快速康复外科治疗在肝移植中的应用价值

目的探讨快速康复外科(FTS)治疗对肝移植患者预后的影响。方法病例纳入标准:(1)病因为肝硬化或符合米兰标准的原发性肝癌;(2)手术方式为改良背驮式肝移植;(3)首次接受肝移植。排除标准:(1)年龄≤16岁;(2)多次肝移植手术;(3)术前或术中行肝动脉插管化疗栓塞或射频消融等治疗手段。本前瞻性随机单盲研究选取2011年1月至2013年12月在南京医科大学第一附属医院由同一医疗小组行肝移植手术且符合上述标准的52例患者。根据围手术期处理的不同分为FTS组(21例)和传统治疗(NFTS)组(31例)。FTS治疗包括完善的术前教育、术前不行肠道准备、术前不放置鼻胃管、术后不放置引流管、术中预防低体温、微创切口、早期运动并加强营养等。比较两组患者术中和术后情况。采用逐步Logistic回归模型评估FTS治疗和临床观察指标之间的关系,以分析FTS治疗对肝移植预后的影响。结果与NFTS组比较,FTS组手术时间和无肝期时间均明显缩短,同时FTS组术中出血量和输血率亦明显减少(均为P0.05)。此外,FTS组患者恢复较好,术后重症监护室(ICU)住院时间和总住院时间均较NFTS组明显缩短(均为P0.05)。Logistic回归分析结果显示,FTS治疗是缩短术后ICU住院时间(比值比为0.301,95%可信区间为0.184~0.494,P=0.000)和总住院时间(比值比为0.148,95%可信区间为0.085~0.257,P=0.000)的有利因素。结论 FTS治疗应用于肝移植围手术期患者,可以有效改善其预后。     

高风险结直肠癌患者快速流程模式的临床应用

目的：探讨快速流程应用于高风险结直肠癌患者的可行性和安全性。方法：回顾性研究2007年11月—2008年12月264例结直肠癌患者的临床资料,分析不同管理模式下患者早期恢复情况及快速流程模式的完成情况。结果：术后早期康复方面,快速流程（FT）组首次下床时间和首次经口进食时间短于传统组且差异有统计学意义（P〈0.05）;术后管道管理方面,首次拔除尿管时间FT组早于传统组,差异有统计学意义（P〈0.05）;术后住院时间方面,FT组也明显短于传统组,差异有统计学意义（P〈0.05）。对于术后并发症发生情况,2组术后并发症发生率的差异无统计学意义（P〉0.05）。结论：在高风险结直肠癌患者中快速流程是安全可行的,可以促进患者早期康复,缩短住院时间,对提高高风险结直肠肿瘤患者围手术期管理质量有着重要的推动作用。     

Oral etodolac,a COX-2 inhibitor,reduces postoperative pain immediately after fast-track cardiac surgery

Purpose The present study was designed to evaluate the efficacy of a cyclooxygenase (COX)-2 inhibitor, etodolac, on postoperative pain after fast-track cardiac surgery, and to examine the changes in plasma etodolac concentration after oral administration.Methods Thirty patients scheduled for elective coronary artery bypass grafting (CABG) surgery were randomly assigned preoperatively in a double-blind fashion to receive either vehicle (n = 15) or etodolac 400mg (n = 15) via a gastric tube at the end of the surgery. Standardized fast-track cardiac anesthesia was used. In both groups, postoperative pain was treated with buprenorphine suppository. Visual analogue pain scores (VASs) were recorded immediately after extubation and at 24h after surgery. Plasma etodolac concentration was measured at 1, 2, and 6h after administration (n = 8).Results No difference was detected in time to extubation between the etodolac group (209 ± 85min, mean ± SD) and the vehicle group (207 ± 98min). VASs were significantly lower in the etodolac (2.3 ± 2.1) vs the vehicle group (5.8 ± 2.0) immediately after extubation (P = 0.009), but no difference was detected in pain scores at 24h after surgery, or in the amount of buprenorphine administered in the intensive care unit (ICU), or in the incidence of side effects. Plasma etodolac concentration was within the pharmaceutically recommended range at 1h, 2h, and 6h after administration.Conclusion The oral use of etodolac with rectal buprenorphine reduces pain scores immediately after cardiac surgery without an increase in side effects.     

