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围手术期营养干预加速胃肠外科术后康复:单中心前瞻队列研究

薛志刚 于健春 康维明 马志强 叶欣 闫超 李子建 蒋林 林国乐 肖毅 陆君阳 吴斌 牛备战 裴丽坚 黄宇光

薛志刚, 于健春, 康维明, 马志强, 叶欣, 闫超, 李子建, 蒋林, 林国乐, 肖毅, 陆君阳, 吴斌, 牛备战, 裴丽坚, 黄宇光. 围手术期营养干预加速胃肠外科术后康复:单中心前瞻队列研究[J]. 协和医学杂志, 2018, 9(6): 526-532. doi: 10.3969/j.issn.1674-9081.2018.06.008
引用本文: 薛志刚, 于健春, 康维明, 马志强, 叶欣, 闫超, 李子建, 蒋林, 林国乐, 肖毅, 陆君阳, 吴斌, 牛备战, 裴丽坚, 黄宇光. 围手术期营养干预加速胃肠外科术后康复:单中心前瞻队列研究[J]. 协和医学杂志, 2018, 9(6): 526-532. doi: 10.3969/j.issn.1674-9081.2018.06.008
Zhi-gang XUE, Jian-chun YU, Wei-ming KANG, Zhi-qiang MA, Xin YE, Chao YAN, Zi-jian LI, Lin JIANG, Guo-le LIN, Yi XIAO, Jun-yang LU, Bin WU, Bei-zhan NIU, Li-jian PEI, Yu-guang HUANG. Perioperative Nutrition Intervention Enhanced Recovery after Gastrointestinal Surgery: a Prospective Single-center Cohort Study[J]. Medical Journal of Peking Union Medical College Hospital, 2018, 9(6): 526-532. doi: 10.3969/j.issn.1674-9081.2018.06.008
Citation: Zhi-gang XUE, Jian-chun YU, Wei-ming KANG, Zhi-qiang MA, Xin YE, Chao YAN, Zi-jian LI, Lin JIANG, Guo-le LIN, Yi XIAO, Jun-yang LU, Bin WU, Bei-zhan NIU, Li-jian PEI, Yu-guang HUANG. Perioperative Nutrition Intervention Enhanced Recovery after Gastrointestinal Surgery: a Prospective Single-center Cohort Study[J]. Medical Journal of Peking Union Medical College Hospital, 2018, 9(6): 526-532. doi: 10.3969/j.issn.1674-9081.2018.06.008

围手术期营养干预加速胃肠外科术后康复:单中心前瞻队列研究

doi: 10.3969/j.issn.1674-9081.2018.06.008
基金项目: 

国家卫生计生委公益性行业科研专项基金 201502022

北京市科技计划项目 D141100000414002

详细信息
    通讯作者:

    于健春  电话: 010-69152629, E-mail: yu-jch@163.com

  • 中图分类号: R619;R656;R657

Perioperative Nutrition Intervention Enhanced Recovery after Gastrointestinal Surgery: a Prospective Single-center Cohort Study

More Information
    Corresponding author: YU Jian-chun   Tel: 010-69152629, E-mail: yu-jch@163.com
  • 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。
  • 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
    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
    肠道准备 肠内营养
    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
    切皮前及缝皮前切口下局麻 局部麻醉(罗哌卡因+利多卡因)
    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
    术中体温保护 预热补液,加温床垫,吹暖风
    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
    下载: 导出CSV

    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(%)]
    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 0.496 0.778 0.625 0.644 0.935 0.449
    ERAS、NRS:同表 1;BMI:体质量指数
    下载: 导出CSV

    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 <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
    下载: 导出CSV
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