加速康复外科程序在肝胆管结石肝切除术中的应用
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摘要
目的:探讨加速康复外科(ERAS)程序在肝胆管结石肝切除术中的应用价值。方法:回顾性分析2013年1月—2016年12月178例采用ERAS处理行肝切除术治疗的肝胆管结石患者(ERAS组)和2009年1月—2012年12月218例按传统方法进行围手术期处理行肝切除术治疗的肝胆管结石患者(常规组)的临床资料。比较两组患者的相关临床指标。结果:与常规组比较,ERAS组术后肝功能指标恢复较好(部分P<0.05),术后住院时间明显缩短、首次排气时间明显提前、体质量下降明显减少、治疗总费用明显下降(均P<0.05)。两组术后总并发症与各并发症发生率差异均无统计学意义(均P>0.05)。两组均无死亡病例。结论:肝胆管结石肝切除术中采用ERAS程序安全、可行,既加速患者术后器官功能的恢复,又可以减少住院时间与治疗费用。
Objective: To investigate the value of using enhanced recovery after surgery(ERAS) programs in liver resection for hepatolithiasis.Methods: The clinical data of 178 patients undergoing liver resection for hepatolithiasis with ERAS management(ERAS group) from January 2013 to December 2016 and 218 patients undergoing liver resection for hepatolithiasis with conventional perioperative management(conventional group) from January 2009 to December 2012 were retrospectively analyzed. The main clinical variables between the two groups of patients were compared.Results: In ERAS group compared with conventional group, the recovery of liver function parameters after surgery was faster(partial P<0.05), the length of postoperative hospital stay was significantly shortened, the time to first flatulence was significantly reduced, the postoperative body weight loss was significantly decreased and the total hospitalization cost was significantly reduced(all P<0.05). There were no statistical differences either in incidence of overall postoperative complications or incidence of specific complication between the two group(allP>0.05). No death occurred in either of the groups.Conclusion: Using ERAS protocol in liver resection for hepatolithiasis is safe and feasible. It can effectively promote the postoperative recovery of the patients, and reduce the length of hospital stay and medical cost.
Objective: To investigate the value of using enhanced recovery after surgery(ERAS) programs in liver resection for hepatolithiasis.Methods: The clinical data of 178 patients undergoing liver resection for hepatolithiasis with ERAS management(ERAS group) from January 2013 to December 2016 and 218 patients undergoing liver resection for hepatolithiasis with conventional perioperative management(conventional group) from January 2009 to December 2012 were retrospectively analyzed. The main clinical variables between the two groups of patients were compared.Results: In ERAS group compared with conventional group, the recovery of liver function parameters after surgery was faster(partial P<0.05), the length of postoperative hospital stay was significantly shortened, the time to first flatulence was significantly reduced, the postoperative body weight loss was significantly decreased and the total hospitalization cost was significantly reduced(all P<0.05). There were no statistical differences either in incidence of overall postoperative complications or incidence of specific complication between the two group(allP>0.05). No death occurred in either of the groups.Conclusion: Using ERAS protocol in liver resection for hepatolithiasis is safe and feasible. It can effectively promote the postoperative recovery of the patients, and reduce the length of hospital stay and medical cost.
引文
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[13]余建中,胡常明,胡晓华.快速康复外科在肝胆管结石围术期的应用[J].肝胆外科杂志,2016,24(2):98-101.Yu JZ,Hu CM,Hu XH.Application effect and influence on stress response of fast track surgery in biliary intestinal RouxenY anastomosis in patients with bile duct stones[J].Journal of Hepatobiliary Surgery,2016,24(2):98-101.
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[16]李宁.加速康复外科治疗中的围手术期营养支持[J].肠外与肠内营养,2008,15(2):65-67.doi:10.3969/j.issn.1007-810X.2008.02.001.Li N.Perioperative nutritional support in enhanced recovery after surgery[J].Parenteral&Enteral Nutrition,2008,15(2):65-67.doi:10.3969/j.issn.1007-810X.2008.02.001.
