上海交通大学学报（医学版） ›› 2023, Vol. 43 ›› Issue (1): 70-78.doi: 10.3969/j.issn.1674-8115.2023.01.009
方芳1(
), 台瑞1, 余倩1, 章雅青2()
收稿日期:2022-09-22
接受日期:2022-12-27
出版日期:2023-01-28
发布日期:2023-01-28
通讯作者:
章雅青
E-mail:fang_fang0604@163.com;zhangyqf@163.com
作者简介:方 芳（1971—），女，主任护师，博士生；电子信箱：fang_fang0604@163.com。
基金资助:
FANG Fang1(), TAI Rui1, YU Qian1, ZHANG Yaqing2()
Received:2022-09-22
Accepted:2022-12-27
Online:2023-01-28
Published:2023-01-28
Contact:
ZHANG Yaqing
E-mail:fang_fang0604@163.com;zhangyqf@163.com
Supported by:摘要：
目的·系统评价预康复对择期行胃肠道手术患者术后恢复的影响。方法·系统检索PubMed、EMbase、Cochrane Library、Web of Science、CINAHL、中国生物医学文献数据库（CBM）、中国知网、万方、维普数据库，检索时限均为建库至2022年1月31日。按照预先设定的标准筛选文献，对文献质量进行评价并提取资料，对纳入的随机对照试验采用RevMan 5.4进行meta分析。主要观察指标为术后总体并发症发生率和手术部位感染发生率，次要观察指标为住院天数、６ min步行试验（6-minute walk test，6MWT）、医院焦虑抑郁量表（Hospital Anxiety and Depression Scale，HADS）评分，以及死亡率和预康复执行的依从性。结果·共纳入16篇文献，其中英文15篇，中文1篇，共1 616例研究对象，纳入研究的总体质量较好。Meta分析结果显示，相较于对照组，实施了预康复的试验组患者术后总体并发症的发生率降低［比值比（odds ratio，OR）=0.57，95%置信区间（confidence interval，CI）0.35~0.94，P=0.030］，手术部位感染发生率降低（OR=0.64，95%CI 0.46~0.90，P=0.009），住院天数缩短［均数差值（mean difference，MD）=-2.45，95%CI -3.17~-1.73，P=0.000］。2组患者术前6MWT水平的差异无统计学意义；试验组术前6MWT水平相较于基线的提升程度优于对照组（MD=24.19，95%CI 3.77~44.60，P=0.020）。2组患者术前HADS评分和术后死亡率差异均无统计学意义。结论·预康复有利于降低胃肠道择期手术患者术后总体并发症发生率，尤其是手术部位感染发生率，从而缩短住院天数，有利于患者康复。
中图分类号:
方芳, 台瑞, 余倩, 章雅青. 预康复对胃肠道择期手术患者术后恢复效果的系统评价[J]. 上海交通大学学报（医学版）, 2023, 43(1): 70-78.
FANG Fang, TAI Rui, YU Qian, ZHANG Yaqing. Effect of prehabilitation on outcomes in patients undergoing elective gastrointestinal surgery: a systematic review[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2023, 43(1): 70-78.
图1 文献筛选流程图
Fig 1 Flowchart of the study screening
| Study | Population | Sample size （I/C） | Intervention method | Control method | Follow-up | Outcome |
|---|---|---|---|---|---|---|
| LÓPEZ-RODRÍGUEZ-ARIAS， 2021［ | Adults， elective surgery for colon or rectal neoplasm | 10/10 | A 30-d trimodal prehabilitation program with recommendations on physical exercise， nutritional supplementation， and relaxation exercises to be performed at home before surgery and the first 30 d after hospital discharge | Standard care | 12 weeks postoper-ative | ①②⑥ |
| BARBERAN-GARCIA， 2018［ | Adults， elective major abdominal surgery with high risk | 62/63 | A personalized prehabilitation program based on their health conditions and social circumstances which encompassed 3 major steps： motivational interview to assess the patients′ adherence profile and to codesign the characteristics of the physical activity program with the patient； personalized program to promote daily physical activity； supervised high-intensity endurance exercise training program | Standard care | Before discharge | ①②③ ④⑤⑥ |
| BOUSQUET-DION， 2018［ | Adults， elective surgery for colon or rectal neoplasm | 37/26 | A 4-week multi-modal home-based exercise program with once-weekly supervision consisted of exercise intervention， nutritional intervention and anxiety-reduction strategies | Standard care | 8 weeks postoper-ative | ①②③ ④⑥⑦ |
| OMMUNDSEN， 2018［ | >65 years， elective colorectal cancer surgery and fulfilling predefined criteria for frailty | 53/63 | A 3-week pragmatic tailored intervention based on the results of the geriatric assessment | Standard care | 3 months postoper-ative | ①②⑤ ⑥ |
| BURDEN， 2017［ | Adults， elective colorectal cancer surgery with preoperative weight loss>1 kg per 3‒6 months | 55/45 | Oral supplementation （10.1 KJ， 0.096 g of protein per mL） at a dose of 250 mL daily for a minimum of 5 d before the operation | Bottled water | 30 days postoper-ative | ①②⑥ ⑦ |
| GILLIS， 2016［ | Adults， elective surgery for colon or rectal neoplasm | 22/21 | A whey protein supplement was provided in a quantity that matched the patient′s need according to the estimated deficit in dietary protein intake for approximately 4 weeks leading up to the surgery | Placebo | 4 weeks postoper-ative | ③⑥ |
