优化加速康复方案在腹腔镜胆囊切除术中的应用
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摘要
目的探讨优化加速康复(ERAS)方案在腹腔镜胆囊切除术(LC)中的应用价值。方法本前瞻性研究对象为2016年11月至2017年4月在内蒙古赤峰市医院行LC的158例患者。患者均签署知情同意书,符合医学伦理学规定。按住院号单双号分组,单号为ERAS组(78例),双号为对照组(80例)。ERAS组男21例,女57例;平均年龄(52±11)岁;采用优化ERAS方案。对照组男27例,女53例;年龄(51±11)岁;采用传统治疗方案。两组患者围手术期指标比较采用t检验或Wilcoxon秩和检验。结果 ERAS组患者的术后6 h疼痛、恶心呕吐评分分别为3(2,5)、1(0,5)分,明显低于对照组的4(2,4)、4(0,4)分(Z=-1.613,-3.590;P<0.05)。ERAS组术后患者排气时间、术后补液量、术后住院时间、住院费用分别为(17±8) h、(2 346±823)ml、(1.47±0.72)d、(1.04±0.12)万元,明显少于对照组的(21±9)h、(3 438±1 149)ml、(2.19±1.05)d、(1.13±0.15)万元(t=-0.045,-0.399,-0.003,-0.239;P<0.05)。ERAS组的术后满意度评分为(1.95±0.22)分,明显高于对照组的(1.75±0.44)分(t=3.625,P<0.05)。两组均无围手术期死亡和并发症发生。结论优化加速康复方案在LC中的应用安全、有效、可行,具有恢复快、花费低优势。超前多模式镇痛可明显减轻患者术后早期的疼痛。
Objective To investigate the application value of optimized program of enhanced recovery after surgery(ERAS) in laparoscopic cholecystectomy(LC). Methods In this prospective study, 158 patients undergoing LC in Chifeng Municipal Hospital, Inner Mongolia Autonomous Region from November 2016 to April 2017 were enrolled. The informed consents of all patients were obtained and the local ethical committee approval was received. Patients were divided into the ERAS(odd number, n=78) and control groups(even number, n=80) according to the hospitalization number. In ERAS group, 21 patients were male and 57 were female, aged(52±11) years on average. The optimized ERAS program was implemented. In control group, 27 cases were male and 53 female, aged(51±11) years on average. The traditional treatment was adopted. Perioperative parameters were compared between two groups by t test or Wilcoxon rank-sum test. Results In ERAS group, the scores of pain, nausea and vomiting 6 h after operation were 3(2, 5) and 1(0, 5), significantly lower than 4(2,4) and 4(0,4) in control group(Z=-1.613,-3.590; P<0.05). In ERAS group,the postoperative exhaust time,postoperative fluid volume,postoperative length of hospital stay,and hospitalization expense were(17±8)h,(2 346±823)ml,(1.47±0.72)d and(10.4±1.2)thousand yuan respectively,significantly less than(21±9)h,(3 438±1 149)ml,(2.19±1.05)d and(11.3±1.5)thousand yuan in control group(t=-0.045,-0.399,-0.003,-0.239;P<0.05).The score of postoperative satisfaction in ERAS group was 1.95±0.22,significantly higher than 1.75±0.44 in control group(t=3.625,P<0.05).No perioperative death and complications occurred in two groups.Conclusions Optimized ERAS program is safe,effective and feasible in LC,which possesses advantages of quick recovery and low cost.Advanced multimodal analgesia can significantly alleviate the early postoperative pain of patients.
Objective To investigate the application value of optimized program of enhanced recovery after surgery(ERAS) in laparoscopic cholecystectomy(LC). Methods In this prospective study, 158 patients undergoing LC in Chifeng Municipal Hospital, Inner Mongolia Autonomous Region from November 2016 to April 2017 were enrolled. The informed consents of all patients were obtained and the local ethical committee approval was received. Patients were divided into the ERAS(odd number, n=78) and control groups(even number, n=80) according to the hospitalization number. In ERAS group, 21 patients were male and 57 were female, aged(52±11) years on average. The optimized ERAS program was implemented. In control group, 27 cases were male and 53 female, aged(51±11) years on average. The traditional treatment was adopted. Perioperative parameters were compared between two groups by t test or Wilcoxon rank-sum test. Results In ERAS group, the scores of pain, nausea and vomiting 6 h after operation were 3(2, 5) and 1(0, 5), significantly lower than 4(2,4) and 4(0,4) in control group(Z=-1.613,-3.590; P<0.05). In ERAS group,the postoperative exhaust time,postoperative fluid volume,postoperative length of hospital stay,and hospitalization expense were(17±8)h,(2 346±823)ml,(1.47±0.72)d and(10.4±1.2)thousand yuan respectively,significantly less than(21±9)h,(3 438±1 149)ml,(2.19±1.05)d and(11.3±1.5)thousand yuan in control group(t=-0.045,-0.399,-0.003,-0.239;P<0.05).The score of postoperative satisfaction in ERAS group was 1.95±0.22,significantly higher than 1.75±0.44 in control group(t=3.625,P<0.05).No perioperative death and complications occurred in two groups.Conclusions Optimized ERAS program is safe,effective and feasible in LC,which possesses advantages of quick recovery and low cost.Advanced multimodal analgesia can significantly alleviate the early postoperative pain of patients.
