Department of Surgery, Division of Vascular Surgery, University of North Carolina, Chapel Hill, NC.
Department of Surgery, Division of Vascular Surgery, Maine Medical Center, Portland, Me.
J Vasc Surg. 2019 Aug;70(2):629-640.e1. doi: 10.1016/j.jvs.2019.01.050. Epub 2019 Mar 25.
Patients undergoing vascular operations face high rates of intraoperative and postoperative complications and delayed return to baseline. Enhanced recovery after surgery (ERAS), with its aim of delivering high-quality perioperative care and accelerating recovery, appears well suited to address the needs of this population.
In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review to characterize the use and effectiveness of ERAS in all types of vascular and endovascular operations. We queried MEDLINE (through PubMed), Embase, Web of Science, Scopus, ProQuest Dissertations and Theses Global, Cochrane Central Register of Controlled Trials, Prospero, and Google Scholar. Two reviewers independently completed screening, review, and quality assessment. Eligible articles described the use of ERAS pathways for vascular operations from January 1, 1997, through December 7, 2017. Details regarding patients' demographics and use of the ERAS pathway or selected ERAS components were extracted. When available, results including perioperative morbidity, mortality, and in-hospital length of stay were collected. The studies with control groups that evaluated ERAS-like pathways were meta-analyzed using random-effects meta-analysis.
In the final analysis, 19 studies were included: four randomized controlled trials and 15 observational studies. By Let Evidence Guide Every New Decision (LEGEND) criteria, the two good-quality studies are randomized controlled trials that evaluated a specific part of an ERAS pathway. All other studies were considered poor quality. Meta-analysis of the five studies describing ERAS-like pathways demonstrated a reduction in length of stay by 3.5 days (P = .0012).
Based on systematic review, the use of ERAS pathways in vascular surgery is limited, and existing evidence of their feasibility and effectiveness is low quality. There is minimal poor- to moderate-quality evidence describing the use of ERAS pathways in open aortic operations. There is scarce, poor-quality evidence related to ERAS pathways in lower extremity operations and no published evidence related to ERAS pathways in endovascular operations. Although the risk of bias is high in most of the studies done to date, all of them observed improvements in length of stay, postoperative diet, and ambulation. It is reasonable to consider the implementation of ERAS pathways in the care of vascular surgery patients, specifically those undergoing open aortic operations, but many of the details will be based on limited data and extrapolation from other surgical specialties until further research is done.
接受血管手术的患者面临术中及术后并发症发生率高和恢复延迟至基线水平的问题。加速康复外科（ERAS）旨在提供高质量的围手术期护理并加速康复，似乎非常适合满足这一人群的需求。
根据系统评价和荟萃分析的首选报告项目的要求，我们进行了一项系统评价，以描述 ERAS 在所有类型的血管和血管内手术中的使用情况及其效果。我们检索了 MEDLINE（通过 PubMed）、Embase、Web of Science、Scopus、ProQuest Dissertations and Theses Global、Cochrane 中央对照试验注册、Prospéro 和 Google Scholar。两名评审员独立完成了筛选、评价和质量评估。合格的文章描述了 1997 年 1 月 1 日至 2017 年 12 月 7 日期间使用 ERAS 途径进行的血管手术。提取了有关患者人口统计学数据以及 ERAS 途径或选定的 ERAS 成分使用情况的详细信息。在有对照组的情况下，收集了包括围手术期发病率、死亡率和住院时间在内的结果。使用随机效应荟萃分析对评估 ERAS 样途径的具有对照组的研究进行荟萃分析。
最终分析包括 19 项研究：4 项随机对照试验和 15 项观察性研究。根据 LEGEND（Let Evidence Guide Every New Decision，让证据指导每一个新决策）标准，两项高质量研究是评估 ERAS 途径特定部分的随机对照试验。其他所有研究均被认为质量较差。对描述 ERAS 样途径的 5 项研究进行荟萃分析表明，住院时间缩短了 3.5 天（P =.0012）。
基于系统评价，血管外科中 ERAS 途径的使用有限，其可行性和有效性的现有证据质量较低。仅有少量低至中等质量的证据描述了开放主动脉手术中 ERAS 途径的使用。关于下肢手术中 ERAS 途径的证据很少，而且没有关于血管内手术中 ERAS 途径的发表证据。尽管迄今为止进行的大多数研究的偏倚风险较高，但所有研究均观察到住院时间、术后饮食和活动能力的改善。考虑在血管外科患者的护理中实施 ERAS 途径是合理的，特别是在接受开放主动脉手术的患者中，但在进一步研究之前，许多细节将基于有限的数据和从其他外科专业领域的推断。