| GILLIS， 2014［ | Adults， elective surgery for colon or rectal neoplasm | 38/39 | A 4-week trimodal prehabilitation program at home included exercise intervention， nutrition intervention， and coping strategies to reduce anxiety | Standard care | 8 weeks postoper-ative | ①③④ ⑥ |
| FUJITANI， 2012［ | ≤80 years， elective total gastrectomy， body weight loss of 10 percent or less within 6 months before entry | 127/117 | Preoperative oral supplementation of 1 000 mL/d in the form of an immunonutrient-enriched enteral feed added to normal diet for 5 d consecutively before the surgery | Normal diet | Before discharge | ①②⑥ |
| BURDEN， 2011［ | Adults， elective surgery for colon or rectal neoplasm | 54/62 | Oral supplementary drink of 400 mL daily， and dietary advice for 10 d before the operation | Dietary advice only | Before discharge | ①②⑥ |
| SMEDLEY， 2004［ | Adults， elective moderate to severe lower gastrointestinal surgery | 48/50 | Oral nutritional supplement in small， frequent quantities between meals for 7 d before the operation， the volume consumed was recorded | Normal diet | Before discharge | ①②⑥ ⑦ |
| GIANOTTI， 2002［ | Adults， major elective surgery for malignancy of the gastrointestinal tract | 102/102 | Oral nutritional supplement （1 000 mL/d） of a formula enriched with arginine， ω-3 fatty acids， and RNA for 5 d before the operation | Standard care | 30 d after discharge | ①②⑤ ⑥ |
| BRAGA， 2002［ | Adults， elective surgery for gastroin-testinal neoplasm， body weight loss of 10% or more within 6 months before entry | 50/50 | Oral nutritional supplement （1 000 mL/d） added to normal diet for 7 d consecutively before the surgery | Normal diet | 30 d after discharge | ①②⑤ ⑥ |
| KABATA， 2015［ | Adults， elective， radical gastroin-testinal and abdominal cancer surgery | 54/48 | Oral nutritional supplement （400 mL/d） added to normal diet for 14 d consecutively before the surgery | Normal diet | 30 d postoper-ative | ①⑤⑥ |
| BARKER， 2013［ | Adults， elective upper and lower gastrointestinal surgery | 46/49 | Three packs of 237 mL of oral nutritional supplement per day for 5 d before the surgery | Standard care | 30 d postoper-ative | ①②⑤ ⑥ |
| BERKEL， 2022［ | ≥60 years， elective surgery for colon or rectal neoplasm | 28/29 | A personalized 3-week （3 sessions per week， 9 sessions in total） supervised exercise program | Standard care | 90 d postoper-ative | ①②⑥ |
| HUANG， 2014［ | Adults， elective， radical gastroin-testinal， cancer surgery | 41/41 | Oral nutritional supplement （25 mL/kg） for 7 d before the surgery | Normal diet | Before discharge | ①②⑥ |
表1 纳入研究的基本信息
Tab 1 Basic information of the selected studies
| Study | Population | Sample size （I/C） | Intervention method | Control method | Follow-up | Outcome |
|---|---|---|---|---|---|---|
| LÓPEZ-RODRÍGUEZ-ARIAS， 2021［ | Adults， elective surgery for colon or rectal neoplasm | 10/10 | A 30-d trimodal prehabilitation program with recommendations on physical exercise， nutritional supplementation， and relaxation exercises to be performed at home before surgery and the first 30 d after hospital discharge | Standard care | 12 weeks postoper-ative | ①②⑥ |
| BARBERAN-GARCIA， 2018［ | Adults， elective major abdominal surgery with high risk | 62/63 | A personalized prehabilitation program based on their health conditions and social circumstances which encompassed 3 major steps： motivational interview to assess the patients′ adherence profile and to codesign the characteristics of the physical activity program with the patient； personalized program to promote daily physical activity； supervised high-intensity endurance exercise training program | Standard care | Before discharge | ①②③ ④⑤⑥ |
| BOUSQUET-DION， 2018［ | Adults， elective surgery for colon or rectal neoplasm | 37/26 | A 4-week multi-modal home-based exercise program with once-weekly supervision consisted of exercise intervention， nutritional intervention and anxiety-reduction strategies | Standard care | 8 weeks postoper-ative | ①②③ ④⑥⑦ |
| OMMUNDSEN， 2018［ | >65 years， elective colorectal cancer surgery and fulfilling predefined criteria for frailty | 53/63 | A 3-week pragmatic tailored intervention based on the results of the geriatric assessment | Standard care | 3 months postoper-ative | ①②⑤ ⑥ |