[17]Noblett SE,Watson DS,Huong H,et al.Pre-operative oral carbohydrate loading in colorectal surgery:a randomized controlled trial[J].Colorectal Dis,2006,8(7):563-569.
[18]郑小兰,罗振中,蔡俊赢,等.快速康复外科理念对肝部分切除患者围术期胰岛素抵抗及炎症反应的影响[J].广东医学,2017,38(5):709-712.doi:10.3969/j.issn.1001-9448.2017.05.014.Zheng XL,Luo ZZ,Cai JY,et al.Impact of enhanced recovery after surgery on perioperative insulin resistance and inflammatory response in patients undergoing partial hepatectomy[J].Guangdong Medical Journal,2017,38(5):709-712.doi:10.3969/j.issn.1001-9448.2017.05.014.
[19]DiFronzo LA,Yamin N,Patel K,et al.Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection[J].J Am Coll Surg,2003,197(5):747-752.
[20]延学军,岳风芝,刘洪锋.快速康复外科理念在腹腔镜直肠癌手术治疗中的临床应用[J].中国普通外科杂志,2017,26(4):524-528.doi:10.3978/j.issn.1005-6947.2017.04.020.Yan XJ,Yue FZ,Liu HF.Clinical application of enhanced recovery surgical concept in laparoscopic surgical treatment of rectal cancer[J].Chinese Journal of General Surgery,2017,26(4):524-528.doi:10.3978/j.issn.1005-6947.2017.04.020.
[21]王继涛,孙佳轶,雷光林,等.快速康复外科联合肝切除术的安全性和有效性的Meta分析[J].中国普通外科杂志,2015,24(1):88-94.doi:10.3978/j.issn.1005-6947.2015.01.017.Wang JT,Sun JY,Lei GL,et al.Safety and efficacy of using fast-track surgery in hepatectomy:a Meta-analysis[J].Chinese Journal of General Surgery,2015,24(1):88-94.doi:10.3978/j.issn.1005-6947.2015.01.017.
[22]Lobo DN,Bostock KA,Neal KR,et al.Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection:a randomised controlled trial[J].Lancet,2002,359(9320):1812-1818.
[23]姚海桥.胆管探查术后T管早期夹闭临床分析[J].蚌埠医学院学报,2007,32(5):597-598.doi:10.3969/j.issn.1000-2200.2007.05.042.Yao HQ.Clinical analysis of early T-tube occlusion after bile duct exploration[J].Journal of Bengbu Medical College,2007,32(5):597-598.doi:10.3969/j.issn.1000-2200.2007.05.042.
[24]马倩红,颜碧莲,梁言珍,等.快速康复外科理念在肝胆外科围术期管理中的应用[J].国际护理学杂志,2017,36(2):253-255.doi:10.3760/cma.j.issn.1673-4351.2017.02.039.Ma QH,Yan BL,Liang YZ,et al.Application of concept of enhanced recovery after surgery in perioperative management of hepatobiliary surgery[J].International Journal of Nursing,2017,36(2):253-255.doi:10.3760/cma.j.issn.1673-4351.2017.02.039.
[25]张盛,蒋佳凯,许锁保,等.规范化多模式镇痛在肝切除术后加速恢复中的临床应用[J].中国普通外科杂志,2017,26(7):948-952.doi:10.3978/j.issn.1005-6947.2017.07.022.Zhang S,Jiang JK,Xu SB,et al.Clinical use of normalized multimodal analgesia in accelerated recovery after hepatectomy[J].Chinese Journal of General Surgery,2017,26(7):948-952.doi:10.3978/j.issn.1005-6947.2017.07.022.
[26]Kehlet H,Dahl JB.Anaesthesia,surgery,and challenges in postoperative recovery[J].Lancet,2003,362(9399):1921-1928.
[2]Underwood TJ,Noble F,Madhusudan N,et al.The Development,Application and Analysis of an Enhanced Recovery Programme for Major Oesophagogastric Resection[J].J Gastrointest Surg,2017,21(4):614-621.doi:10.1007/s11605-017-3363-8.
