LEER模式下的质量控制体系在原发性肝癌患者围术期的应用

目的 探索LEER模式[少痛（less pain）、早动（early move）、早食（early eat）、安心（reassuring）]下采取的质量控制体系在原发性肝癌患者围手术期的应用价值。方法 回顾性分析乐山市人民医院肝胆胰外科2018年1月至2021年6月99例行根治性手术治疗的原发性肝癌患者围术期的临床资料,其中采用传统ERAS模式进行围术期管理的41例患者设为常规组,采用LEER模式下建立的质量控制体系进行围术期管理的58例患者设为LEER组,比较两组患者在术后整体恢复情况、术后并发症发生率及患者就医体验方面的差异。结果 与常规组相比,LEER组在住院时间（[ 9.75±1.29）d vs（8.23±1.52）d,t=6.896,P<0.001]、术后首次下床活动时间[（3.11±0.54）d vs（2.69±0.98）d,t=3.745,P=0.048]、术后肛门排气时间[（2.63±0.98）d vs （2.18±0.53）d,t=2.931,P=0.032]、术后饮食恢复时间[（4.38±1.81）d vs（3.52±1.34）d,t=2.525,P=0.049]、围术期疼痛控制满意度[（4.27±0.41）vs（4.76±0.32）,t=1.568,P=0.036],就医体验[（3.98±0.48）vs（4.63±0.51）,t=2.827,P=0.041]方面均优于常规组。两组在手术时间、手术出血量、住院费用、术后并发症方面无明显差异（P>0.05）。结论 LEER模式下建立的质量控制体系能确保加速康复外科措施精准、系统、全面、高效执行,整体促进术后患者加速康复,缩短住院时间,患者能获得较好的就医体验。     

加速康复外科在老年患者行腹腔镜胆囊切除术联合胆总管切开探查取石术中的应用

目的 探讨加速康复外科（enhanced recovery after surgery,ERAS）在老年患者行腹腔镜胆囊切除术（LC）联合腹腔镜胆总管切开探查取石术（LCBDE）中的应用经验。方法 回顾性分析上海市宝山区仁和医院2015年4月至2019年4月145例老年患者（65岁以上）择期行LC联合LCBDE手术的临床资料,按围手术期管理方案分为ERAS组（55例）和传统组（90例）,比较两组患者术前1 d和术后1 d的应激反应指标、肝肾功能指标,术后并发症发生率、术后康复情况及患者满意度。结果 与传统组比较,ERAS组术后1 d应激反应指标WBC [（10.83±2.06）×10⁹/L vs（ 11.94±1.68）×10⁹/L,t=3.53,P＜0.01]、CRP [（25.22±8.38） mg/L vs（28.42±9.29）mg/L,t=2.09,P=0.04]、血糖水平[（4.91±1.02）mmol/L vs（ 6.01±1.10）mmol/L,t=5.99,P＜0.01]均较低,差异具有统计学意义。两组术前1 d及术后1 d肝肾功能指标（ALT、TBIL及BUN）比较,差异无统计学意义（P＞0.05）。ERAS组总体并发症发生率较传统组低（15/55 vs 71/90,χ²=37.69,P＜0.01）,差异有统计学意义;其中ERAS组恶心呕吐（3/55 vs 18/90,χ²=5.83,P=0.02）、戳孔疼痛（2/55 vs 18/90,χ²=7.69,P＜0.01）的发生率明显低于传统组。术后ERAS组肛门排气时间[（1.2±0.4）d vs（ 1.6±0.5）d,t=4.45,P＜0.01]、住院时间[（7.2±1.1）d vs（ 9.0±2.4）d,t=5.36,P＜0.01]、住院费用[（1.75±0.31）万元 vs（1.96±0.26）万元,t=4.29,P＜0.01]及患者满意度[（94.34±13.42）分 vs（ 82.78±10.71）分,t=5.73,P＜0.01]均明显优于传统组,差异均具有统计学意义。结论 ERAS应用于老年患者LC联合LCDBE围手术期安全有效,可减轻患者应激反应,降低术后并发症发生率,加快术后康复,缩短住院时间,提高患者满意度。     

