Multimodal Optimization of Surgical Care Shows Beneficial Outcome in Gastrectomy Surgery

Background: The aim of this trial was to compare multimodal optimization with conventional perioperative management in a consecutive series of patients undergoing gastrectomy procedures. Methods: According to randomized controlled studies and conclusions made by meta‐analyses in colorectal surgery, optimized perioperative measures were designed and applied in gastrectomy surgery. Thirty‐three patients were randomized to the optimized group and 30 patients to a control group. Two groups were treated in 1 center by a single surgical team in different wards. Both groups used patient‐controlled intravenous analgesia for postoperative analgesia. The primary end point was length of postoperative hospital stay. Secondary outcomes included bowel function recovery after surgery, perioperative changes of inflammatory factors, glucocorticoid, insulin resistance, and body composition. Perioperative complications and adverse events were also recorded. Results: The groups were similar in terms of age, sex ratio, and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM score). The optimized group was associated with a significantly shorter postoperative hospital stay compared with the conventional care group (P < .001). Durations of urinary catheterization and abdominal drainage were also less (P < .001). The diet program in the optimization group was well tolerated and was associated with an earlier recovery of gut function (P < .001). Proinflammatory factors were less elevated and body composition was more stable in the optimized group than in controls. There were no differences in morbidity or mortality between the groups. Conclusions: Optimization of care in gastrectomy can shorten postoperative hospital stay and provides multiple beneficial outcomes, including hastening the return of gut function, without increasing morbidity.     

早期拔除胸腔引流管在VATS食管癌切除术中的应用

目的:探讨早期拔除胸腔引流管在电视胸腔镜下（VATS）食管癌切除术促进术后康复中应用的可行性。方法:100例行电视胸腔镜下食管癌切除术病人,随机分为ERAS组和对照组,每组50例。ERAS组采取术后早期拔除胸管,对照组采用传统方式拔管。对比观察两组病人拔管时间、拔管前总引流量、胸腔积液发生率、胸腔穿刺率、住院时间、治疗费用的差异。结果:ERAS组拔管时间早于对照组,差异有统计学意义（P＜0.05）;ERAS组总引流量少于对照组,差异有统计学意义（P＜0.05）;两组病人胸腔积液发生率无显著差异（P＞0.05）;胸腔穿刺率无显著差异（P＞0.05）;ERAS组住院时间及治疗费用均低于对照组,差异有统计学意义（P＜0.05）。结论:早期拔除胸腔引流管在电视胸腔镜下食管癌切除术术后中的应用是安全可行的,并且恢复更快,住院费用更少。     

加速康复外科从理论到实践——我们还需要做什么?

加速康复外科(enhanced recovery after surgery,ERAS)的临床实践已有充分的证据改变了外科手术的结果,缩短住院日并节约费用.但是目前ERAS无论是被应用的广度还是深度却远远不够,原因何在呢？我们分析可能主要原因是缺少”可操作、可评估、可重复”的临床方案.可操作主要是指临床方案简单易行,团队和患者依从性均好;可评估是指方案应用前、中、后均有客观评估标准及处理方案;可重复是临床方案在本单位及推广过程中重复性好.     

多模式镇痛复合不同浓度罗哌卡因切口浸润在加速康复外科术后镇痛的效果

目的 探讨在多模式镇痛中复合不同浓度罗哌卡因切口浸润在加速康复外科(ERAS)行开腹结直肠手术术后镇痛的效果.方法 选择择期加速康复外科开腹结直肠手术患者62例,随机分为2组,每组31例.R1组:0.5％罗哌卡因20 mL术毕切口局部浸润;R2组:0.375％罗哌卡因20 mL术毕切口局部浸润.术后均行舒芬太尼静脉自控镇痛(PCIA).分别观察并记录手术结束0、2、4、6、24、48 h各组静息视觉模拟评分(VAS)、Prince-Henry疼痛评分;记录术后首次追加舒芬太尼时间,术后6、24、48 h舒芬太尼消耗量及患者实际按压PCIA泵次数;记录患者术后首次排气排便、离床活动时间及术后住院时长;记录患者术后48 h内不良反应的发生情况.结果 两组患者的一般情况、手术时间、切口长度、手术方式及术中补液量比较,差异均无统计学意义.两组术后备时间点VAS、Prince-Henry评分及不良反应发生情况比较,差异无统计学意义.R1组与R2组比较,首次追加舒芬太尼时间延长[(60.97±20.79) min vs.(37.74±33.14) min],6h舒芬太尼消耗量减少[(16.80±1.74) μg vs.(21.62±2.62) μg],6h镇痛泵按压次数减少[2(1 ～3)次vs.12(10～ 14)次];术后首次排气排便时间提前[(21.47±2.45)h vs.(27.47±3.10)h],差异均有统计学意义(P＜0.05).结论 在多模式镇痛中复合0.5％罗哌卡因20 mL术毕切口局部浸润,可为开腹行结直肠手术患者提供早期良好的术后镇痛,同时减少术后早期PCIA舒芬太尼使用量,加速胃肠功能恢复.     

