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Feasibility of Enhanced Recovery after Surgery Program in the Perioperative Management of Pancreaticoduodenectomy
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摘要:
目的 探讨加速康复外科(enhanced recovery after surgery, ERAS)模式在胰十二指肠切除术围手术期管理中应用的安全性及有效性。 方法 2016年4月至2018年4月在北京协和医院基本外科接受胰十二指肠切除术的患者, 其中符合入选和排除标准的63例患者纳入ERAS组, 同期行常规胰十二指肠切除术的60例患者设为对照组, 观察并比较两组患者术中及术后相关指标、并发症发生情况和临床结局。 结果 ERAS组和对照组基线资料均衡可比, 无统计学差异。ERAS组以腹腔镜手术为主, 而对照组开腹手术居多(P < 0.01);ERAS组的手术时间较对照组延长(P < 0.01), 但术中出血量显著降低(P < 0.01), 术后胃管拔除时间(P < 0.05)和恢复流食时间(P < 0.05)早于对照组, 住院时间明显短于对照组(P=0.024), 住院费用亦低于对照组(P < 0.05)。ERAS组的胃排空障碍发生率明显少于对照组(3.2%比13.3%, P < 0.05), 总并发症发生率、胰瘘、胆瘘、术后出血、感染、二次入院、二次手术发生率及死亡率等指标两组间差异无统计学意义。ERAS组中腹腔镜手术组的术中出血量(P < 0.01)、术后住院天数(P < 0.05)、住院费用(P < 0.05)显著低于开腹手术组。 结论 ERAS理念下行胰十二指肠切除术安全有效, 可加速患者康复, 且不增加并发症的发生风险。 Abstract:Objective The aim of this study was to explore the safety and effectiveness of enhanced recovery after surgery (ERAS) in perioperative management of pancreaticoduodenectomy. Methods Among the patients undergoing pancreaticoduodenectomy from April 2016 to April 2018 in the Department of General Surgery of Peking Union Medical College Hospital, 63 patients who met the inclusion and exclusion criteria were enrolled in ERAS group and the other 60 patients in the control group. The perioperative parameters, postoperative complications, and clinical outcomes were compared between the two groups. Results There was no difference between the ERAS group and the control group in baseline data. The operative approach of the ERAS group was mainly laparoscopicsurgery and that of the control group was mainly open surgery (P < 0.01). The operation time in ERAS group was longer than that in control group (P < 0.01) while the intraoperative blood loss was significantly reduced (P < 0.01). Compared with the control group, the ERAS group had the shorter time of gastric tube removal, earlier postoperative fluid intake, shorter postoperative hospital stay, and significantly less hospitalization expenses (all P < 0.05). The incidence of delayed gastric emptying of the ERAS group was significantly lower than that of the control group (3.2% vs. 13.3%, P < 0.05). There was no significant difference in the incidence of total complications, pancreatic fistula, biliary fistula, postoperative hemorrhage, secondary hospital admission, secondary surgery, and death between the two groups. In the ERAS group, the intraoperative blood loss (P < 0.01), postoperative hospital stays (P < 0.05), and the hospitalization expenses (P < 0.05) of the laparoscopic subgroup were significantly lower than those of the open subgroup. Conclusion ERAS is safe and effective for the perioperative management of pancreaticoduodenectomy, which can significantly accelerate the recovery of patients without increasing the risk of complications. -
Key words:
- enhanced recovery after surgery /
- pancreaticoduodenectomy
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表 1 胰十二指肠切除术ERAS组与对照组围手术期临床管理路径
