背景:随着人口老龄化,越来越多的老年人前来做手术。与年龄相关的生理储备和功能能力下降会导致手术后的虚弱和不良结局。因此,优化老年患者的围手术期护理势在必行。增强术后恢复(ERAS)途径和微创手术(MIS)可能会影响手术结果,但目前对老年患者的使用和影响尚不清楚.这项研究的目的是为接受大型腹部手术的老年人的围手术期护理提供循证建议。
方法:专家共识确定了与围手术期护理相关的关键术语和指标的工作定义。使用PubMed进行了系统的文献综述和荟萃分析,Embase,科克伦图书馆,以及Clinicaltrials.gov数据库,提供24个预先定义的康复主题领域的关键问题,MIS,和ERAS在腹部大手术中(结直肠,上消化道(UGI),疝,和肝胰胆管(HPB))以根据GRADE方法生成循证建议。
结果:老年人被定义为65岁及以上。最初从搜索参数中检索了超过20,000篇文章。在172项研究的三个主题领域进行了证据综合,对MIS和ERAS主题进行荟萃分析。建议老年患者使用MIS和ERAS,尤其是在接受结直肠手术时。专家意见建议进行康复治疗,停止吸烟和饮酒,纠正所有结直肠贫血,UGI,疝,和老年人的HPB程序。所有建议都是有条件的,证据的确定性低至非常低,结直肠手术中的ERAS项目除外。
结论:MIS和ERAS适用于接受腹部大手术的老年人,有证据支持在结直肠手术中使用。尽管专家意见支持康复,没有足够的证据支持使用。这项工作已经确定了进一步研究的证据空白,以优化接受大型腹部手术的老年人。
BACKGROUND: As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery.
METHODS: Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology.
RESULTS: Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery.
CONCLUSIONS: MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.