| Purpose This paper aims to conduct a systematic review on the safety and effectiveness of enhanced recovery after surgery (ERAS) within hepatectomy perioperative period. ERAS relieves surgical stress and trauma of patients within perioperative period and realizes the goal of accelerating recovery of surgical patients by adopting a whole set of optimized management measures in perioperative period and more accurate surgical operations with smaller trauma. Since its initiation, ERAS has obtained rapid development and clinical promotion. At present, it has been extensively applied to clinical subjects such as gastrointestinal surgery, joint osteopathic surgery, urinary surgery, gynaecology and obstetrics, etc. Compared with traditional perioperative management concept, ERAS has its own features and advantages. Hepatectomy, as a basic surgical method of hepatic surgery, is the preferred and significant therapeutic method for most kinds of primary and secondary diseases of liver, and its safety and effectiveness have been proved by various researches and clinical practice. While in the meantime, hepatectomy is also a complex abdomen surgery with great stress reaction, slow postoperative recovery, many postoperative complications and high mortality. There is no doubt that rapid and well recovery of hepatectomy is of great clinical significance and it will be an important direction of the development of hepatectomy. However, there are really less studies on the combination of ERAS and hepatectomy, and no uniform conclusions of its safety and effectiveness has been proposed. This paper expects to evaluate the application of ERAS within hepatectomy perioerative period and to provide reliable basis of evidence-based medicine for clinical application through normative retrieval and screening and by carefully reading relevant literatures on application of ERAS within hepatectomy perioerative period.Method To use a computer to retrieve in Chinese databases such as CNKI, WanFang database, VIP database as well as English databases such as Cochrane Library, PubMed and EMBASE both in English and Chinese, and retrieval time is limited from June of 2005 to June of 2015. It acquired randomized controlled tirals (RCT) and clinical controlled trial (CCT) about application of ERAS in hepatectomy in all databases. After strict literature incorporating, excluding and screening, Cochrane Reviewer Handbook 5.1 bias risk evaluation standards were used to evaluate quality of incorporated literatures and corresponding bias sources. After careful full-text reading of incorporated literatures which conformed to standards, it conducted data extraction (including baseline data and final effect indexes), and these extracted data were used to conduct baseline data comparison. If there was no obvious difference after baseline data comparison, Review Manager 5.3 software was used to conduct systematic evaluation on final effect indexes. Weighted mean difference was used to conduct statistics of measurement data and odds ratio was adopted to conduct statistics of enumeration data. Calculations of all statistical magnitudes were within 95% reliability scope. Heterogeneity analysis of effect sizes shall be conducted before calculating combined effect sizes and heterogeneity analysis adopted chi-square test. If there was no statistical heterogeneity (namely when I2> 50%, P< 0.05), then fixed effect model was adopted to combine statistical quantity. Funnel plot analysis was used to judge whether there was publication bias. This study sets P value as 0.05 to act as critical value of statistical difference.Results After careful reading and evaluation of full texts of screened literatures, finally 9 (6 English ones and 3 Chinese ones) were incorporated. Among incorporated researches,5 were RCT research literatures and 4 were CCT research literatures. There were totally 518 incorporated cases whereby there were 457 ones in ERAS experimental group and 518 one in the control group with traditional treatment. Quality evaluation of incorporated 9 literatures was conducted according to Cochrane Reviewer Handbook 5.1 bias risk evaluation standards. After evaluation, there were 2 literatures with grade A quality,5 with grade B quality and 2 with grade C quality. In execution condition analysis of ERAS measures, all incorporated literatures basically executed core content of ERAS. However, as present ERAS researches was still in a starting and exploring stage, each research had its own understanding of ERAS. Among different medical centers, ERAS concepts were mostly approximate, but concrete execution details were really different. Through data extraction, it’s found that baseline data in ERAS experimental group and control group basically had good comparability except for statistical difference in a few evaluation indexes.The final effect results were evaluated using the Review Manager 5.3 Software. The results indicated that the hospitalization time was statistically heterogeneous after combined analysis of WMD (I2=84%, P<0.01). The combined analysis of hospitalization time was performed using the random effect model. Software analysis results showed that the postoperative hospitalization time showed statistically significant difference between ERAS group and traditional concept group (WMD=-1.98,95% CI=-2.68～-1.28, P<0.01). ERAS could shorten the postoperative hospitalization time. The postoperative functional rehabilitation time was statistically heterogeneous after combined analysis of WMD (I2=79%, P<0.01). The combined analysis of postoperative functional rehabilitation time was performed using the random effect model. Software analysis results showed that postoperative functional rehabilitation time showed significant difference between ERAS group and traditional concept group (WMD=-2.08,95% CI=-3.27～0.98, P<0.01), and the difference was statistically significant. ERAS could shorten the postoperative functional rehabilitation time. The incidence of postoperative complications was statistically heterogeneous after combined analysis of OR (I2=3%, P=0.41), The fixed effect model could be used for combined analysis of postoperative complications incidence. Software analysis showed that the incidence of postoperative complications showed no significant difference between ERAS group and traditional concept group (OR=0.84,95% CI=0.61～1.16, P=0.29), and the difference was not statistically significant. ERAS could not increase the incidence of postoperative complications. The readmission rate was statistically heterogeneous after combined analysis of OR (I2=0%, P=0.75). The fixed effect model could be used for combined analysis of readmission rate. Software analysis results showed the readmission rates showed no significant difference between ERAS group and traditional concept group (OR=1.62, 95% CI=0.74～3.51, P=0.23), and the difference was not statistically significant. ERAS could not increase the readmission rate after discharge in 30 days. The hospitalization expense was statistically heterogeneous after combined analysis of WMD (I2=92%, P<0.01). The random effect model was used for combine analysis of perioperative hospitalization expenses. Software analysis results showed perioperative hospitalization expenses were significantly different between ERAS group and traditional concept group (WMD=-0.40,95% CI=0.68～-0.11, P<0.01), and the difference was statistically significant. ERAS could decrease the perioperative hospitalization expenses. The results of publication biases showed that the approximate distributions of 9 studies were inverted infundibula and uniformly distributed in infundibula, suggesting that the publication bias had little effect on the Systematic evaluation and there was no significant publication bias.Conclusion As for the perioperative management in hepatectomy patients, compared with the traditional surgery strategy, ERAS strategy could significantly shorten the postoperative hospitalization time, shorten the postoperative functional rehabilitation time and reduce the hospitalization expenses. Meanwhile, ERAS could not increase the incidence of perioperative complications and readmission rate. ERAS strategy had better safety and effectiveness, worth to be popularized for hepatectomy patients in clinical practice. However, the existing specific studies on ERAS strategy for hepatectomy patients were really in small quantity. Moreover, the present studies had certain insufficiencies after our careful discussion and evaluation. The final conclusion also need more high-quality, multi-center, large-sample randomized controlled clinical trials to confirm and continuous improvement.Discussion The main problems existing in the combination of ERAS and hepatectomy were analyzed and discussed in detail after systematic evaluation. The problems included:Firstly, there was no uniform opinion on the specific ERAS aiming at hepatectomy in academic world. The current ERAS research only remains in the concept. The different medical centers have different understandings on ERAS. There was no uniform guide. Secondly, there are many aspects to be improved in the specific experimental design, baseline information comparability and final comparability of ERAS, which greatly weakens the persuasiveness of these current research conclusions. Thirdly, the minimally invasive laparoscopic technology advances rapidly nowadays, the precise liver surgery concept is put forward and developing, the higher requirements will undoubtedly be proposed for accelerating the development of ERAS, which can provide the opportunity for the development of ERAS. Finally, the specific clinical application, existing mistakes and its future development prospect of hepatectomy were discussed at last in this paper.As a hepatic surgeon, the optimum treatment effect and greatest benefit with minimal trauma are our persistent pursuits, also the main theme of the future development of liver surgery. The ultimate goal of perioperative management in hepatectomy patients is to optimize the curative effect, to minimalize the systemic trauma, to maximize liver function protection and to improve the postoperative rehabilitation quality. Finally the perfect unification of the safety, effectiveness and completion is our goal of liver sugery. On the one hand, the combined application of ERAS and hepatectomy can change the previous traditional concept of liver surgery, on the other hand, it can provide a wide platform for continuous development of liver surgery. It is worth our further exploration and research. |
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