结直肠癌患者围手术期快速康复外科新理念治疗的效果观察

目的:观察结、直肠癌患者围手术期应用快速康复外科(FTS)新理念治疗的临床效果.方法:选取91例结、直肠癌手术患者,随机分为快速康复组(FTS组)48例和常规治疗对照组(对照组)43例.FTS组采用FTS新理念进行围手术期处理,包括术前心理辅导、口服肠内营养粉及导泻药物导泻,术中控制输液量、采用小手术切口,术后用非甾体...     

快速康复外科在根治性全膀胱切除术中的应用

快速康复外科是由丹麦外科医师Kehlet提出,旨在通过减轻围术期的应激反应而促进患者术后康复,减少手术并发症.距快速康复外科理念提出已有近20余年,在这期间,快速康复外科理念在国外得到了极大地发展,并在普外科,尤其是结直肠外科、心胸外科、妇科等进行应用,取得了极大地成功,后被黎介寿院士引入我国,并迅速被外科医师所接受,尤其是在结直肠切除手术中的成功应用已成为典范,但在根治性全膀胱切除术中应用相对较少,本文就快速康复外科理念在根治性全膀胱切除术中的应用作一综述,以期能促进这一理念在该术式中的推广应用.     

快速康复外科在结直肠癌根治术中的应用评价

【摘要】 目的 探讨FTS应用于结直肠癌(CRC)根治术中的效果。方法〓对92例结直肠癌患者分别给予快速康复方案((n=46)作为实验组和传统方案(n=46)作为对照组。对比两组的疗效、并发症及生活质量。结果〓术后FTS组抑郁、焦虑评分明显低于对照组(P<0.001)。术后FTS组白细胞水平明显低于对照组,两组间差异显著(P<0.001)。术后FTS组白蛋白、总蛋白水平下降幅度明显小于对照组,组间差异显著(P<0.001)。FTS组术后评价手术疗效及医疗成本的各项指标明显优于对照组,组间比较差异显著(P<0.01)。FTS组恶心、呕吐的比例低于对照组(P=0.0205),其余并发症组间比较无显著性差异(P>0.05)。术后FTS组生活质量各项评分皆高于对照组(P<0.05)。其中生理领域、心理领域评分两组间差异更显著(P<0.01)。结论〓给予CRC患者以FTS治疗,可以减少缓解患者抑郁、焦虑等不良情绪,提高综合疗效,减少并发症,最终提高术后生活质量,有利于患者尽快康复。     

快速康复理念在肝胆外科围手术期的体会

【摘要】〓目的〓探讨腹腔镜及胆道镜在肝胆手术快速康复外科的应用。方法〓分析总结2009年11月至2014年5月192例行肝胆手术患者采用快速康复外科理念指导下进行诊治,及腹腔镜及胆道镜在肝胆手术中应用的经验和体会。结果〓死亡病例。192例病人远期随访,行保胆取石114例,有4例复发,1例行胆囊切除术,3例无明显症状,予以定期随访。经“T”管窦道胆道镜探查取石46例,均经1次到最多5次完成取石。其他肝胆手术32例,2例出现但漏,经保守均治愈。结论〓肝胆手术中,只要发挥腹腔镜及胆道镜优势,能够体现快速康复外科的理念。     

腹腔镜结直肠癌手术患者围手术期应用快速康复外科的系统评价

目的系统评价腹腔镜结直肠癌手术患者应用快速康复外科（FTs）的安全性和有效性。方法计算机检索2000年1月至2012年3月CNKI、万方、Pubmed、EMBACE、CochraneLibrary数据库关于腹腔镜结直肠癌根治术围手术期应用FTS的随机对照试验（RCT）或临床对照试验（CCT）。采用RevMan5．1软件进行Meta分析。结果6项RCT和7项CCT研究纳入研究．共1795例患者,其中FTS组955例,对照组840例。与对照组相比．FTS组患者术后排气更快（WMD=-1．37,95％CI：-1．55～-1．19,P〈0．05）,术后进食更早（WMD=-2．62,95％CI：-2．69～-2．55,P〈0．05）,术后住院时间缩短（WMD=-1．63,95％CI：-1．92～-1．34,P〈0．05）,术后并发症发生率降低（OR=0．52,95％CI：0．41～0．67,P〈O．05）;但两组术后再入院率的差异无统计学意义（P〉0．05）。结论FTS理念应用于腹腔镜结直肠癌根治术,可有效促进术后肠功能恢复,减少并发症的发生,缩短住院时间。     

Further reduction of hospital stay for laparoscopic colon resection by modifications of the fast-track care plan

Background

Fast-track surgery has been described as a plan to facilitate early recovery. We present one surgeon's modifications to fast-track surgery for laparoscopic colectomy patients.

