儿童肝移植术后立即拔管与延迟拔管的比较：系统综述与荟萃分析。
完整摘要 · 中文译文
未标记：原位肝移植（OLT）术后在手术室内立即拔管（IE）在成人中越来越多地被采用，但儿科证据仍然有限。本系统综述和荟萃分析旨在识别与IE相关的因素，并比较儿童OLT术后IE与延迟拔管（DE）之间的结局。检索了MEDLINE、EMBASE、Scopus、CINAHL、Web of Science和Cochrane Library，检索时间自建库至2025年10月30日。纳入比较儿童OLT受者中IE与DE的研究。结局包括再插管、死亡率、血栓形成、再手术、气管切开、PICU和住院时间（LOS）。所有结局均预先设定随机效应荟萃分析；并进行了敏感性分析、荟萃回归和亚组分析。偏倚风险采用ROBINS-I评估。共纳入12项回顾性单中心研究，包括1323例患者（在考虑两个中心级队列重叠后为1158例独立儿童）。IE与较低的再插管几率相关（OR 0.32，95% CI 0.17-0.59）和较低的死亡率相关（OR 0.35，95% CI 0.18-0.68）；两项估计均经无需校正的Peto比值比确认（分别为0.29和0.31）。血栓形成或再手术方面未观察到显著差异。IE与较短的PICU住院时间相关（SMD - 0.88，95% CI - 1.39至- 0.37）、较短的住院时间相关（SMD - 1.16，95% CI - 2.00至- 0.31）。供者类型亚组分析显示，PICU和住院时间的效应量与总体分析方向一致，但亚组内估计值均未达到统计学 cal significance. Meta-regression identified intraoperative transfusion differences as predictor of hospital LOS (β = - 0.045, p = 0.006, R2 = 57.1%), a pattern more consistent with confounding by indication than with a beneficial mechanism of transfusion itself. CONCLUSIONS: IE was associated with lower reintubation, mortality, and shorter LOS in pediatric OLT, but these findings derive exclusively from retrospective studies at high risk of selection bias, and causality cannot be established. Children undergoing IE were likely older and in better preoperative condition; hospital LOS findings are particularly susceptible to confounding. Prospective multicenter studies are needed to confirm these outcomes benefit. WHAT IS KNOWN: • Delayed extubation with prolonged mechanical ventilation has been standard after pediatric orthotopic liver transplantation. • Immediate extubation in the operating room is increasingly used after adult liver transplantation experiences. • Pediatric evidence on immediate extubation comes from single-center retrospective studies. WHAT IS NEW: • This meta-analysis of 12 studies found immediate extubation associated with lower reintubation, mortality, and shorter length of stay. • These associations likely reflect selection bias rather than a proven causal benefit. • Immediate extubation appears feasible and safe in selected children, but prospective multicenter studies are needed to determine patients benefiting from this approach.
完整摘要 · 英文原文
UNLABELLED: Immediate extubation (IE) in the operating room following orthotopic liver transplantation (OLT) is increasingly adopted in adults but pediatric evidence remains limited. This systematic review and meta-analysis aimed to identify factors associated with IE and compare outcomes between IE and delayed extubation (DE) after pediatric OLT. MEDLINE, EMBASE, Scopus, CINAHL, Web of Science, and Cochrane Library were searched from inception to October 30, 2025. Studies comparing IE and DE in pediatric OLT recipients were included. Outcomes included reintubation, mortality, thrombosis, reoperation, tracheostomy, PICU, and hospital length of stay (LOS). Random-effects meta-analysis was pre-specified for all outcomes; sensitivity, meta-regression, and subgroup analyses were performed. Risk of bias was assessed with ROBINS-I. Twelve retrospective single-center studies comprising 1323 patients (1158 unique children after accounting for two center-level cohort overlaps) were included. IE was associated with lower odds of reintubation (OR 0.32, 95% CI 0.17-0.59) and mortality (OR 0.35, 95% CI 0.18-0.68); both estimates were confirmed by a correction-free Peto odds ratio (0.29 and 0.31, respectively). No significant differences were observed for thrombosis or reoperation. IE was associated with shorter PICU LOS (SMD - 0.88, 95% CI - 1.39 to - 0.37), hospital LOS (SMD - 1.16, 95% CI - 2.00 to - 0.31). Donor-type subgroup analyses showed effect sizes in the same direction as the overall analysis for PICU and hospital LOS, but none of the within-subgroup estimates reached statistical significance. Meta-regression identified intraoperative transfusion differences as predictor of hospital LOS (β = - 0.045, p = 0.006, R2 = 57.1%), a pattern more consistent with confounding by indication than with a beneficial mechanism of transfusion itself. CONCLUSIONS: IE was associated with lower reintubation, mortality, and shorter LOS in pediatric OLT, but these findings derive exclusively from retrospective studies at high risk of selection bias, and causality cannot be established. Children undergoing IE were likely older and in better preoperative condition; hospital LOS findings are particularly susceptible to confounding. Prospective multicenter studies are needed to confirm these outcomes benefit. WHAT IS KNOWN: • Delayed extubation with prolonged mechanical ventilation has been standard after pediatric orthotopic liver transplantation. • Immediate extubation in the operating room is increasingly used after adult liver transplantation experiences. • Pediatric evidence on immediate extubation comes from single-center retrospective studies. WHAT IS NEW: • This meta-analysis of 12 studies found immediate extubation associated with lower reintubation, mortality, and shorter length of stay. • These associations likely reflect selection bias rather than a proven causal benefit. • Immediate extubation appears feasible and safe in selected children, but prospective multicenter studies are needed to determine patients benefiting from this approach.