[3]Collins JW,Adding C,Hosseini A,et al.Introducing an enhanced recovery programme to an established totally intracorporeal robot-assisted radical cystectomy service[J].Scand J Urol,2016,50(1):39-46.doi:doi.org/10.3109/21681805.2015.1076514.
[4]Talboys R,Mak M,Modi N,et al.Enhanced recovery programme reduces opiate consumption in hip hemiarthroplasty[J].Eur JOrthop Surg Traumatol,2016,26(2):177-181.doi:10.1007/s00590-015-1722-2.
[5]Kehlet H,Wilmore DW.Fast-track surgery[J].Br J Surg,2005,92(1):3-4.
[6]Maessen J,Dejong C H,Hausel J,et al.A protocol is not enough to implement an enhanced recovery programme for colorectal resection[J].Br J Surg,2007,94(2):224-231.
[7]江志伟,李宁,黎介寿.快速康复外科的概念及临床意义[J].中国实用外科杂志,2007,27(2):131-133.doi:10.3321/j.issn:1005-2208.2007.02.013.Jiang ZW,Li N,Li JS.Concept and clinical significance of enhanced recovery after surgery[J].Chinese Journal of Practical Surgery,2007,27(2):131-133.doi:10.3321/j.issn:1005-2208.2007.02.013.
[8]黎介寿.营养与加速康复外科[J].肠外与肠内营养,2 0 0 7,14(2):65-67.doi:10.3969/j.issn.1007-810X.2007.02.001.Li JS.Nutrition and enhanced recovery after surgery[J].Parenteral&Enteral Nutrition,2007,14(2):65-67.doi:10.3969/j.issn.1007-810X.2007.02.001.
[9]Karran A,Wheat J,Chan D,et al.Propensity Score Analysis of an Enhanced Recovery Programme in Upper Gastrointestinal Cancer Surgery[J].World J Surg,2016,40(7):1645-1654.doi:10.1007/s00268-016-3473-6.
[10]陈虎,张栋,潘飞,等.快速康复外科在肝切除围手术期应用的M eta分析[J].中华肝胆外科杂志,2016,22(6):361-366.doi:10.3760/cma.j.issn.1007-8118.2016.06.001.Chen H,Zhang D,Pan F,et al.Enhanced recovery after surgery in perioperative management of hepatectomy:a Meta-analysis[J].Chinese Journal of Hepatobiliary Surgery,2016,22(6):361-366doi:10.3760/cma.j.issn.1007-8118.2016.06.001.
[11]Kehlet H.Fast-track colorectal surgery[J].Lancet,2008,371(9615):791-793.doi:10.1016/S0140-6736(08)60357-8.
[12]Pessaux P,Regimbeau JM,Dondéro F,et al.Randomized clinical trial evaluating the need for routine nasogastric decompression after elective hepatic resection[J].Br J Surg,2007,94(3):297-303.
[13]余建中,胡常明,胡晓华.快速康复外科在肝胆管结石围术期的应用[J].肝胆外科杂志,2016,24(2):98-101.Yu JZ,Hu CM,Hu XH.Application effect and influence on stress response of fast track surgery in biliary intestinal RouxenY anastomosis in patients with bile duct stones[J].Journal of Hepatobiliary Surgery,2016,24(2):98-101.
[14]Petrowsky H,Demartines N,Rousson V,et al.Evidence-based value of prophylactic drainage in gastrointestinal surgery:a systematic review and meta-analyses[J].Ann Surg,2004,240(6):1074-1084.
[15]Fong Y,Brennan MF,Brown K,et al.Drainage is unnecessary after elective liver resection[J].Am J Surg,1996,171(1):158-162.
[16]李宁.加速康复外科治疗中的围手术期营养支持[J].肠外与肠内营养,2008,15(2):65-67.doi:10.3969/j.issn.1007-810X.2008.02.001.Li N.Perioperative nutritional support in enhanced recovery after surgery[J].Parenteral&Enteral Nutrition,2008,15(2):65-67.doi:10.3969/j.issn.1007-810X.2008.02.001.
