Departments of1Neurosurgery and.
2Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
J Neurosurg Pediatr. 2020 Nov 20;27(2):225-238. doi: 10.3171/2020.7.PEDS20444. Print 2021 Feb 1.
More than 7500 children undergo surgery for scoliosis each year, at an estimated annual cost to the health system of $1.1 billion. There is significant interest among patients, parents, providers, and payors in identifying methods for delivering quality outcomes at lower costs. Enhanced recovery after surgery (ERAS) protocols have been suggested as one possible solution. Here the authors conducted a systematic review of the literature describing the clinical and economic benefits of ERAS protocols in pediatric spinal deformity surgery.
The authors identified all English-language articles on ERAS protocol use in pediatric spinal deformity surgery by using the following databases: PubMed/MEDLINE, Web of Science, Cochrane Reviews, EMBASE, CINAHL, and OVID MEDLINE. Quantitative analyses of comparative articles using random effects were performed for the following clinical outcomes: 1) length of stay (LOS); 2) complication rate; 3) wound infection rate; 4) 30-day readmission rate; 5) reoperation rate; and 6) postoperative pain scores.
Of 950 articles reviewed, 7 were included in the qualitative analysis and 6 were included in the quantitative analysis. The most frequently cited benefits of ERAS protocols were shorter LOS, earlier urinary catheter removal, and earlier discontinuation of patient-controlled analgesia pumps. Quantitative analyses showed ERAS protocols to be associated with shorter LOS (mean difference -1.12 days; 95% CI -1.51, -0.74; p < 0.001), fewer postoperative complications (OR 0.37; 95% CI 0.20, 0.68; p = 0.001), and lower pain scores on postoperative day (POD) 0 (mean -0.92; 95% CI -1.29, -0.56; p < 0.001) and POD 2 (-0.61; 95% CI -0.75, -0.47; p < 0.001). There were no differences in reoperation rate or POD 1 pain scores. ERAS-treated patients had a trend toward higher 30-day readmission rates and earlier discontinuation of patient-controlled analgesia (both p = 0.06). Insufficient data existed to reach a conclusion about cost differences.
The results of this systematic review suggest that ERAS protocols may shorten hospitalizations, reduce postoperative complication rates, and reduce postoperative pain scores in children undergoing scoliosis surgery. Publication biases exist, and therefore larger, prospective, multicenter data are needed to validate these results.
每年有超过 7500 名儿童接受脊柱侧弯手术，估计卫生系统为此每年花费 11 亿美元。患者、家长、医护人员和支付方都非常关注如何以更低的成本实现高质量的治疗效果。加速康复外科（ERAS）方案被认为是一种可能的解决方案。本研究对描述 ERAS 方案在儿科脊柱畸形手术中临床和经济效益的文献进行了系统性回顾。
作者通过以下数据库检索了所有关于 ERAS 方案在儿科脊柱畸形手术中应用的英文文章：PubMed/MEDLINE、Web of Science、Cochrane 综述、EMBASE、CINAHL 和 OVID MEDLINE。对于以下临床结局，使用随机效应模型对比较性文章进行了定量分析：1）住院时间（LOS）；2）并发症发生率；3）伤口感染率；4）30 天再入院率；5）再次手术率；6）术后疼痛评分。
在 950 篇综述文章中，有 7 篇被纳入定性分析，6 篇被纳入定量分析。ERAS 方案最常被引用的益处包括 LOS 更短、导尿管更早拔除和患者自控镇痛泵更早停用。定量分析显示，ERAS 方案与 LOS 更短（平均差值-1.12 天；95%置信区间-1.51，-0.74；p<0.001）、术后并发症更少（比值比 0.37；95%置信区间 0.20，0.68；p=0.001）以及术后第 0 天（POD）和第 2 天（POD）疼痛评分更低（术后第 0 天疼痛评分平均差值-0.92；95%置信区间-1.29，-0.56；p<0.001；术后第 2 天疼痛评分平均差值-0.61；95%置信区间-0.75，-0.47；p<0.001）有关。再次手术率或 POD1 疼痛评分无差异。ERAS 治疗组 30 天再入院率和患者自控镇痛泵停用时间更早的趋势更高（均 p=0.06）。由于数据不足，无法得出关于成本差异的结论。
本系统回顾的结果表明，ERAS 方案可能缩短住院时间、降低术后并发症发生率并减轻儿童脊柱侧弯手术患者的术后疼痛。存在发表偏倚，因此需要更大规模、前瞻性、多中心的数据来验证这些结果。
