Karunakaran Monish, Jonnada Pavan Kumar, Barreto Savio George
Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Gurgaon 122001, Haryana, India.
Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru 560029, Karnataka, India.
World J Clin Cases. 2021 May 6;9(13):3024-3037. doi: 10.12998/wjcc.v9.i13.3024.
Enhanced recovery after surgery is steadily gaining importance in patients undergoing pancreatic surgery, including pancreatoduodenectomy (PD). While clinical pathways targeting enhanced-recovery can achieve their intended outcome in reducing length of stay, compliance to these pathways, and their relevance is poorly understood. The aim of this systematic review was to assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.
To assess the impact of deviations from/non-compliance to a clinical pathway on post-PD outcomes.
A systematic review of major reference databases was undertaken, according to preferred reporting items for systematic reviews and meta-analysis guidelines, between January 2000 and November 2020 relating to compliance with clinical pathways and its impact on outcomes in patients undergoing PD. A meta-analysis was performed using fixed-effects or random-effects models.
Eleven studies including 1852 patients were identified. Median overall compliance to all components of the clinical pathway was 65.7% [interquartile range (IQR): 62.7%-72.3%] with median compliance to post-operative parameters of the clinical pathway being 44% (IQR: 34.5%-52.25%). Meta-analysis using a fixed-effects model showed that ≥ 50% compliance to a clinical pathway predicted significantly fewer post-operative complications [pooled odds ratio (OR): 9.46, 95% confidence interval (CI): 5.00-17.90; < 0.00001] and a significantly shorter length of hospital stay [pooled mean difference (MD): 4.32, 95%CI: -3.88 to -4.75; < 0.0001]. At 100% compliance which was associated with significantly fewer post-operative complications (pooled OR: 11.25, 95%CI: 4.71-26.84; < 0.00001) and shorter hospital stay (pooled MD of 4.66, 95%CI: 2.81-6.51; < 0.00001).
Compliance to post-PD clinical pathways remains low. Deviations are associated with an increased risk of complications and length of hospital stay. Under-standing the relevance of deviations to clinical pathways post-PD presents pancreatic surgeons with opportunities to actively pursue an enhanced-recovery of their patients.
在包括胰十二指肠切除术（PD）在内的胰腺手术患者中，术后加速康复正日益受到重视。虽然针对加速康复的临床路径能够在缩短住院时间方面达到预期效果，但其依从性以及相关性仍知之甚少。本系统评价的目的是评估偏离/不遵守临床路径对PD术后结局的影响。
评估偏离/不遵守临床路径对PD术后结局的影响。
根据系统评价和Meta分析的首选报告项目指南，对2000年1月至2020年11月期间主要参考文献数据库进行系统评价，内容涉及PD患者对临床路径的依从性及其对结局的影响。采用固定效应或随机效应模型进行Meta分析。
共纳入11项研究，涉及1852例患者。临床路径所有组成部分的总体依从性中位数为65.7%[四分位间距（IQR）：62.7%-72.3%]；临床路径术后参数的依从性中位数为44%（IQR：34.5%-52.25%）。采用固定效应模型的Meta分析显示，对临床路径的依从性≥50%可显著减少术后并发症[合并比值比（OR）：9.46, 95%置信区间（CI）：5.00-17.90；P<0.00001]，并显著缩短住院时间[合并平均差（MD）：4.32, 95%CI：-3.88至-4.75；P<0.0001]。依从性达100%时，术后并发症显著减少（合并OR：11.25, 95%CI：4.71-26.84；P<0.00001），住院时间缩短（合并MD为4.66, 95%CI：2.81-6.51；P<0.00001）。
PD术后临床路径的依从性仍然较低。偏离与并发症风险增加和住院时间延长相关。了解PD术后偏离临床路径的相关性为胰腺外科医生提供了积极促进患者加速康复的机会。
