Avaliação da efetividade do pré-condicionamento tecidual para redução dos efeitos da isquemia/reperfusão na cirurgia hepática e no transplante hepático: revisão sistemática com metanálise.
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2022-05-25
Autores
Oliveira, Glauber Correia de
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Universidade Estadual Paulista (Unesp)
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Objetivos: Avaliar os eventuais benefícios do pré-condicionamento isquêmico (PCI) na cirurgia hepática e no transplante hepático, por meio de revisão sistemática da literatura com metanálise, e avaliar a sua aplicabilidade na prática clínica. Métodos: Foram realizadas buscas de artigos relacionados ao tema nas línguas Portuguesa, Inglesa e Espanhola, indexados ao MEDLINE (Literatura Internacional em Ciências e Saúde) via PubMED, LILACS (Literatura Latino Americana e do Caribe em Ciências da Saúde), SCOPUS, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), SciELO, WEB OF SCIENCE, e PubMED, e fontes adicionais de ensaios publicados e não publicados. Resultados: As buscas forneceram um total de 2077 artigos, dos quais foram selecionados 17 relacionados à Cirurgia Hepática, e 13 ao transplante hepático, que totalizaram 1052 pacientes submetidos a ressecções hepáticas e 660 pacientes submetidos a transplante hepático. A aplicação do PCI não altera o tempo cirúrgico das ressecções hepáticas e dos transplantes hepáticos. Os pacientes do grupo PCI submetidos a hepatectomias apresentaram menor sangramento (Diferença Média de -49.97 ml, IC 95%, -86.32 a -13.6, I²: 64%) e o número de pacientes que necessitaram de transfusão sanguínea também foi menor nesse grupo (RR 0.71, IC 95%, 0.53 a 0.96; I²=0%). Ainda em relação à cirurgia hepática o PCI reduziu o risco de ascite no pós-operatório (RR 0.40, IC 95%, 0.17 a 0.93; I²=0%). Já em relação à aplicação do PCI no transplante hepático, o grupo submetido ao PCI apresentou menor risco de trombose da artéria hepática no pós-operatório (RR 0.22, IC 95%, 005 a 1.0; I²=0%) e menor pico nas dosagens pós-operatórias de AST (DM – 228.22, IC 95%, -414.24 - 42.20; i² 70%) e ALT (DM -213.80, IC 95%, -379.29 a -48.31; I²=48%). Os demais desfechos não sofreram alterações estatisticamente significativas ou tiveram suas metanálises consideradas como impróprias devido à heterogeneidade elevada. Conclusão: O PCI é aplicável na prática clínica tanto para pacientes submetidos a ressecções hepáticas, quanto para pacientes submetidos a transplantes hepáticos, com algum efeito benéfico. Porém, não encontramos evidências suficientes para estimular sua utilização como rotina.
Objective: Assess the possible benefits of ischemic preconditioning (IPC) in liver surgery and liver transplantation, through a systematic review of the literature with meta-analysis, and to evaluate its applicability in clinical practice. Methods: Searches were carried out for articles related to the topic in Portuguese, English and Spanish, indexed to MEDLINE (Medical Literature Analysis and Retrievel System Online) via PUBMED, LILACS (Latin American and Caribbean Literature Health Sciences), SCOPUS, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), SciELO, WEB OF SCIENCE, PubMED, and additional sources of published and unpublished trials. Results: The searches yielded a total of 1753 articles, of which 17 related to Liver Surgery and 12 to liver transplantation were selected, totaling 1052 patients undergoing liver resections and 535 patients undergoing liver transplantation. The application of IPC does not change the surgical time of liver resections and liver transplants. Patients in the IPC group undergoing hepatectomies had less bleeding (Mean Difference -49.97 ml, 95% CI, -86.32 to -13.6, I²: 64%) and the number of patients requiring blood transfusion was also lower in this group (RR 0.71, 95% CI, 0.53 to 0.96; I²=0%). Still in relation to liver surgery, IPC reduced the risk of ascites in the postoperative period (RR 0.40, 95% CI, 0.17 to 0.93; I²=0%). Regarding the application of IPC in liver transplantation, the group undergoing IPC had a lower risk of postoperative hepatic artery thrombosis (RR 0.22, 95% CI, 005 to 1.0; I²=0%) and a lower peak in the postoperative dosages of AST (MD – 228.22, 95% CI, -414.24 - 42.20; i² 70%) and ALT (MD -213.80, IC 95%, -379.29 a -48.31; I²=48%). The other outcomes did not undergo statistically significant changes or have had their meta-analysis considered inadequate due to high heterogeneity. Conclusion: IPC is applicable in clinical practice both for patients undergoing liver resections and for patients undergoing liver transplantation, with some beneficial effect. However, we did not find sufficient evidence to encourage its routine use.
Objective: Assess the possible benefits of ischemic preconditioning (IPC) in liver surgery and liver transplantation, through a systematic review of the literature with meta-analysis, and to evaluate its applicability in clinical practice. Methods: Searches were carried out for articles related to the topic in Portuguese, English and Spanish, indexed to MEDLINE (Medical Literature Analysis and Retrievel System Online) via PUBMED, LILACS (Latin American and Caribbean Literature Health Sciences), SCOPUS, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), SciELO, WEB OF SCIENCE, PubMED, and additional sources of published and unpublished trials. Results: The searches yielded a total of 1753 articles, of which 17 related to Liver Surgery and 12 to liver transplantation were selected, totaling 1052 patients undergoing liver resections and 535 patients undergoing liver transplantation. The application of IPC does not change the surgical time of liver resections and liver transplants. Patients in the IPC group undergoing hepatectomies had less bleeding (Mean Difference -49.97 ml, 95% CI, -86.32 to -13.6, I²: 64%) and the number of patients requiring blood transfusion was also lower in this group (RR 0.71, 95% CI, 0.53 to 0.96; I²=0%). Still in relation to liver surgery, IPC reduced the risk of ascites in the postoperative period (RR 0.40, 95% CI, 0.17 to 0.93; I²=0%). Regarding the application of IPC in liver transplantation, the group undergoing IPC had a lower risk of postoperative hepatic artery thrombosis (RR 0.22, 95% CI, 005 to 1.0; I²=0%) and a lower peak in the postoperative dosages of AST (MD – 228.22, 95% CI, -414.24 - 42.20; i² 70%) and ALT (MD -213.80, IC 95%, -379.29 a -48.31; I²=48%). The other outcomes did not undergo statistically significant changes or have had their meta-analysis considered inadequate due to high heterogeneity. Conclusion: IPC is applicable in clinical practice both for patients undergoing liver resections and for patients undergoing liver transplantation, with some beneficial effect. However, we did not find sufficient evidence to encourage its routine use.
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Pré-condicionamento isquêmico, Isquemia - Reperfusão, Cirurgia hepatobiliar, Transplante hepático, Ischemic preconditioning, Ischaemia-reperfusion, Hepatobiliary surgery, Liver transplant, Traumatismo por reperfusão, Pesquisa médica, Fígado - Transplante