胰十二指肠切除术患者的限制性与自由性液体疗法：一项系统回顾和Meta分析
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Restrictive Versus Liberal Fluid Regimens in Patients Undergoing Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis
背景与目的
胰十二指肠切除术与显著的发病率和死亡率有关，这可能受围手术期液体管理的影响。目前尚不清楚宽松和限制性的液体疗法是否会影响胰十二指肠切除术患者的死亡率和发病率。
方 法
搜索medline、embase、cochrane library和clinicaltrials.gov数据库，以比较胰十二指肠切除术患者限制性和自由性围术期液体的研究。在接受胰十二指肠切除术的患者中，前瞻性和回顾性研究均符合纳入标准，其中患者结局按严格和宽松的围术期液体管理方案分层，以死亡率为主要结局。在研究确定后，进行系统回顾和meta分析，并进行试验序列分析。
结 果
共纳入13项研究，包括5项前瞻性试验和8项回顾性分析，共3062例患者。在整个队列研究中，限制性液体方案与自由液体方案相比，死亡率显著降低(优势比0.54;95% CI 0.31-0.94, p = 0.03)。并发症发生率无显著性差异。亚组分析显示，这一结果是由回顾性研究得出的。试验序列分析的结果表明，这种死亡率优势可能是由于I型统计错误，需要更多的患者数量才能得出最终结论。
结 论
限制性液体疗法与胰十二指肠切除术后死亡率的降低有关。鉴于这一发现与发病的重要原因缺乏关联，并考虑到最近发表的文献研究结果，因此需要从实际角度解释这一发现的临床相关性。
原始文献摘要
BACKGROUND:
Pancreaticoduodenectomy is associated with significant morbidity and mortality which may be influenced by perioperative fluid management. It remains unclear whether liberal and restrictive fluid regimens impact mortality and morbidity in patients undergoing pancreaticoduodenectomy.
Aim：
The aim of this study was to compare the effects of preloading with ringer's solution and Voluven on hemodynamic changes in patients underwent elective Caesarean section under spinal anesthesia.
Methed:
Medline, EMBASE, Cochrane Library and clinicaltrials.gov were searched for studies comparing restrictive and liberal perioperative fluids in patients undergoing pancreaticoduodenectomy. Both prospective and retrospective studies in those undergoing pancreaticoduodenectomy were eligible for inclusion where the patient outcomes were stratified to restrictive and liberal perioperative fluid management regimens, with mortality as the primary outcome. Following study identification, a systematic review and meta-analysis with trial sequential analysis was completed.
Results：
Thirteen studies including five prospective trials and eight retrospective analyses totalling 3062 patients were included.Restrictive fluid regimens were associated with a significant reduction in mortality compared to liberal fluid regimens for the overall cohort (odds ratio 0.54; 95% CI 0.31–0.94, p = 0.03). There were no significant differences in complication profile. Subgroup analysis revealed this result was contributed to significantly by retrospective studies. The results of the trial sequential analysis suggest this mortality benefit may be due to a type I statistical error and that further patient numbers are required for definitive conclusions.
Conclusion:
Restrictive fluid regimens are associated with a reduction in mortality following pancreaticoduodenectomy. The clinical relevance of this finding needs to be interpreted pragmatically given the lack of association with significant causes of morbidity and in considering the results of the recently published RELIEF study.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：唐剑 编辑：何幼芹 审校：王贵龙