引文
[1]中国加速康复外科专家组.中国加速康复外科围手术期管理专家共识(2016)[J].中华外科杂志,2016,54(6):413-418.
[2]Varadhan KK,Neal KR,Dejong CH,et al.The enhanced recovery after surgery(ERAS)pathway for patients undergoing major elective open colorectal surgery:a meta-analysis of randomized controlled trials[J].Clin Nutr,2010,29(4):434-440.
[3]Kim JW,Kim WS,Cheong JH,et al.Safety and efficacy of fasttrack surgery in laparoscopic distal gastrectomy for gastric cancer:a randomized clinical trial[J].World J Surg,2012,36(12):2879-2887.
[4]Muehling B,Schelzig H,Steffen P,et al.A prospective randomized trial comparing traditional and fast-track patient care in elective open infrarenal aneurysm repair[J].World J Surg,2009,33(3):577-585.
[5]Feng F,Ji G,Li JP,et al.Fast-track surgery could improve postoperative recovery in radical total gastrectomy patients[J].World J Gastroenteral,2013,19(23):3642-3648.
[6]Santillan A,Govan L,Zahurak ML,et al.Feasibility and economic impact of a clinical pathway for pap test utilization in Gynecologic Oncology practice[J].Gynecol Oncol,2008,109(3):388-393.
[7]Jones EL,Wainwright TW,Foster JD,et al.A systematic review of patient reported outcomes and patient experience in enhanced recovery after orthopaedic surgery[J].Ann R Coll Surg Engl,2014,96(2):89-94.
[8]Xiong JJ,Szatmary P,Huang W,et al.Enhanced recovery after surgery program in patients undergoing pancreaticoduodenectomy:a PRISMA-compliant systematic review and meta-analysis[J].Medicine,2016,95(18):e3497.
[9]中国研究型医院学会肝胆胰腺外科专业委员会.肝胆胰外科术后加速康复专家共识(2015版)[J].临床肝胆病杂志,2016,32(6):1040-1045.
[10]中国医师协会外科医师分会胆道外科医师委员会.胆道手术加速康复外科专家共识(2016版)[J].中华消化外科杂志,2017,16(1):6-13.
[11]中华医学会肠外肠内营养学分会加速康复外科协作组.结直肠手术应用加速康复外科中国专家共识(2015版)[J].中华消化外科杂志,2015,14(8):606-608.
[12]中国研究型医院学会机器人与腹腔镜外科专业委员会.胃癌胃切除手术加速康复外科专家共识(2016版)[J].中华消化外科杂志,2017,16(1):14-17.
[13]中国医师协会器官移植分会移植免疫学组,中华医学会外科学分会手术学组,广东省医师协会器官移植医师分会.加速康复外科优化重型肝炎肝移植围手术期管理临床实践的专家共识[J].临床肝胆病杂志,2017,33(9):1646-1654.
[14]中国医师协会胸外科分会快速康复专家委员会.食管癌加速康复外科技术应用专家共识(2016版)[J].中华胸心血管外科杂志,2016,32(12):717-722.
[15]周宗科,翁习生,曲铁兵,等.中国髋、膝关节置换术加速康复--围术期管理策略专家共识[J].中华骨与关节外科杂志,2016,9(1):1-9.
[16]中华医学会外科学分会外科手术学学组,中国医疗保健国际交流促进会,加速康复外科学分会肝脏外科学组.肝切除术后加速康复中国专家共识(2017版)[J/CD].中华肝脏外科手术学电子杂志,2017,6(4):254-260.
[17]周宗科,翁习生,孙天胜,等.中国骨科手术加速康复--围手术期血液管理专家共识[J].中华骨与关节外科杂志,2017,10(1):1-7.
[18]李卡,冯金华,胡艳杰,等.医疗供给侧改革下加速康复外科应用[J].解放军医院管理杂志,2016,23(12):1140-1143.
[19]Adachi YU,Sano H,Doi M,et al.Preemptive analgesia by nonsteroidal anti-inflammatory drugs[J].Anesth Analg,2006,103(5):1331-1332.