Methods

We performed a retrospective review of 48 consecutive patients undergoing elective laparoscopic colectomy treated by a modified fast-track plan between 2004 and 2008. Elements included preoperative education, pre-anesthesia dexamethasone, immediate postoperative general diet, no urinary catheter, no epidural anesthesia, and no flatus or bowel movement as a discharge requirement. Data collected included the following: age, sex, body mass index, resection indications, surgical time, blood loss, pain score, time to ambulation, time to bowel function, length of stay, complications, and mortality.

Results

The mean length of stay was 37 hours (1.5 d), with 29 of 48 patients discharged without passage of flatus or stool. Only 1 patient required readmission.

Conclusions

Our modified fast-track plan achieved significant improvement in length of stay for laparoscopic colectomy compared with previous results.     

快速康复外科理念在食管癌治疗中的应用

目的探讨快速康复外科理念在食管癌患者围手术期的应用及对患者的临床结局的影响。方法收集2011年1-6月间南京医科大学附属淮安第一医院胸外科接受食管癌根治术的食管鳞癌患者117例,其中4-6月63例（研究组）,围手术期采用快速康复外科理念进行处理：1～3月接受手术54例（对照组）,围手术期按常规处理。结果研究组术后排气时间、术后拔除胸腔引流管时间、术后住院时间及住院总费用均显著低于对照组（P〈O．05）：手术时间两组差异无统计学意义（P〉0．05）。研究组和对照组总并发症的发生率分别为7．9％（5／63）和24．1％（13／54）,差异有统计学意义（P〈0．05）。结论食管癌患者围手术期应用快速康复外科理念,可促进术后肠功能恢复．减少术后并发症发生率．从而改善患者的临床结局．     

Implementation of the scientific evidence into daily practice – example from fast-track colonic cancer surgery

Objective  To report the implementation and results of fast-track surgery for colonic cancer in the daily routine.
Method  A total of 131 consecutive patients scheduled for elective colonic cancer resections entered a fast-track perioperative course after thorough information. The regimen contained: no preoperative bowel cleansing, transverse and small abdominal incisions, no dains nor tubes, mobilization and normal meal the evening on the day of surgery, epidural analgesia, oral laxatives, and a planned discharge on postoperative day 3.
Results  Median number of days postoperative in hospital were 4 days (range 1–46). Eighty-nine per cent experienced an uncomplicated course, 3% were readmitted within 30 days, and the 30-day mortality was 3.8%.
Conclusion  Fast-track surgery is feasible in an unselected patient population scheduled for elective colon cancer resections without compromising quality.     

快速康复外科联合精准肝切除对非选择性肝切除患者的应用价值

目的探讨快速康复外科技术及精准肝切除的引入在非选择性肝切除患者中的应用价值。 方法选取2009年1月至2014年1月武汉黄陂区人民医院收治的345例肝切除的手术患者,随机分为传统组及快速康复组,传统组155例,按照常规开腹手术方法以及通气后进饮食等传统围手术期治疗方案进行治疗;快速康复组190例,应用快速康复外科技术联合精准肝切除技术。对比分析两组患者术后C反应蛋白(CRP)、血皮质醇、血糖等变化以及术后离床时间、进食时间、肛门排气时间、住院天数、住院费用等指标,并观察记录不良反应及并发症。 结果快速康复组手术前后皮质醇、血糖水平变化小于传统组(P<0.05),离床时间、进食时间、肛门排气时间明显提前(P<0.05),住院天数、住院费用少于传统组,且并未增加并发症及再入院率。 结论快速康复外科技术联合精细肝切除的引入对于非选择性肝切除患者是成功且较安全的。     

