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。

Application of enhanced recovery after surgery in laparoscopic cholecystectomy combined with common bile duct exploration for elderly patients

Objective To investigate the application effect of enhanced recovery after surgery (ERAS) for laparoscopic cholecystectomy (LC) combined with laparoscopic common bile duct exploration (LCBDE) in elderly patients. Methods Clinical data of 145 elderly patients (over 65 years) who underwent LC combined with LCBDE between Apr. 2015 and Apr. 2019 in Renhe Hospital was retrospectively analyzed. Among them, 55 patients received ERAS perioperative management (ERAS group), and 90 patients received traditional perioperative management (traditional group). Differences in stress response parameters, liver and kidney function before and after surgery, postoperative complications incidence, postoperative recovery and satisfaction between the two groups were compared. Results The stress response parameters, including white blood cell (WBC) count (10.83±2.06)×10⁹/L vs (11.94±1.68)×10⁹/L, t=3.53, P<0.01], C-reactive protein (CRP) level (25.22±8.38)mg/L vs (28.42±9.29)mg/L, t=2.09, P=0.04] and blood glucose level (4.91±1.02)mmol/L vs (6.01±1.10)mmol/L, t=5.99, P<0.01], were significantly lower in ERAS group than those in traditional group 1 d aftersurgery (P<0.05). There were no statistical significant difference in liver and kidney function index between the two groups (P>0.05). The overall complication rate of ERAS group was lower than that of traditional group (15/55 vs 71/90, χ²=37.69, P<0.01), the incicences of inausea and vomiting (3/55 vs 18/90, χ²=5.83, P=0.02), pain in trocar incision sites (2/55 vs 18/90, χ²=7.69, P<0.01) were significantly lower in ERAS group than that in traditional group. Postoperative recovery, including time of flatus (1.23±0.42)d vs (1.58±0.50)d, t=4.45, P<0.01], length of hospitalization time (7.16±1.07)d vs (8.96±2.36)d, t=5.36, P<0.01], hospitalization expense (1.75±0.31) ten thousand Yuan vs (1.96±0.26) ten thousand Yuan, t=4.29, P<0.01] and satisfaction (94.34±13.42)points vs(82.78±10.71)points, t=5.73, P<0.01] were significantly better in ERAS group than those in traditional group (P<0.01). Conclusion ERAS is a safe and effective procedure that can be used in perioperative management of LC combined with LCBDE for elderly patients, which can reduce stress response and postoperative complications incidence, accelerate postoperative recovery, and shorten hospitalization time, improve patient satisfaction.