背景:最近的研究表明,低分子量肝素(LMWH)可能在减轻急性胰腺炎(AP)的严重程度中发挥作用。本系统综述和荟萃分析旨在综合现有证据,证明LMWH治疗中重度和重度AP的有效性和安全性。
方法:本系统评价和荟萃分析是根据2020年更新的PRISMA指南和Cochrane干预措施系统评价手册进行的。在MEDLINE进行了系统搜索,Cochrane中央受控试验登记册,Scopus,和EMBASE,涵盖截至2024年2月发表的研究。随机对照试验(RCT)和观察性研究(n-RCT)报告了接受LMWH以及标准治疗(干预)的患者的AP结局差异。与未使用LMWH的标准治疗(对照)的患者相比,符合资格。随机效应模型用于计算合并的相对风险(RR)和平均差异(MD)与相应的95%CI。
结果:13项研究纳入荟萃分析,均在2004年至2022年之间发布。八项研究是随机对照试验,五个是n-RCT。分析了来自13,709名患者(6.971干预和6.738对照)的数据。干预组和对照组比较显示LMWH在总死亡率方面优于标准治疗(RR=0.44,95%CI=0.31;0.64,P<0.0001,I2=51%),急性坏死集合(RR=0.24,95%CI=0.09;0.62,P=0.003,I2=0%),和器官衰竭(RR=0.67,95%CI=0.48;0.93,P=0.02,I2=78%)。与对照组相比,干预组表现出更好的结果(RR=0.64,95%CI=0.44;0.94,P=0.02,I2=0%),住院时间(MD=-6.08,95%CI=-10.08;-2.07,P=0.003,I2=98%),需要手术干预(RR=0.50,95%CI=0.29;0.87,P=0.01,I2=61%),血管血栓形成(RR=0.43,95%CI=0.31;0.61,P<0.00001,I2=0%)。
结论:中度至高质量的证据表明,LMWH的早期干预可以改善非轻度AP的死亡率预后,器官衰竭,降低血管血栓形成的发生率。根据我们的发现,主张将LMWH纳入中重度至重度AP的治疗方案.
BACKGROUND: Recent studies suggest that low-molecular-weight heparin (LMWH) may play a role in mitigating the severity of acute pancreatitis (AP). This systematic
review and meta-analysis aims to synthesise existing evidence on the effectiveness and safety of LMWH in the treatment of moderately-severe and severe AP.
METHODS: This systematic
review and meta-analysis was conducted in accordance with the 2020 update of the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The systematic search was conducted in MEDLINE, the Cochrane Central Register of Controlled Trials, Scopus, and EMBASE, covering studies published up to February 2024. Randomised controlled trials (RCTs) and observational studies (n-RCTs) that reported the differences in the outcomes of AP for patients receiving LMWH in addition to the standard treatment (Intervention), compared to patients managed by standard treatment without LMWH (Control) were eligible. A random-effects model was used to calculate the pooled relative risk (RR) and mean differences (MD) with the corresponding 95% CI.
RESULTS: Thirteen studies were included in the meta-analysis, all published between 2004 and 2022. Eight studies were RCTs, and five were n-RCTs. Data from 13,709 patients (6.971 Interventions and 6.738 Controls) were analysed. The comparison of Intervention and Control groups showed the superiority of LMWH to standard treatments in terms of overall mortality (RR = 0.44, 95% CI = 0.31; 0.64, P < 0.0001, I2 = 51%), acute necrotic collections (RR = 0.24, 95% CI = 0.09; 0.62, P = 0.003, I2 = 0%), and organ failure (RR = 0.67, 95% CI = 0.48; 0.93, P = 0.02, I2 = 78%). The Intervention group showed superior outcomes compared with the Control group for gastrointestinal bleeding (RR = 0.64, 95% CI = 0.44; 0.94, P = 0.02, I2 = 0%), length of hospital stay (MD= - 6.08, 95% CI = - 10.08; - 2.07, P = 0.003, I2 = 98%), need for operative interventions (RR = 0.50, 95% CI = 0.29; 0.87, P = 0.01, I2 = 61%), and vascular thrombosis (RR = 0.43, 95% CI = 0.31; 0.61, P < 0.00001, I2 = 0%).
CONCLUSIONS: Moderate to high-quality evidence suggests that early intervention with LMWH could improve the prognosis of non-mild AP in terms of mortality, organ failure, and decreased incidence of vascular thrombosis. In light of our findings, integrating LMWH into the treatment regimen for moderate-severe to severe AP is advocated.