快通道麻醉在结直肠肿瘤术后快速康复中的应用

目的 探讨快通道麻醉(fast-track anesthesia,FTA)应用于结直肠肿瘤患者术后快速康复(enhanced recovery after surgery,ERAS)中的可行性. 方法 将需手术治疗的104例择期结直肠肿瘤患者按随机数字表法分为传统对照组和快康观察组,每组52例.其中快康观察组按FTA方法进行麻醉,传统对照组按传统麻醉方法进行麻醉,观察并比较两组麻醉前(T0)、气管插管后5 min(T1)、切皮时(T2)、探查时(T3)、拔除气管导管后5 min(T4)的HR及MAP变化,观察患者全身麻醉药丙泊酚及肌松药维库溴铵的用量、术后苏醒时间、肛门排气时间、术后住院时间,统计术后并发症肺部感染和吻合口漏的发生率. 结果 快康观察组手术过程中HR、MAP波动较传统对照组较小(P＞0.05).快康观察组术中麻醉药物的用量明显比传统对照组要少[丙泊酚(287±26) mg比(414±36) mg;维库溴铵(13.6±2.5) mg比(15.8±2.3) mg] (P＜0.05),快康组患者术后苏醒时间[(14±4)min比(26±13) min]、肛门恢复排气时间[(26±13)h比(54±19)h]、术后住院时间[(5.6±1.3)d比(8.0±2.6)d]及肺部感染发生率(3.85％比9.62％)均小于传统对照组,差异有统计学意义(P＜0.05),两组吻合口漏发生率差异无统计学意义(P＞0.05). 结论 FTA贯穿整个围手术期,对促进患者ERAS起着重要作用.     

加速康复外科理念在腹腔镜直肠癌根治术围手术期的应用价值

目的:探讨加速康复外科理念在腹腔镜直肠癌根治术围手术期的应用价值.方法:2009年1月至2010年12月为30例腹腔镜直肠癌根治术患者施行加速康复外科(fast track surgery,FrS)处理,以同期30例未行FTN的患者为对照组,观察两组患者手术前后体重与电解质的变化、营养状况、术后排气时间、排便时间、首次...     

快速康复外科联合腹腔镜胃癌根治术安全性和有效性的系统评价

目的系统评价快速康复外科（FTS）联合腹腔镜胃癌根治术的安全性和有效性。方法计算机检索1994年1月至2012年12月CNKI、万方、维普、PubMed、EMBASE、CochraneLibrary数据库关于glS联合腹腔镜对照两者单独应用于胃癌根治术的随机对照试验（RCT）或临床对照试验（CCT）,对符合标准的文献提取相关数据后采用RevMan5．1．0软件进行Meta分析。结果3项RCT和2项CCT纳入研究,共有524例患者,其中试验组（gl＇S联合腹腔镜）257例,对照组（单纯FTS或单纯腹腔镜）267例。Meta分析结果显示：试验组较对照组术后首次排气时间明显提前（SMD=-1．29,95％CI：-2．17—0．40．P〈0．05）．住院时间明显缩短（WMD=-1．72,95％CI：-2．56—0．89,P〈0．05）,术后并发症发生率明显降低（OR=0．51,95％CI：0．31～0．84,P〈0．05）,但手术时间、淋巴结清扫数量、术中出血量和住院费用方面两组差异无统计学意义（均P〉0．05）。结论FTS联合腹腔镜胃癌根治术能有效促进术后肠功能恢复,缩短住院时间,减少术后并发症,加速患者康复。     

Persistent pain in patients following scoliosis surgery

Chronic or persistent pain is increasingly recognised as a consequence of surgery in a number of different disciplines. The pain often exhibit qualities that differ from the acute post-operative pain and may represent changes in the central nervous system. There is lack of information regarding the incidence of persistent pain in patients following spinal surgery for scoliosis. This study aims to estimate the incidence of persistent pain following spinal surgery for scoliosis in a group of mainly adolescent patients. Questionnaires were distributed to consecutive patients attending the outpatient clinic of a hospital with specialist services in paediatric orthopaedics and spinal surgery. One hundred and five patients out of 122 eligible patients completed the survey. Fifty-two percent had ongoing pain upon hospital discharge either in the primary surgical site and/or in the iliac bone graft site. Approximately 10 and 7% of all patients had back and pelvic pain persisting beyond 12 months, respectively. A small proportion described elements of neuropathic pain. There was a trend suggesting that those who experienced more severe post-operative pain were more likely to develop persistent pain. These data are consistent with those reports that implicate surgery as the trigger for chronic pain.     