[17]Noblett SE,Watson DS,Huong H,et al.Pre-operative oral carbohydrate loading in colorectal surgery:a randomized controlled trial[J].Colorectal Dis,2006,8(7):563-569.
[18]郑小兰,罗振中,蔡俊赢,等.快速康复外科理念对肝部分切除患者围术期胰岛素抵抗及炎症反应的影响[J].广东医学,2017,38(5):709-712.doi:10.3969/j.issn.1001-9448.2017.05.014.Zheng XL,Luo ZZ,Cai JY,et al.Impact of enhanced recovery after surgery on perioperative insulin resistance and inflammatory response in patients undergoing partial hepatectomy[J].Guangdong Medical Journal,2017,38(5):709-712.doi:10.3969/j.issn.1001-9448.2017.05.014.
[19]DiFronzo LA,Yamin N,Patel K,et al.Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection[J].J Am Coll Surg,2003,197(5):747-752.
[20]延学军,岳风芝,刘洪锋.快速康复外科理念在腹腔镜直肠癌手术治疗中的临床应用[J].中国普通外科杂志,2017,26(4):524-528.doi:10.3978/j.issn.1005-6947.2017.04.020.Yan XJ,Yue FZ,Liu HF.Clinical application of enhanced recovery surgical concept in laparoscopic surgical treatment of rectal cancer[J].Chinese Journal of General Surgery,2017,26(4):524-528.doi:10.3978/j.issn.1005-6947.2017.04.020.
[21]王继涛,孙佳轶,雷光林,等.快速康复外科联合肝切除术的安全性和有效性的Meta分析[J].中国普通外科杂志,2015,24(1):88-94.doi:10.3978/j.issn.1005-6947.2015.01.017.Wang JT,Sun JY,Lei GL,et al.Safety and efficacy of using fast-track surgery in hepatectomy:a Meta-analysis[J].Chinese Journal of General Surgery,2015,24(1):88-94.doi:10.3978/j.issn.1005-6947.2015.01.017.
[22]Lobo DN,Bostock KA,Neal KR,et al.Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection:a randomised controlled trial[J].Lancet,2002,359(9320):1812-1818.
[23]姚海桥.胆管探查术后T管早期夹闭临床分析[J].蚌埠医学院学报,2007,32(5):597-598.doi:10.3969/j.issn.1000-2200.2007.05.042.Yao HQ.Clinical analysis of early T-tube occlusion after bile duct exploration[J].Journal of Bengbu Medical College,2007,32(5):597-598.doi:10.3969/j.issn.1000-2200.2007.05.042.
[24]马倩红,颜碧莲,梁言珍,等.快速康复外科理念在肝胆外科围术期管理中的应用[J].国际护理学杂志,2017,36(2):253-255.doi:10.3760/cma.j.issn.1673-4351.2017.02.039.Ma QH,Yan BL,Liang YZ,et al.Application of concept of enhanced recovery after surgery in perioperative management of hepatobiliary surgery[J].International Journal of Nursing,2017,36(2):253-255.doi:10.3760/cma.j.issn.1673-4351.2017.02.039.
[25]张盛,蒋佳凯,许锁保,等.规范化多模式镇痛在肝切除术后加速恢复中的临床应用[J].中国普通外科杂志,2017,26(7):948-952.doi:10.3978/j.issn.1005-6947.2017.07.022.Zhang S,Jiang JK,Xu SB,et al.Clinical use of normalized multimodal analgesia in accelerated recovery after hepatectomy[J].Chinese Journal of General Surgery,2017,26(7):948-952.doi:10.3978/j.issn.1005-6947.2017.07.022.
[26]Kehlet H,Dahl JB.Anaesthesia,surgery,and challenges in postoperative recovery[J].Lancet,2003,362(9399):1921-1928.