围术期使用类固醇激素预防肝切除术后缺血再灌注损伤和手术应激反应的系统回顾及Meta分析

doi:10.3877/cma.j.issn.1674-0793.2014.02.016

背景

目前已有多种方法可预防肝切除术后缺血再灌注损伤和手术应激反应，如缺血预处理、间歇性或选择性肝门阻断及药物性预防，但是关于类固醇激素的作用效果目前仍存在争议。

方法

选择MEDLINE、Embase及CENTRAL等数据库，筛选出围手术期静脉使用类固醇激素的治疗组及安慰剂作为对照组的所有随机对照研究（RCTs）和非随机对照研究（non-RCTs）。严格评价和Meta分析按照系统综述和荟萃分析优先报告（PRISMA声明）的要求来进行。

结果

共6篇文献被纳入本研究，其中包括5项RCTs。结果显示静脉使用糖皮质激素的患者术后并发症的发生率比对照组低24%（RR=0.76，95% CI=0.57~0.99，P=0.047）。与对照组相比，治疗组术后早期白细胞介素10（IL-10）的水平显著提高。研究还发现类固醇可以显著降低术后血清胆红素及炎性标记物IL-6及C反应蛋白（CRP）的水平。术后感染及切口并发症的发生率两组无差异。

结论

肝切除患者围手术期使用类固醇激素有益于术后恢复。

表1 被纳入研究的主要特征

作者（发表年份）	研究设计	国家	病例数		给药方案	血流阻断	观察指标	Jadad评分
作者（发表年份）	研究设计	国家	治疗组	对照组	给药方案	血流阻断	观察指标	Jadad评分
Hayashi等^[35] （2011）	RCT	日本	102	98	肝门阻断前给予氢化可的松500 mg；术后第1,2,3天分别给予氢化可的松300,200,100 mg	间歇性肝门阻断	并发症，AST，ALT，胆红素，INR，CRP，IL-6, IL-10,住院时间	3
Schmidt等^[36] （2007）	RCT	德国	10	10	术前给予甲强龙30mg/kg，滴注时间30 min	无血流阻断	并发症，AST，ALT，胆红素，INR，CRP，IL-6, IL-8, IL-10, TNF-α,住院时间	4
Aldrighetti等^[37] （2006）	RCT	意大利	36	37	麻醉诱导前给予500 mg甲强龙	间歇性肝门阻断	并发症，AST，ALT，胆红素，INR，CRP，IL-6,住院时间	2
Muratore等^[38] （2003）	RCT	意大利	25	28	肝切除之前给予甲强龙30 mg/kg，滴注时间30 min	连续性肝门阻断	并发症，AST，ALT，胆红素，PT, IL-6,住院时间	2
Yamashita等^[39] （2001）	RCT	日本	17	16	术前给予甲强龙500 mg，滴注时间2 h	连续性肝门阻断	并发症，AST，ALT，胆红素，PT，CRP，IL-6, IL-10,住院时间	2
Shimada等^[40] （1996）	Non-RCT	日本	6	11	术前给予甲强龙30 mg/kg，滴注时间3 h;手术完毕给予1 g；术后第1天给予1 g	无血流阻断	并发症，AST，胆红素，IL-6，CRP	1

表1 被纳入研究的主要特征

作者（发表年份）	研究设计	国家	病例数		给药方案	血流阻断	观察指标	Jadad评分
作者（发表年份）	研究设计	国家	治疗组	对照组	给药方案	血流阻断	观察指标	Jadad评分
Hayashi等^[35] （2011）	RCT	日本	102	98	肝门阻断前给予氢化可的松500 mg；术后第1,2,3天分别给予氢化可的松300,200,100 mg	间歇性肝门阻断	并发症，AST，ALT，胆红素，INR，CRP，IL-6, IL-10,住院时间	3
Schmidt等^[36] （2007）	RCT	德国	10	10	术前给予甲强龙30mg/kg，滴注时间30 min	无血流阻断	并发症，AST，ALT，胆红素，INR，CRP，IL-6, IL-8, IL-10, TNF-α,住院时间	4
Aldrighetti等^[37] （2006）	RCT	意大利	36	37	麻醉诱导前给予500 mg甲强龙	间歇性肝门阻断	并发症，AST，ALT，胆红素，INR，CRP，IL-6,住院时间	2
Muratore等^[38] （2003）	RCT	意大利	25	28	肝切除之前给予甲强龙30 mg/kg，滴注时间30 min	连续性肝门阻断	并发症，AST，ALT，胆红素，PT, IL-6,住院时间	2
Yamashita等^[39] （2001）	RCT	日本	17	16	术前给予甲强龙500 mg，滴注时间2 h	连续性肝门阻断	并发症，AST，ALT，胆红素，PT，CRP，IL-6, IL-10,住院时间	2
Shimada等^[40] （1996）	Non-RCT	日本	6	11	术前给予甲强龙30 mg/kg，滴注时间3 h;手术完毕给予1 g；术后第1天给予1 g	无血流阻断	并发症，AST，胆红素，IL-6，CRP	1

图1 系统回顾和Meta分析的筛选过程

图2 方法学评估

图3 发病率的漏斗图。每个圆点代表一项研究，实线描述的是效应大小（总RR值=0.76）。零假设（log_RR=0）左侧的研究支持介入治疗。漏斗图的不对称提示可能存在发表偏倚

图4 围术期应用类固醇激素对术后发病率影响的Meta分析。固定效应模型显示RR值和95% CI

图5 围术期应用类固醇激素对术后第1天血清胆红素水平影响的Meta分析。随机效应模型显示加权均数差和95% CI

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