Fast-track surgery in laparoscopic radical prostatectomy: basic principles

Fast-track surgery describes innovative treatment concepts ensuring a faster convalescence phase. The aim of this study was to allow hospital discharge 3 days after surgery without additional complications in patients receiving LRPE for localized prostate cancer. Twenty-five patients each were randomized in the study groups to verify if a fast-track regimen could be transferred into clinical routine. The perioperative data, early complications, hospital stay as well as readmission rate were analyzed. The mean postoperative stay was 3.6 days in the fast-track group versus 6.7 days in the conventional group. The overall complications were significantly less in the fast-track procedure. The readmission rate was low and not significant. Patients receiving an LRPE benefit from a suitable fast-track concept. The postoperative hospital stay could be shortened nearly by half with a significantly decreased overall complication rate. Thus, fast-track concepts might contribute to saving resources in the long term. However, more evidence based on larger prospective trials is needed to achieve optimal quality of life for patients perioperatively.     

快速康复外科和腹腔镜在结直肠癌治疗中的应用

目的 了解近年来快速康复外科及腹腔镜技术应用于结直肠癌治疗的进展,探索两者联合应用于结直肠癌治疗的可能性.方法 收集国内、外有关结直肠外科领域快速康复外科和腹腔镜治疗的临床和基础研究的相关文献并作综述.结果 同传统的治疗方式相比,两者应用于结直肠癌的治疗均可以获得良好的临床疗效.结论 快速康复外科和腹腔镜技术应用于结直肠癌的治疗是可行的,但两者联合应用的效果还需要随机对照试验研究的证实.     

Fast-track surgery in infants and children

Background/Purpose

Fast-track surgery is not well established for infants and children. The aim of our prospective study was to investigate the feasibility of fast-track concepts for pediatric surgical procedures including laparoscopic techniques.

Methods

Fast-track concepts, including immediate postoperative feeding, immediate mobilization, and morphine sparing pain treatment, were established for pyeloplasty, appendectomy, bowel anastomosis, fundoplication, hypospadia repair, and full/partial nephrectomy. All consecutive patients undergoing these procedures were prospectively investigated from June 2004 to June 2005. Patients with additional relevant diseases, reoperation, and perforated appendicitis were excluded from fast-track treatment. The length of hospital stay was compared with data derived from the German reimbursement system with German diagnosis-related groups for patients with a similar case mix index and hospitals with a similar structure.

Results

Of a total of 159 patients (mean age, 5.8 ± 5.3 years), 113 (71%) were finally treated according to the fast-track protocols. There were no complications associated with fast-track surgery. The intensity of pain during the immediate postoperative period was higher than 5 on a 10-point scale in children older than 4 years. Analgesia was excellent at all other time points. The mean hospital stay of fast-track patients was 2.3 ± 1 days and was significantly shorter (P < .01) compared with German diagnosis-related group data for all procedures (pyeloplasty, 1.9 ± 0.9 vs 12.2 ± 0.2; nephrectomy, 1.9 ± 1.0 vs 14.4 ± 2.8; bowel anastomosis, 3.2 ± 0.6 vs 12.9 ± 2.4; fundoplication, 3.2 ± 0.8 vs 15.2 ± 4.2; appendectomy, 3.7 ± 2.4 vs 6.3 ± 1.8; hypospadia repair, 2.1 ± 1 vs 8.4 ± 1.4). Two readmissions were recorded. Ninety-six percent of patients and parents scored the fast-track concepts as excellent.

Conclusion

The feasibility of fast-track concepts in children is excellent, with short duration of hospitalization and high comfort.     

Need for simulation in laparoscopic colorectal surgery training

The dissemination of laparoscopic colorectal surgery (LCS) has been slow despite increasing evidence for the clinical benefits, with a prolonged learning curve being one of the main restrictions for a prompt uptake. Performing advanced laparoscopic procedures requires dedicated surgical skills and new simulation methods designed precisely for LCS have been established: These include virtual reality simulators, box trainers, animal and human tissue and synthetic materials. Studies have even demonstrated an improvement in trainees’ laparoscopic skills in the actual operating room and a staged approach to surgical simulation with a combination of various training methods should be mandatory in every colorectal training program. The learning curve for LCS could be reduced through practice and skills development in a riskfree setting.