Guo Xingjun, Liu Gongpan, Zhang Xiaobin
Department of Hepatobiliary Surgery, Dongying People's Hospital, Dongying, Shandong, China.
Medicine (Baltimore). 2017 Dec;96(48):e8217. doi: 10.1097/MD.0000000000008217.
The protective role (decrease ischemia-reperfusion injury) of ischemic preconditioning (IP) before continuous vascular occlusion in liver resection is controversial. This meta-analysis aimed to compare the advantages and any potential disadvantages of IP maneuver.
A systematic search in the Embase, Medline, PubMed databases, and the Cochrane Library was performed using both medical subject headings (MeSH) and truncated word searches to identify all randomized controlled trials (RCTs) published on this topic. The primary outcomes were postoperative morbidity, mortality, postoperative aspartate aminotransferase (AST) level, alanine aminotransferase (ALT) level, and total bilirubin (TB) level. Pooled odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (95% CIs) were calculated using either the random effects model or fixed effects model.
Thirteen RCTs involving 918 patients were analyzed to achieve a summated outcome. The patients have been divided into IP group (n = 455) and no IP group (n = 463) before continuous vascular occlusion. No significant difference was found in postoperative mortality between both groups (P = .30). Subgroup analysis revealed that the postoperative morbidity in the cirrhosis subgroup was significantly less for the IP group compared with the control group (P = .01). In the cirrhosis subgroup, the result was stable (P = .04), without heterogeneity (P = .59; I = 0%). Meta-analysis of AST level on postoperative day (POD) 1 indicated lower postoperative AST level in the IP group (P = .04). The analysis of ALT level showed lower ALT level in the IP group versus control group (P = .02). However, there was no difference in postoperative AST and ALT level after excluding 1 study with statistical heterogeneity (all P > .05). With respect to postoperative TB level, there was no significant difference between 2 groups.
IP cannot decrease the hospital mortality for patients undergoing hepatectomy. IP may be beneficial for patients with cirrhosis due to less morbidity in patients with liver cirrhosis. However, we cannot conclude that IP can decrease ischemia-reperfusion injury because it did not significantly decrease postoperative AST, ALT, and TB levels.
在肝切除术中持续血管阻断前进行缺血预处理（IP）的保护作用（减少缺血再灌注损伤）存在争议。本荟萃分析旨在比较IP操作的优势和任何潜在劣势。
在Embase、Medline、PubMed数据库和Cochrane图书馆进行系统检索，使用医学主题词（MeSH）和截断词检索来识别关于该主题发表的所有随机对照试验（RCT）。主要结局指标为术后发病率、死亡率、术后天冬氨酸转氨酶（AST）水平、丙氨酸转氨酶（ALT）水平和总胆红素（TB）水平。采用随机效应模型或固定效应模型计算合并比值比（OR）和加权平均差（WMD）以及95%置信区间（95%CI）。
分析了13项涉及918例患者的RCT以得出综合结果。在持续血管阻断前，患者被分为IP组（n = 455）和非IP组（n = 463）。两组术后死亡率无显著差异（P = 0.30）。亚组分析显示，与对照组相比，IP组肝硬化亚组的术后发病率显著更低（P = 0.01）。在肝硬化亚组中，结果稳定（P = 0.04），无异质性（P = 0.59；I² = 0%）。术后第1天AST水平的荟萃分析表明IP组术后AST水平更低（P = 0.04）。ALT水平分析显示IP组ALT水平低于对照组（P = 0.02）。然而，排除1项具有统计学异质性的研究后，术后AST和ALT水平无差异（所有P > 0.05）。关于术后TB水平，两组之间无显著差异。
IP不能降低肝切除患者的医院死亡率。由于肝硬化患者发病率较低，IP可能对肝硬化患者有益。然而，我们不能得出IP可减少缺血再灌注损伤的结论，因为它并未显著降低术后AST、ALT和TB水平。
