围手术期精准静脉通路管理策略在复杂肝胆胰脾及腹部大血管手术患者中的结局与器官保护效果：一项系统评价与荟萃分析。
完整摘要 · 中文译文
背景与目的：随着外科技术的不断进步，复杂的肝胆胰（HPB）及血管外科手术越来越多地应用于临床。尽管此类手术能够改善患者预后，但其带来的广泛手术创伤和严重生理紊乱会触发强烈的生理应激反应，显著增加围术期器官损伤的风险。这已成为阻碍术后恢复、加重医疗系统负担的重大临床挑战。目前临床实践中常规的液体管理策略主要以静态血流动力学参数为指导，缺乏对患者个体生理储备和手术应激水平的动态适应性，容易导致容量复苏不足或过量，从而加剧器官功能障碍。围术期精准静脉通路管理（PVAM）是一种创新性治疗策略，整合了先进的血流动力学监测、算法指导治疗和专用通路支持。该方法克服了常规管理的局限性，为个体化围术期管理提供了新方向。本荟萃分析旨在系统评价围术期精准静脉通路管理（PVAM）对接受复杂肝胆胰及血管手术患者器官特异性并发症发生率和临床结局的影响，旨在阐明其器官保护价值和临床可行性，提供h 为在高风险外科患者中临床实施该策略提供了高质量的循证支持。 方法：在PubMed、Embase、Cochrane Library和Web of Science数据库中进行系统检索，检索截止日期设为2024年4月15日。纳入比较围手术期精准静脉通路管理（PVAM）（整合先进血流动力学监测、目标导向治疗和专用通路）与标准治疗的随机对照试验（RCT）和前瞻性队列研究，研究对象为接受复杂肝胆胰或大血管手术的成人。主要结局包括急性肾损伤（AKI）和临床相关术后胰瘘（CR-POPF）。采用随机效应模型合成数据。 结果：共纳入14项研究，涉及2，158例患者。围手术期精准静脉通路管理（PVAM）显著降低了AKI的发生率（RR=0.61，95% CI 0.49-0.76；P<0.001）和CR-POPF的发生率（RR=0.69，95% CI 0.54-0.88；P=0.002），同时还降低了总体并发症发生率（RR=0.76，95% CI 0.65-0.89）并缩短了住院时间（MD=-2.4天，95% CI -3.8至-1.0）。 结论：围手术期精准静脉通路管理（PVAM）策略在复杂肝胆胰及血管手术患者中显示出显著的肾脏和胰腺保护作用，促进了术后恢复，从而支持将其整合到临床实践中。
完整摘要 · 英文原文
BACKGROUND & AIMS: With continuous advances in surgical techniques, complex hepatobiliary pancreatic (HPB) and vascular surgical procedures are increasingly being applied clinically. Whilst such operations can improve patient prognosis, the extensive surgical trauma and severe physiological disruption they entail trigger intense physiological stress responses, significantly heightening the risk of perioperative organ injury. This has become a critical clinical challenge that impedes postoperative recovery and exacerbates the burden on healthcare systems. Current conventional fluid management strategies in clinical practice are primarily guided by static haemodynamic parameters. They lack dynamic adaptability to individual patient physiological reserves and surgical stress levels, readily leading to inadequate or excessive volume resuscitation, thereby exacerbating organ dysfunction. Precision Venous Access Management (PVAM) during the perioperative period represents an innovative therapeutic strategy integrating advanced haemodynamic monitoring, algorithm-guided therapy, and specialised access support. This approach overcomes the limitations of conventional management, offering a new direction for individualised perioperative care. This meta-analysis aims to systematically evaluate the impact of perioperative precision venous access management (PVAM) on organ-specific complication rates and clinical outcomes in patients undergoing complex hepatobiliary, pancreatic, and vascular surgery. It seeks to clarify its organ-protective value and clinical feasibility, providing high-quality evidence-based support for the clinical implementation of this strategy in high-risk surgical patients. METHODS: Systematic searches were conducted in PubMed, Embase, the Cochrane Library, and Web of Science databases, with the search cutoff date set at 15 April 2024. Randomised controlled trials (RCTs) and prospective cohort studies comparing perioperative precision venous access management (PVAM) (integrating advanced haemodynamic monitoring, goal-directed therapy, and specialised access) with standard treatment in adults undergoing complex hepatobiliary-pancreatic or major vascular surgery were included. Primary outcomes comprised acute kidney injury (AKI) and clinically relevant postoperative pancreatic fistula (CR-POPF). Data were synthesised using a random-effects model. RESULTS: Fourteen studies involving 2,158 patients were included. Perioperative precision venous access management (PVAM) significantly reduced the incidence of AKI (RR=0.61, 95% CI 0.49-0.76; P<0.001) and CR-POPF (RR=0.69, 95% CI 0.54-0.88; P=0.002), while also reducing the overall complication rate (RR=0.76, 95% CI 0.65-0.89) and shortening hospital stay (MD=-2.4 days, 95% CI -3.8 to -1.0). CONCLUSIONS: The perioperative precision venous access management (PVAM) strategy demonstrates significant renal and pancreatic protective effects, promoting postoperative recovery in patients undergoing complex hepatobiliary, pancreatic, and vascular surgery, thereby supporting its integration into clinical practice.