中医外治技术联合快速康复外科理念对肝胆外科术后患者的临床疗效

目的:探讨中医外治技术联合快速康复外科(ERAS)理念促进肝胆外科患者康复的临床疗效。方法:选择于2018 年8 月—2020 年10 月在我科行腹腔镜手术的患者308 例,随机分为外治组156 例,对照组152 例。对照组行腹腔镜手术+ERAS 理念,外治组在前者基础上加用中医外治技术,比较两组患者在术后肠鸣音恢复、肛门首次排气及排便时间、疼痛评分、住院天数、相关并发症等方面的差异。结果:外治组术后肠鸣音恢复、肛门首次排气排便时间均短于对照组(P <0.05),术后疼痛评分低于对照组(P <0.05),行肝脏手术及胰腺手术患者的住院时间均短于对照组(P <0.05)。但两组相关并发症发生率差异无统计学意义(P <0.05)。结论:中医外治技术联合ERAS 理念在肝胆外科围手术期的应用能减轻术后患者的疼痛,促进胃肠道功能的恢复,缩短住院时间,值得临床推广应用。     

Principles of preoperative assessment and enhanced recovery optimization for thoracic anaesthesia

A comprehensive preoperative assessment is imperative for patients undergoing lung surgery, ideally by way of a multidisciplinary team approach. This not only allows for clinicians to risk stratify patients and gain informed consent, but also to explore avenues in optimizing patients prior to surgery and plan for the delivery of the most appropriate postoperative care. A tripartite risk assessment combining risks of operative mortality, perioperative adverse cardiac events and postoperative dyspnoea should be assessed and discussed with patients. Those patients who continue towards surgical management may then be optimized with patient education addressing nutritional status, smoking cessation and alcohol dependency as well as the management of anaemia and physiological prehabilitation. This article aims to review existing guidelines for preoperative assessment in thoracic surgery as well as the latest preoperative guidance for enhanced recovery specific to thoracic surgery.     

快速康复外科理念用于胃节段切除术治疗早期胃癌的临床评价

目的探讨快速康复外科理念(ERAS)用于胃节段切除术治疗早期胃癌的临床效果。方法回顾性队列分析2017年8月至2020年11月接受胃节段切除术的87例早期胃癌患者临床资料,根据围术期是否应用ERAS理念分为ERAS组(47例,应用ERAS理念)和传统组(40例,传统外科康复理念)。采用SPSS 23.0统计分析软件,术后恢复指标、营养状况、疼痛程度、QLQ-C30量表评分以(±s)表示,独立t检验;并发症用χ²检验。P<0.05为差异有统计学意义。结果ERAS组肠音恢复时间、肛门排气时间、首次排便时间、切口愈合时间、术后住院时间均比传统组短(P<0.05)。术后7 d ERAS组自评-主观全面评定量表(PG-SGA)总分、视觉模拟评分法(VAS)评分比传统组低(P<0.05)。术后12周ERAS组QLQ-C30量表各维度评分均比传统组高(P<0.05)。ERAS组术后并发症总发生率为12.8%比传统组30.0%低(P<0.05)。结论ERAS理念用于胃节段切除术治疗早期胃癌可加速术后恢复进程,缓解疼痛,改善术后营养状况及生存质量,临床应用价值高。     

加速康复外科理念在青少年特发性脊柱侧凸围术期的应用

目的 探讨加速康复外科（ERAS）在手术治疗青少年特发性脊柱侧凸（AIS）病人中的应用效果。方法 收集2016年1月至2020年12月在我院接受AIS手术治疗的138例病人的病例资料。将2016年1月至2018年6月给予常规围术期管理措施的69例病人纳入对照组,2018年7月至2020年12月进行ERAS理念管理的69例病人纳入观察组,进行对照研究。记录两组病人手术时间、出血量、术后输血人数等指标,以及手术前后疼痛程度、心理状况、生活质量和炎症因子变化。结果 观察组手术时间、出血量、术后输血人数、并发症发生率和住院时间均低于对照组（P＜0.05）,观察组护理满意度高于对照组（92.75% vs. 73.91%,P=0.003）。观察组术后24 h、3 d的疼痛视觉模拟量表（VAS）评分低于对照组（P＜0.05）;而术后7 d的VAS评分与对照组比较,差异无统计学意义（P＞0.05）。两组术后7 d的焦虑自评量表、抑郁自评量表、简体中文版脊柱侧凸研究学会22项问卷表评分,以及血清白细胞介素-6、肿瘤坏死因子α水平与术前比较,差异均有统计学意义（P均＜0.05）;两组间比较,观察组明显低于对照组,差异均有统计学意义（P均＜0.05）。结论 ERAS能减少AIS病人围术期失血和不良反应,有利于疼痛的早期控制,降低炎症因子,减轻不良情绪,提高生活质量,进而促进病人早期康复。     