[20]Kehlet H,Slim K.The future of fast-track surgery[J].Br J Surg,2012,99(8):1025-1026.
[21]Sarkut P,Kilicturgay S,Aktas H,et al.Routine use of prophylactic antibiotics during laparoscopic cholecystectomy does not reduce the risk of surgical site infections[J].Surg Infect,2017,18(5):603-609.
[2]Varadhan KK,Neal KR,Dejong CH,et al.The enhanced recovery after surgery(ERAS)pathway for patients undergoing major elective open colorectal surgery:a meta-analysis of randomized controlled trials[J].Clin Nutr,2010,29(4):434-440.
[3]Kim JW,Kim WS,Cheong JH,et al.Safety and efficacy of fasttrack surgery in laparoscopic distal gastrectomy for gastric cancer:a randomized clinical trial[J].World J Surg,2012,36(12):2879-2887.
[4]Muehling B,Schelzig H,Steffen P,et al.A prospective randomized trial comparing traditional and fast-track patient care in elective open infrarenal aneurysm repair[J].World J Surg,2009,33(3):577-585.
[5]Feng F,Ji G,Li JP,et al.Fast-track surgery could improve postoperative recovery in radical total gastrectomy patients[J].World J Gastroenteral,2013,19(23):3642-3648.
[6]Santillan A,Govan L,Zahurak ML,et al.Feasibility and economic impact of a clinical pathway for pap test utilization in Gynecologic Oncology practice[J].Gynecol Oncol,2008,109(3):388-393.
[7]Jones EL,Wainwright TW,Foster JD,et al.A systematic review of patient reported outcomes and patient experience in enhanced recovery after orthopaedic surgery[J].Ann R Coll Surg Engl,2014,96(2):89-94.
[8]Xiong JJ,Szatmary P,Huang W,et al.Enhanced recovery after surgery program in patients undergoing pancreaticoduodenectomy:a PRISMA-compliant systematic review and meta-analysis[J].Medicine,2016,95(18):e3497.
[9]中国研究型医院学会肝胆胰腺外科专业委员会.肝胆胰外科术后加速康复专家共识(2015版)[J].临床肝胆病杂志,2016,32(6):1040-1045.
[10]中国医师协会外科医师分会胆道外科医师委员会.胆道手术加速康复外科专家共识(2016版)[J].中华消化外科杂志,2017,16(1):6-13.
[11]中华医学会肠外肠内营养学分会加速康复外科协作组.结直肠手术应用加速康复外科中国专家共识(2015版)[J].中华消化外科杂志,2015,14(8):606-608.
[12]中国研究型医院学会机器人与腹腔镜外科专业委员会.胃癌胃切除手术加速康复外科专家共识(2016版)[J].中华消化外科杂志,2017,16(1):14-17.
[13]中国医师协会器官移植分会移植免疫学组,中华医学会外科学分会手术学组,广东省医师协会器官移植医师分会.加速康复外科优化重型肝炎肝移植围手术期管理临床实践的专家共识[J].临床肝胆病杂志,2017,33(9):1646-1654.
[14]中国医师协会胸外科分会快速康复专家委员会.食管癌加速康复外科技术应用专家共识(2016版)[J].中华胸心血管外科杂志,2016,32(12):717-722.
[15]周宗科,翁习生,曲铁兵,等.中国髋、膝关节置换术加速康复--围术期管理策略专家共识[J].中华骨与关节外科杂志,2016,9(1):1-9.
[16]中华医学会外科学分会外科手术学学组,中国医疗保健国际交流促进会,加速康复外科学分会肝脏外科学组.肝切除术后加速康复中国专家共识(2017版)[J/CD].中华肝脏外科手术学电子杂志,2017,6(4):254-260.
[17]周宗科,翁习生,孙天胜,等.中国骨科手术加速康复--围手术期血液管理专家共识[J].中华骨与关节外科杂志,2017,10(1):1-7.
[18]李卡,冯金华,胡艳杰,等.医疗供给侧改革下加速康复外科应用[J].解放军医院管理杂志,2016,23(12):1140-1143.
[19]Adachi YU,Sano H,Doi M,et al.Preemptive analgesia by nonsteroidal anti-inflammatory drugs[J].Anesth Analg,2006,103(5):1331-1332.
[20]Kehlet H,Slim K.The future of fast-track surgery[J].Br J Surg,2012,99(8):1025-1026.
[21]Sarkut P,Kilicturgay S,Aktas H,et al.Routine use of prophylactic antibiotics during laparoscopic cholecystectomy does not reduce the risk of surgical site infections[J].Surg Infect,2017,18(5):603-609.