| BURDEN， 2017［ | Adults， elective colorectal cancer surgery with preoperative weight loss>1 kg per 3‒6 months | 55/45 | Oral supplementation （10.1 KJ， 0.096 g of protein per mL） at a dose of 250 mL daily for a minimum of 5 d before the operation | Bottled water | 30 days postoper-ative | ①②⑥ ⑦ |
| GILLIS， 2016［ | Adults， elective surgery for colon or rectal neoplasm | 22/21 | A whey protein supplement was provided in a quantity that matched the patient′s need according to the estimated deficit in dietary protein intake for approximately 4 weeks leading up to the surgery | Placebo | 4 weeks postoper-ative | ③⑥ |
| GILLIS， 2014［ | Adults， elective surgery for colon or rectal neoplasm | 38/39 | A 4-week trimodal prehabilitation program at home included exercise intervention， nutrition intervention， and coping strategies to reduce anxiety | Standard care | 8 weeks postoper-ative | ①③④ ⑥ |
| FUJITANI， 2012［ | ≤80 years， elective total gastrectomy， body weight loss of 10 percent or less within 6 months before entry | 127/117 | Preoperative oral supplementation of 1 000 mL/d in the form of an immunonutrient-enriched enteral feed added to normal diet for 5 d consecutively before the surgery | Normal diet | Before discharge | ①②⑥ |
| BURDEN， 2011［ | Adults， elective surgery for colon or rectal neoplasm | 54/62 | Oral supplementary drink of 400 mL daily， and dietary advice for 10 d before the operation | Dietary advice only | Before discharge | ①②⑥ |
| SMEDLEY， 2004［ | Adults， elective moderate to severe lower gastrointestinal surgery | 48/50 | Oral nutritional supplement in small， frequent quantities between meals for 7 d before the operation， the volume consumed was recorded | Normal diet | Before discharge | ①②⑥ ⑦ |
| GIANOTTI， 2002［ | Adults， major elective surgery for malignancy of the gastrointestinal tract | 102/102 | Oral nutritional supplement （1 000 mL/d） of a formula enriched with arginine， ω-3 fatty acids， and RNA for 5 d before the operation | Standard care | 30 d after discharge | ①②⑤ ⑥ |
| BRAGA， 2002［ | Adults， elective surgery for gastroin-testinal neoplasm， body weight loss of 10% or more within 6 months before entry | 50/50 | Oral nutritional supplement （1 000 mL/d） added to normal diet for 7 d consecutively before the surgery | Normal diet | 30 d after discharge | ①②⑤ ⑥ |
| KABATA， 2015［ | Adults， elective， radical gastroin-testinal and abdominal cancer surgery | 54/48 | Oral nutritional supplement （400 mL/d） added to normal diet for 14 d consecutively before the surgery | Normal diet | 30 d postoper-ative | ①⑤⑥ |
| BARKER， 2013［ | Adults， elective upper and lower gastrointestinal surgery | 46/49 | Three packs of 237 mL of oral nutritional supplement per day for 5 d before the surgery | Standard care | 30 d postoper-ative | ①②⑤ ⑥ |
| BERKEL， 2022［ | ≥60 years， elective surgery for colon or rectal neoplasm | 28/29 | A personalized 3-week （3 sessions per week， 9 sessions in total） supervised exercise program | Standard care | 90 d postoper-ative | ①②⑥ |
| HUANG， 2014［ | Adults， elective， radical gastroin-testinal， cancer surgery | 41/41 | Oral nutritional supplement （25 mL/kg） for 7 d before the surgery | Normal diet | Before discharge | ①②⑥ |
图2 纳入文献的风险偏倚
Fig 2 Risk bias of the included studiesNote: “+”—up to the standard; “-”—failure to meet the standard; “?”—not mentioned or described clearly in the literature.
图3 预康复对术后总体并发症发生率影响的森林图
Fig 3 Forest plot: the effect of prehabilitation program on the incidence of postoperative complications
图4 预康复对术后SSI发生率影响的森林图
Fig 4 Forest plot: the effect of prehabilitation program on the incidence of surgical site infection
图5 预康复对住院天数影响的森林图
Fig 5 Forest plot: the effect of prehabilitation program on the length of hospital stay
图6 预康复提升术前6MWT水平的森林图
Fig 6 Forest plot: the effect of prehabilitation program on the change of preoperative 6MWT
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