胰腺手术后的术后疼痛治疗：一项含荟萃分析与试验序贯分析的系统评价。
完整摘要 · 中文译文
背景：大型胰腺手术与显著的术后疼痛相关，这种疼痛会妨碍早期活动和恢复。针对胰十二指肠切除术的ERAS指南推荐多模式阿片类药物节约型镇痛，其中强烈推荐硬膜外镇痛，并将连续切口浸润作为替代方案。其他技术可能有益，但其有效性和安全性仍不明确。 目的：探讨接受全胰切除术、胰十二指肠切除术和远端胰切除术患者不同术后镇痛方式的疗效和不良事件。 数据库与数据处理：本项已在PROSPERO注册的系统综述（注册号CRD420251085003）按照PRISMA指南进行报告。在Medline、Cochrane对照试验中心注册库和Embase中进行了随机对照试验的检索。使用Review Manager进行荟萃分析，使用RoB 2评估偏倚风险，进行了试验序贯分析，并使用GRADE评估证据确定性。 结果：共纳入18项随机对照试验，涉及1468名患者，并进行了10项荟萃分析。荟萃分析显示，与安慰剂/无干预相比，COX抑制剂在术后第二天（POD2）静息时疼痛评分降低。在POD1-POD2期间，硬膜外镇痛与创伤更小的策略（椎旁阻滞和切口浸润）相比疼痛评分相似，但在POD3时创伤更小的技术疼痛评分更低。荟萃分析规模较小，GRADE推荐等级从极低到低不等。 结论：现有证据不足以确立任何单一镇痛策略在胰腺大手术后具有优越性。包括环氧化酶（COX）抑制剂、椎旁阻滞和持续伤口浸润在内的若干镇痛策略显示出有希望的结果。需要更大规模的随机对照试验（RCTs）以提供更强有力的循证建议。 意义声明：硬膜外镇痛长期以来一直被认为是胰腺大手术后术后疼痛治疗的金标准。本综述通过证明侵入性较小的策略如持续伤口浸润和椎旁阻滞在术后最初几天提供相当的疼痛评分，并且在术后第3天评分显著更低，从而为该领域增添了证据。这支持将侵入性较小的策略定位为硬膜外镇痛的可行替代方案。
完整摘要 · 英文原文
BACKGROUND: Major pancreatic surgery is associated with significant postoperative pain that impairs early mobilisation and recovery. ERAS guidelines for pancreaticoduodenectomy recommend multimodal opioid-sparing analgesia, with a strong recommendation for epidural analgesia and continuous wound infiltration as an alternative. Other techniques may be beneficial, but their efficacy and safety remain uncertain. OBJECTIVE: To investigate the efficacy and adverse events of different postoperative analgesic modalities for patients undergoing total pancreatectomy, pancreaticoduodenectomy and distal pancreatectomy. DATABASES AND DATA TREATMENT: This PROSPERO-registered systematic review (ID CRD420251085003) reported in accordance with the PRISMA guidelines. A search for randomised controlled trials was conducted in Medline, Cochrane Central Register of Controlled Trials and Embase. Meta-analyses were performed in Review Manger, risk of bias was assessed with RoB 2, trial sequential analyses were performed, and the certainty of evidence was evaluated using GRADE. RESULTS: Eighteen RCTs comprising 1468 patients were included, and 10 meta-analyses were performed. Meta-analyses demonstrated reduced pain scores at rest on postoperative day (POD) two with COX-inhibitors compared with placebo/no intervention. Pain scores were similar when comparing epidural analgesia with less invasive strategies (paravertebral block and wound infiltration) on POD1-POD2, but lower with the less invasive techniques on POD3. Meta-analyses were small, and GRADE recommendations ranged from very low to low. CONCLUSIONS: The available evidence was insufficient to establish the superiority of any single analgesic strategy after major pancreatic surgery. Several analgesic strategies, including COX inhibitors, paravertebral block and continuous wound infiltration, showed promising results. Larger RCTs are needed to provide stronger evidence-based recommendations. SIGNIFICANCE STATEMENT: Epidural analgesia has long been considered the gold standard for treatment of postoperative pain after major pancreatic surgery. The present review adds to the field by demonstrating that less invasive strategies as continuous wound infiltration and paravertebral block provide comparable pain scores in the first postoperative days, with a significantly lower score on postoperative day three. This supports positioning less invasive strategies as viable alternatives to epidural analgesia.