时间 ERAS组 对照组 入院 ·术前麻醉及营养评估 ·常规入院宣教 ·宣教ERAS理念 术前1 d ·正常经口进食 ·禁食禁水 ·术前2 h饮用400 ml麦芽糊精果糖 ·机械性肠道准备 ·不行机械性肠道准备 手术当天 ·预防性应用抗生素 ·预防性应用抗生素 ·全麻联合硬膜外麻醉 ·常规全麻 ·目标导向性液体治疗 ·术后返回普通病房 ·术中注意保温 ·术后第一夜ICU过渡 术后第1天 ·转回外科病房 ·拔除尿管 ·早期拔除鼻胃管及尿管患者下地活动 ·视引流情况留置/拔除胃管 ·预防血栓 ·鼓励患者床旁坐起 ·镇痛泵止痛 ·预防血栓 ·呼吸功能锻炼 ·肠外营养支持 ·肠外营养支持 术后第2天 ·下床活动至少3次 ·拔除尿管下地活动 ·尝试小口饮水 ·排气后小口饮水 ·预防恶心呕吐 ·咀嚼口香糖 术后第3天 ·饮水不限量，进食米汤、米粥 ·全肠外营养 ·若引流情况符合要求(淀粉酶＜5000 U/L且引流量＜300 ml可拔除或外退腹腔引流管) ·继续留置腹腔引流管 术后第4~7天 ·过渡饮食，进半流食或流食·减停肠外营养 ·逐步恢复饮水及流食 ·继续肠外营养支持 ERAS:加速康复外科 
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表 2 胰十二指肠切除术ERAS组与对照组患者的基线资料
临床资料 ERAS组(n=63) 对照组(n=60) P值 年龄(x±s, 岁) 58.3±10.3 56.5±13.3 0.408 女性[n(%)] 22(34.9) 27(45.0) 0.253 体质量指数(x±s，kg/m2) 22.27±3.18 23.36±3.23 0.217 既往史[n(%)] 胰腺炎 6(9.5) 8(13.3) 0.506 糖尿病 14(22.2) 11(28.3) 0.592 高血压 19(30.2) 17(28.3) 0.823 吸烟史 7(11.1) 6(10.0) 0.841 饮酒史 13(20.6) 15(25.0) 0.563 病理诊断[n(%)] 胰腺癌 35(55.6) 28(46.7) 0.324 导管内乳头状瘤 8(12.6) 4(6.7) 0.259 神经内分泌瘤 4(6.3) 3(5.0) 0.746 实性假乳头状瘤 3(4.8) 3(5.0) 0.951 胰腺炎 1(1.6) 2(3.3) 0.530 囊腺瘤 1(1.6) 1(1.7) 0.972 胆管癌 3(4.8) 5(8.3) 0.422 壶腹癌 3(4.8) 6(10.0) 0.264 十二指肠癌 2(3.2) 4(6.7) 0.368 胃肠道间质瘤 2(3.2) 2(3.3) 0.960 其他 1(1.6) 2(3.3) 0.530 ERAS:同表 1
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表 3 胰十二指肠切除术ERAS组与对照组手术情况比较
组别 手术方式[n(%)] 手术时间(x±s, min) 术中出血量(x±s, ml) 术中输血例数[n(%)] 术后胃管拔除时间(x±s, d) 术后恢复排气排便时间(x±s, d) 术后恢复流食时间(x±s, d) 首次下地活动时间(x±s, d) 术后住院时间(x±s, d) 住院费用(x±s, 元) 开腹手术 腹腔镜中转开腹手术 腹腔镜辅助 完全腹腔镜手术 ERAS组(n=63) 17(27.0) 10(15.9) 6(9.5) 30(47.6) 486±111 439±349 29(46.0) 2.2±1.3 2.6±0.9 3.3±1.5 1.9±0.6 12.4±7.2 102 514±47 275 对照组(n=60) 45(75.0) 8(13.3) 4(6.7) 3(5.0) 345±116 773±304 34(56.7) 5.4±4.2 3.8±1.6 6.0±2.2 3.2±0.8 19.6±11.6 141 897±12 139 P值 ＜0.01 0.690 0.562 ＜0.01 ＜0.01 ＜0.01 0.238 0.012 0.681 0.015 0.467 0.024 0.018 ERAS:同表 1
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表 4 胰十二指肠切除术ERAS组与对照组术后并发症比较
并发症 ERAS组(n=63) 对照组(n=60) P值 总例数 26(41.3) 29(48.3) 0.431 Clavian-Dindo Ⅰ~Ⅱ 24(38.1) 25(41.7) 0.685 Clavian-Dindo Ⅲ~Ⅳ 2(3.2) 4(6.7) 0.368 临床胰瘘 2(3.2) 4(6.7) 0.368 B级 1(1.6) 3(5.0) 0.286 C级 1(1.6) 1(1.7) 0.972 胃排空障碍 2(3.2) 8(13.3) 0.039 胆瘘 3(4.8) 3(5.0) 0.951 术后出血 1(1.6) 3(5.0) 0.286 腹腔积液 6(9.5) 4(6.7) 0.562 腹腔感染 4(6.3) 3(5.0) 0.746 肺部感染 5(7.9) 6(10.0) 0.688 胆道感染 2(3.2) 1(1.7) 0.587 泌尿系感染 1(1.6) 1(1.7) 0.972 肺栓塞 1(1.6) 0(0) 0.327 下肢血栓 3(4.8) 1(1.7) 0.333 肝脓肿 1(1.6) 1(1.7) 0.972 切口液化/感染 1(1.6) 2(3.4) 0.530 二次手术 2(3.2) 2(3.4) 0.960 二次入院 1(1.6) 2(3.4) 0.530 死亡 0(0) 0(0) - ERAS:同表 1
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表 5 胰十二指肠切除术ERAS组中腹腔镜与开腹手术亚组临床资料比较
组别 年龄(x±s，岁) 女性[n(%)] 体质量指数(x±s，kg/m2) 手术时间(x±s, min) 术中出血量(x±s, ml) 术中输血例数[n(%)] 并发症例数[n(%)] 术后恢复排气排便时间(x±s, d) 术后恢复流食时间(x±s, d) 首次下地活动时间(x±s, d) 术后住院时间(x±s, d) 住院费用(x±s, 元) 腹腔镜手术组(n=36) 56.3±4.5 12(33.3) 21.92±2.56 492±205 339±233 21(45.6) 17(36.9) 2.3±0.7 2.3±1.1 1.7±0.5 9.2±3.4 101 514±12 436 开腹手术组(n=27) 59.7±5.7 10(37.0) 22.34±1.87 305±117 473±245 8(47.1) 9(52.9) 2.6±1.3 2.7±1.4 2.2±0.4 12.1±6.5 122 431±9766 P值 0.532 0.832 0.256 ＜0.010 ＜0.010 0.921 0.252 0.602 0.581 0.442 0.016 0.021 ERAS:同表 1
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