Perioperative Nutrition Intervention Enhanced Recovery after Gastrointestinal Surgery: a Prospective Single-center Cohort Study
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摘要:
目的 探索围手术期营养干预的加速康复外科(enhanced recovery after surgery, ERAS)流程对胃肠外科手术患者的安全性和有效性。 方法 本研究为单中心前瞻性队列研究, 连续纳入2015年12月至2018年4月期间在北京协和医院基本外科行胃肠手术的患者, 在胃肠与营养代谢专业组接受手术治疗及ERAS管理的患者进入ERAS组, 在其他专业组接受传统围手术期管理者进入对照组。ERAS组围绕术前营养评估、口服或管饲营养补充、术后早期肠内营养等措施, 结合其他ERAS管理流程, 主要包括微创手术、全身麻醉或联合硬膜外阻滞等多模式镇痛、术后镇痛以非甾体类抗炎药为主; 对照组采用传统围手术期措施, 主要包括开腹或微创手术、全身麻醉、术后镇痛应用阿片类镇痛药物等。主要结局指标为术后住院天数, 次要结局指标包括住院总费用、术后并发症发生率、术后60 d内再入院率。 结果 共纳入204例患者, ERAS组和对照组各102例。ERAS组术后住院天数较对照组明显缩短[(7.2±4.5)d比(9.8±4.8)d, P < 0.001], 住院总费用亦显著降低[(41 125±18 593)元比(51 512±19 453)元, P < 0.001]。两组术后Clavien-Dindo分级Ⅱ级及以上并发症发生率和术后60 d内再入院率无统计学差异(9.8%比13.7%, 2.9%比2.0%, P均>0.05)。 结论 围手术期营养干预在胃肠外科中应用安全有效, 有利于患者术后实现加速康复。 Abstract:Objective The aim of this study was to evaluate the safety and efficacy of enhanced recovery after surgery (ERAS) program focusing on the concept of integrative clinical nutrition for the gastrointestinal surgery. Methods This study was a prospective single-center cohort study. Patients who underwent gastrointestinal surgery in the Department of General Surgery of Peking Union Medical College Hospital from December 2015 to April 2018 were continuously enrolled in the study. Patients who were treated by the professional team of gastrointestinal and nutritional metabolism and received ERAS management were assigned to the ERAS group, and patients who were treated by the other professional teams and received traditional perioperative management were assigned to the control group. The ERAS program included especially focusing on the preoperative nutritional assessment, nutritional supplements by oral or tube feeding, early postoperative enteral nutrition, combination with other series of ERAS items including minimally invasive surgery, multimodal analgesia, non-steroidal antiinflammatory drugs as major postoperative analgesic meditation, and so on. The control group was under traditional perioperative management including open or minimally invasive surgery, general anesthesia, opioid analgesia, and so on. The primary outcome was the postoperative length of stay, the secondary outcomes included total hospitalization cost, the incidence of postoperative complications, and readmission rate within postoperative 60 days. Results Two hundred and four patients undergoing gastrointestinal surgery were enrolled, 102 patients in the ERAS group and the other 102 in the control group. The postoperative length of stay in the ERAS group was significantly shorter than that in the control group[(7.2±4.5)days vs. (9.8±4.8)days, P < 0.001] and total hospitalization cost in the ERAS group was significantly lower than that in the control group[(41 125±18 593)Yuan vs. (51 512±19 453)Yuan, P < 0.001] as well. There was no significant difference in the incidence of postoperative complications (Clavien-Dindo classification ≥ grade Ⅱ, ERAS group 9.8% vs. control group 13.7%, P=0.646) and readmission rate within postoperative 60 days (ERAS group 2.9% vs. control group 2.0%, P=1.000) between the two groups. Conclusion Perioperative nutrition-focused ERAS programs are safe and effective for the gastrointestinal surgery and might enhance the recovery after surgery. -
表 1 胃肠外科ERAS组与对照组围手术期流程主要措施比较
管理措施 ERAS组 对照组 术前宣教 有,同时行焦虑评估和指导 有 术前营养评估及干预 采用NRS 2002量表筛查,存在营养风险者予营养预康复措施 无 肠道准备 肠内营养 无 不采用或减量机械性肠道准备 传统机械性肠道准备 术前禁食禁饮 术前6 h禁食 术前禁食禁饮6~8 h 术前2~3 h口服17.5%葡萄糖补液盐300 ml 无 切皮前及缝皮前切口下局麻 局部麻醉(罗哌卡因+利多卡因) 无 手术方式 腹腔镜手术,必要时中转开腹 腹腔镜手术或开腹手术 上消化道手术(如全胃-D2)选择性留置空肠营养管或鼻空肠营养管 无 术中体温保护 预热补液,加温床垫,吹暖风 无 术后镇痛 非甾体类消炎药 曲马多或阿片类 胃管、导尿管、引流管留置 不常规留置或术后早期拔除 常规留置1~3 d导尿管和胃管,出院前拔除引流管 术后早期EN POD1开始序贯EN支持治疗 排气后逐步开始EN 术后床旁活动 POD1开始 POD2-3开始 ERAS:加速康复外科;NRS:营养风险筛查;EN:肠内营养;POD:术后住院天数 表 2 胃肠外科ERAS组与对照组患者基线资料比较
组别 年龄(x±s,岁) 性别[n(%)] BMI(x±s,(kg/m2) 疾病[n(%)] 术前白蛋白(x±s,g/L) 谷丙转氨酶(x±s,U/L) NRS 2002评分[n(%)] 男 女 胃癌 结直肠癌 胃肠道间质瘤 其他 ≥3分 术前口服营养补充 ERAS组(n=102) 53.6±13.3 59(57.8) 43(42.2) 23.76±4.59 42(41.2) 24(23.5) 23(22.5) 13(12.7) 41.4±4.3 20.53±11.41 56(54.9) 56(54.9) 对照组(n=102) 55.0±15.7 56(54.9) 46(45.1) 23.49±2.76 44(43.1) 27(26.5) 20(19.6) 11(10.8) 41.5±4.2 19.15±10.78 - - P值 0.496 0.778 0.625 0.644 0.935 0.449 ERAS、NRS:同表 1;BMI:体质量指数 表 3 胃肠外科ERAS组与对照组术后营养干预模式及临床一般情况比较
组别 术后营养干预模式 术后白蛋白(x±s, g/L) 术后肝功能 留置胃管[n(%)] 胃管留置时间[M(Q), d] 留置引流管([n(%)] 引流管留置时间[M(Q), d] 术后住院时间(x±s, d) 住院总费用(x±s, 元) 开始EN(x±s, d) 应用PN(x±s, d) 谷丙转氨酶(x±s, U/L) 谷丙转氨酶升高[n(%)] ERAS组(n=102) 2.4±1.8 1.96±1.67 39.00±3.53 18.71±6.43 0(0) 38(37.2) 0(0, 1) 49(48.0) 2(0, 6) 7.2±4.5 41 125±18 593 对照组(n=102) 5.1±1.2 6.03±1.92 39.58±4.61 34.18±33.31 10(9.8) 70(68.6) 2(1, 3) 101(99.0) 6(5, 7) 9.8±4.8 51 512±19 453 P值 <0.001 <0.001 0.434 0.001 0.001 <0.001 0.076 <0.001 <0.001 <0.001 <0.001 ERAS、EN:同表 1;PN:肠外营养 -
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