postoperative complications, readmission rate, and mortality. These results contribute to our understanding of the importance of the ERAS protocol in gastric cancer patients and are consistent with previous publications, further supporting the value of implementing the ERAS protocol in this patient population. However, it is important to note that more high-quality research is needed to validate these findings and address heterogeneity and methodological issues. Future studies should focus on optimizing and expanding the content of the ERAS protocol, particularly in the areas of nutrition strategies and the incorporation of adjunctive treatments such as Sugammadex and giving high-flow nasal cannula for oxygen supply in post-anesthesia care unit (PACU). By doing so, we can guide clinical practice, improve the care and recovery process of surgical patients, and ultimately enhance their quality of life and prognosis. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/89765 |
DOI: | 10.6342/NTU202300961 |
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顯示於系所單位: | 臨床醫學研究所 |
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