超声引导下的II型胸神经阻滞复合改良的前锯肌平面阻滞对乳腺癌患者术后康复的应用价值

目的:探究超声引导下II型胸神经阻滞(PECS-II)复合改良的前锯肌平面阻滞(serratus anterior plane block,SAPB)对乳腺癌患者术后康复的效果。方法:回顾性分析177 例行乳腺癌改良根治术患者的相关临床资料,根据麻醉方式是否联合超声引导下II型胸神经阻滞复合改良的前锯肌平面阻滞,分为全身麻醉组（G组）、全身麻醉+II型胸神经阻滞复合改良的前锯肌平面阻滞（GPS组）两组,G组给予常规全身麻醉,GPS组在麻醉完成后按神经阻滞方案给予患者PECS-II复合改良的SAPB,比较两组患者基本资料,术后自主呼吸恢复时间、拔除喉罩时间和完全清醒时间、术后疼痛评分,术中术后阿片类药物使用量、镇痛不全和恶心呕吐发生率及平均住院时间等数据。结果:与G组相比,GPS组患者术后自主呼吸恢复时间、拔除喉罩时间和完全清醒时间较短（P＜0.05）,术后疼痛评分,术中术后阿片类药物使用量均较低（P＜0.05）,镇痛不全及恶心呕吐发生率较低（P＜0.05）,平均住院时间减少（P＜0.05）。结论:对于乳腺癌改良根治术,超声引导下的PECS-II复合改良的SAPB能够缩短患者的麻醉苏醒时间,减少阿片类药物的用量和术后急性慢性疼痛的发生,降低术后恶心呕吐,缩短平均住院时间,加快患者康复,提高患者生存质量。     

快速康复外科理念在股骨粗隆间骨折患者中应用观察

目的 探讨加速康复外科（ERAS）对股骨近端抗旋髓内钉（PFNA）固定的粗隆间骨折患者的影响。方法 回顾性研究纳入100例粗隆间骨折患者,分为ERAS组（50例）和对照组（50例）,记录两组的住院天数、Harris髋关节评分（HHS）、视觉模拟量表（VAS）、日常生活活动量表（ADL）。结果 ERAS 手术与较短的住院时间、较低的术后VAS评分、较早的活动和术后3个月的平均HHS评分显著改善相关,平均住院时间从6.3±2.8减少到4.9±2.6天。结论 股骨粗隆间骨折患者围手术期接受ERAS处理能够减少住院时间而不增加术后并发症和再入院率。     

Enhanced Recovery After Surgery Protocols in Lower Extremity Joint Arthroplasty: Using Observational Data to Identify the Optimal Combination of Components

BackgroundEnhanced recovery after surgery (ERAS) protocols are increasingly used in orthopedic surgery. Data are lacking on which combinations of ERAS components are (1) the most commonly used and (2) the most effective in terms of outcomes.MethodsThis retrospective cohort study utilized claims data (Premier Healthcare, n = 1,539,432 total joint arthroplasties, 2006-2016). Eight ERAS components were defined: (A) regional anesthesia, (B) multimodal analgesia, (C) tranexamic acid, (D) antiemetics on day of surgery, (E) early physical therapy, and avoidance of (F) urinary catheters, (G) patient-controlled analgesia, and (H) drains. Outcomes were length of stay, “any complication,” and hospitalization cost. Mixed-effects models measured associations between the most common ERAS combinations and outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported.ResultsIn 2006-2012 and 2013-2016, the most common ERAS combinations were B/D/E/F/G/H (20%, n = 172,397) and B/C/D/E/F/G/H (17%, n = 120,266), respectively. The only difference between the most commonly used ERAS combinations over the years is the addition of C (addition of tranexamic acid to the protocol). The most pronounced beneficial effects in 2006-2012 were seen for combination A/B/D/E/F/G/H (6% of cases vs less prevalent ERAS combinations) for the outcome of “any complication” (OR 0.87, CI 0.83-0.91, P < .0001). In 2013-2016, the strongest effects were seen for combination B/C/D/E/F/G/H (17% of cases) also for the outcome of “any complication” (OR 0.86, CI 0.83-0.89, P < .0001). Relatively minor differences existed between ERAS protocols for the other outcomes.ConclusionDespite varying ERAS protocols, maximum benefits in terms of complication reduction differed minimally. Further study may elucidate the balance between an increasing number of ERAS components and incremental benefits realized.Level of EvidenceIII.