HIV treatment outcomes among people who acquired HIV via injecting drug use in the Asia‐Pacific region: a longitudinal cohort study

INTRODUCTIONData on HIV treatment outcomes in people who inject drugs (PWID) in the Asia‐Pacific are sparse despite the high burden of drug use. We assessed immunological and virological responses, AIDS‐defining events and mortality among PWID receiving antiretroviral therapy (ART).METHODSWe investigated HIV treatment outcomes among people who acquired HIV via injecting drug use in the TREAT Asia HIV Observational Database (TAHOD) between January 2003 and March 2019. Trends in CD4 count and viral suppression (VS, HIV viral load <1000 copies/mL) were assessed. Factors associated with mean CD4 changes were analysed using repeated measures linear regression, and combined AIDS event and mortality were analysed using survival analysis.RESULTSOf 622 PWID from 12 countries in the Asia‐Pacific, 93% were male and the median age at ART initiation was 31 years (IQR, 28 to 34). The median pre‐ART CD4 count was 71 cells/µL. CD4 counts increased over time, with a mean difference of 401 (95% CI, 372 to 457) cells/µL at year‐10 (n = 78). Higher follow‐up HIV viral load and pre‐ART CD4 counts were associated with smaller increases in CD4 counts. Among 361 PWID with ≥1 viral load after six months on ART, proportions with VS were 82%, 88% and 93% at 2‐, 5‐ and 10‐years following ART initiation. There were 52 new AIDS‐defining events and 50 deaths during 3347 person‐years of follow‐up (PYS) (incidence 3.05/100 PYS, 95% CI, 2.51 to 3.70). Previous AIDS or TB diagnosis, lower current CD4 count and adherence <95% were associated with combined new AIDS‐defining event and death.CONCLUSIONSDespite improved outcomes over time, our findings highlight the need for rapid ART initiation and adherence support among PWID within Asian settings.     

Analgesic Effects of Ultrasound‐Guided Iliohypogastric/Ilioinguinal Nerve Block Combined with Lateral Femoral Cutaneous Nerve Block in Total Hip Arthroplasty via Direct Anterior Approach: A Retrospective Cohort Study

ObjectiveThis study aimed to explore the efficacy and safety of the combination of lateral femoral cutaneous nerve blocks (LFCNB) and iliohypogastric/ilioinguinal nerve blocks (IHINB) on postoperative pain and functional outcomes after total hip arthroplasty (THA) via the direct anterior approach (DAA).MethodsIn this retrospective cohort study, patients undergoing THA via the DAA between January 2019 and November 2019 were stratified into two groups based on their date of admission. Sixty‐seven patients received LFCNB and IHINB along with periarticular infiltration analgesia (PIA) (nerve block group), and 75 patients received PIA alone (control group). The outcomes included postoperative morphine consumption, postoperative pain assessed using the visual analogue scale (VAS), the QoR‐15 score, and functional recovery measured as quadriceps strength, time to first straight leg rise, daily ambulation distance, and duration of hospitalization. The Oxford hip score and the UCLA activity level rating were assessed at 1 and 3 months after surgery. In addition, postoperative complications were recorded. Patients were also compared based on the type of incision used during surgery (traditional longitudinal or “bikini” incision).ResultsPatients in the nerve block group showed significantly lower postoperative morphine consumption, lower resting VAS scores within 12 h postoperatively, lower VAS scores during motion within 24 h postoperatively, and better QoR‐15 scores on postoperative day 1. These patients also showed significantly better functional recovery during hospitalization. At 1‐month and 3‐month outpatient follow up, the two groups showed no significant differences in Oxford hip score or UCLA activity level rating. There were no significant differences in the incidence of postoperative complications. Similar results were observed when patients were stratified by type of incision, except that the duration of hospitalization was similar.ConclusionCompared to PIA alone, a combination of LFCNB and IHINB along with PIA can improve early pain relief, reduce morphine consumption, and accelerate functional recovery, without increasing complications after THA via the DAA.