21例颈椎前路手术的加速康复外科理念应用体会

目的 探索加速康复围手术期管理方法在颈椎前路手术中的作用。方法 回顾分析2019年7月至2021年6月我科收治的42例颈椎病患者,其中加速康复组和传统组各21例,比较两组患者围手术期资料（手术时间、出血量、引流放置时间、离床活动时间、术后住院时间）、临床疗效、吞咽功能。结果 两组基线资料差异无明显统计学意义（P>0.05）。在围手术期资料方面,加速康复组手术时间、术中出血量与传统组无明显差异（P>0.05）,而引流管放置时间、术后离床活动时间、术后住院时间均较传统组短（P<0.05）。在临床疗效方面,两组术后1天、1月、6月VAS评分及术后1月、6月JOA评分均较术前明显改善（P<0.05）,加速康复组术后1天VAS评分优于传统组（P<0.05）,其余时点及VAS评分、JOA评分两组间无明显统计学差异（P>0.05）。在吞咽功能评分方面,加速康复组在术后1天、术后1月轻度及以下吞咽困难比例较传统组高,中度吞咽困难患者比例较低（P<0.05）,而术后6月两组吞咽困难评分差异无明显统计学意义（P>0.05）。在术后并发症方面,加速康复组出现1例皮肤浅层感染,2例尿潴留,传统组出现1例肺部感染,经过保守治疗后好转,无再次手术患者,无其他重大并发症。结论 加速康复理念运用于颈椎前路手术中,可改善围手术期疗效,缩短住院时间,有利于提高患者手术体验。     

加速康复外科理念在腹腔镜结直肠恶性肿瘤手术中的应用

目的:探讨加速康复外科(ERAS)理念在结直肠恶性肿瘤患者腹腔镜手术围手术期实施的有效性和安全性。方法:将45 例结直肠恶性肿瘤患者分为加速康复外科组(ERAS 组)和对照组,其中ERAS 组24 例,围手术期采用加速康复外科方法处理,对照组21 例,围手术期采用传统方法处理,比较两组在术后康复指标、疼痛评分及并发症等方面的差异。结果:两组患者年龄、性别、体质指数(BMI)等一般资料差异无统计学意义。与对照组相比,加速康复外科组患者术后首次排气时间提前[(2.71±0.23)d vs(4.17±0.15)d]、术后第1 天血糖更稳定[(6.23±0.32) mmol/L vs(8.17±0.53) mmol/L]、术后第1 天疼痛评分更低[(1.42±0.19) vs(2.75±0.18)]、导尿管留置时间缩短[(1.73±0.21) d vs(4.00±0.28) d]、腹腔引流管留置时间缩短[(4.14±0.23) d vs 7.69±0.31) d]、术后住院d 数更短[(6.92±0.28) d vs(9.58±0.56) d],差异均有统计学意义(P <0.05),且并未增加术后并发症发生率。结论:以加速康复外科理念为基础的一系列治疗措施能够促进结直肠恶性肿瘤患者的术后康复。     

胃肠外科近20年进展和发展趋势

进入21世纪已经20年了,回顾胃肠外科发展历程,疾病谱的改变对胃肠外科医师提出了更高的要求。微创技术、代谢外科、围手术期综合管理和外科质量控制、专业化和多学科团队等全新的理念和治疗模式不断出现并迅速推广,不仅推动了胃肠外科的发展,也是胃肠外科发展的趋势。     

Perioperative nutritional support of patients undergoing pancreatic surgery in the age of ERAS

ObjectiveThe results achieved through the Enhanced Recovery After Surgery (ERAS) approach in gastrointestinal surgery have led to its enthusiastic acceptance in pancreatic surgery. However, the ERAS program also involves an early oral feeding that is not always feasible after pancreatoduodenectomy. The aim of this review was to investigate in the literature whether the difficulty with early oral feeding in these patients was adequately balanced by perioperative enteral or parenteral nutritional support as recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines or whether these recommendations have lost value in the “bundle” of the ERAS.MethodsWe reanalyzed both ESPEN guidelines and literature regarding the ERAS program in surgical pancreatic patients.ResultsThere was a high prevalence of malnutrition (and consequently of postoperative complications) in patients with pancreatic cancer, and there is evidence that many of these patients should be candidates for perioperative nutritional support according to ESPEN guidelines. The start of oral fluid and solid feeding was quite variable in literature reporting the use of ERAS in pancreatic cancer surgery, with a consistent gap between the recommended and the effective start of both the feedings. The use of nasogastric/jejunal tube or of a needle-catheter jejunostomy was discouraged by the ERAS guidelines but their use could prove beneficial in patients who are recognized at high risk for postoperative complications according to the scores available in the literature.ConclusionThe current practice of the ERAS program in these patients appears to neglect some ESPEN recommendations. On the other hand, both ESPEN and ERAS recommendations could be combined for a supplemental benefit for the patient.     

营养管理在胃癌加速康复外科治疗病人中的应用

[目的]探讨营养管理在胃癌加速康复外科治疗病人中的应用效果。[方法]选择在我科住院确诊为胃癌行胃癌D2根治术的病人101例,按时间先后顺序分为对照组52例、观察组49例。对照组按常规护理,观察组术后进行规范营养管理,由营养师根据病人情况配制专用口服营养液,按时按量供应。比较两组病人进食时间、进食量、术后排气时间、腹胀情况及舒适度评分。[结果]两组病人术后肛门排气时间、进食时间差异无统计学意义(P>0.05);观察组术后前3 d进食量、腹胀情况、舒适度均优于对照组(P<0.05)。[结论]对胃癌加速康复外科治疗病人术前、术后进行规范营养管理,能促进病人肠功能恢复,增加进食量,提高舒适度。     

Enhanced Recovery after Surgery (ERAS) Protocol Is a Safe and Effective Approach in Patients with Gastrointestinal Fistulas Undergoing Reconstruction: Results from a Prospective Study

Background and Aims: An enterocutaneous fistula (ECF) poses a major surgical problem. The definitive surgical repair of persistent fistulas remains a surgical challenge with a high rate of re-fistulation and mortality, and the reasons for that is not the surgical technique alone. Enhanced Recovery after Surgery (ERAS^®) is an evidence-based multimodal perioperative protocol proven to reduce postoperative complications. The aim of the study was to assess the clinical value of the ERAS protocol in surgical patients with ECF. Methods: ERAS protocol was used in all patients scheduled for surgery for ECF at the Stanley Dudrick’s Memorial Hospital in Skawina between 2011 and 2020. A multidisciplinary team (MDT) was in charge of the program and performed annual audits. A consecutive series of 100 ECF patients (44 females, 56 males, mean age 54.1 years) were evaluated. Postoperative complications rate, readmission rate, length of hospital stay, prevalence of postoperative nausea and vomiting were assessed. Registered under ClinicalTrials.gov Identifier no. {"type":"clinical-trial","attrs":{"text":"NCT04771832","term_id":"NCT04771832"}}NCT04771832. Results: ERAS protocol was successfully introduced for ECF surgeries; however, eight modifications to the ERAS program was performed in 2015. They led to improvement of surgical outcomes: reduction of postoperative nausea and vomiting (15 vs. 17% patients, p = 0.025), overall complication rate (11 vs. 10, p = 0.021), median length of hospital stay (overall and after surgery, p = 0.022 and 0.002, respectively). Conclusions: ERAS protocol can be successfully used for ECF patients. Prescheduled audits can contribute to the improvement of care.