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.     

加速康复外科在胃结直肠癌微创手术中个体化实施的经验

目的:总结加速康复外科(enhanced recovery after surgery,ERAS)在胃癌、结直肠癌微创手术中个体化实施的经验体会。方法:为82例胃、结直肠癌患者行腹腔镜胃癌、结直肠癌根治术,其中43例行腹腔镜手术+围手术期ERAS(ERAS组),39例行腹腔镜手术+传统围手术期处理(对照组)。观察两组严重并发症发生率、排气时间、胃管拔除时间、引流管拔除时间、一般症状恢复时间等指标。结果:两组严重并发症发生率差异无统计学意义,ERAS组排气时间、胃管拔除时间、引流管拔除时间及一般症状恢复时间优于对照组,差异有统计学意义。结论:ERAS在胃、结直肠癌微创手术中可分步骤实施,遵循个体化的原则更容易推广。     

加速康复外科在老年结直肠癌患者中的应用

目的探讨围手术期中将加速康复外科（ERAS）理念应用于老年结直肠癌患者的安全性和有效性。 方法收集2015年2月至2017年1月烟台毓璜顶医院应用ERAS理念的结直肠癌手术患者的临床资料,共纳入160例患者,根据年龄分为青年组（<65岁,97例）和老年组（≥65岁,63例）,对比研究两组患者的胃肠功能恢复情况、术后并发症、术后住院时间。 结果相对于青年组,老年组患者ASA评分更高（χ²=10.960,P=0.001）,并且明显合并更多的基础病（P<0.05）。两组患者手术类型、手术方式以及术后并发症总发生率、严重并发症发生率差异无统计学意义（χ²=0.171、1.039、0.296、0.001,P=0.680、0.595、0.586、0.979）。老年组患者非手术并发症尤其是心血管并发症更常见。青年组患者二次手术率为6.2%,再入院率为5.2%;老年组分别为9.5%、3.2%,两组差异无统计学意义（χ²=0.641、0.041,P=0.433、0.839）。老年组患者肠功能恢复较慢,术后首次肛门排气、术后首次肛门排便、住院时间较青年组患者明显延长（Z=1.89、2.37、3.11,P=0.034、0.013、0.001）。 结论加速康复外科在老年患者结直肠癌手术中的应用是安全有效的。     

加速康复外科对腹腔镜辅助结直肠癌根治术后患者免疫功能及近期结局的影响

目的:探讨加速康复外科措施对腹腔镜辅助结直肠癌根治术后患者免疫功能及近期结局的影响。方法:选取120例行腹腔镜辅助结直肠癌根治术的患者,随机分为常规治疗组(n=60)与加速康复组(n=60),对比分析两组患者围手术期C反应蛋白、免疫球蛋白(IgA、IgM、IgG)、白细胞介素6、外周血T细胞亚群(CD3~+、CD4~+、CD8~+)的水平及近期临床指标的变化情况。结果:患者均顺利完成手术,无一例中转开腹。术后第3天、第7天,加速康复组免疫指标恢复情况较常规治疗组理想,差异有统计学意义(P0.05);加速康复组术后首次排气时间[(1.6±0.5)dvs.(3.6±0.7)d]、排便时间[(3.8±0.7)dvs.(5.6±0.7)d]、进半流质饮食时间[(2.6±0.7)dvs.(4.5±0.4)d]具有明显优势,感染并发症(肺部感染、泌尿系感染)(6vs.24)、深静脉血栓(0vs.6)、术后住院时间[(5.7±0.8)dvs.(12.1±2.7)d]、总住院时间[(10.4±0.8)dvs.(14.7±1.4)d]及总住院费用[(48874±785)元vs.(54935±823)元]均明显减少,差异有统计学意义(P0.05)。结论:加速康复外科措施应用于腹腔镜辅助结直肠癌根治术安全、可靠,在促进术后免疫功能恢复、减少并发症、缩短住院时间、节约医疗成本方面优势明显。     

促进术后恢复综合方案在结直肠癌根治术中的应用

目的评价促进术后恢复综合方案（ERAS）在结直肠癌根治性手术中的作用。方法复旦大学附属中山医院普通外科结直肠专业组于2006年9月1日至2007年2月27日收治的符合人选标准的结直肠癌手术患者74例，被随机分为ERAS组和对照组。评价手术前后的应激指标、营养和代谢状况、术中肠道情况、术后恢复、并发症发生率、平均住院天数和住院费用。结果研究过程中，有6例中途出组。实际ERAS组34例，对照组34例；两组性别、年龄、BMI指数和结直肠原发疾病以及手术类型等具可比性。ERAS组胰岛素抵抗指数（HOMA—IR）变化幅度低于对照组，但各点的HOMA—IR指数差异无统计学意义（P〉0．05）；术中ERAS组胰高血糖素水平高于对照组（P〈0．05）；术后第1天皮质醇水平低于对照组（P〈0．05），血糖水平明显低于对照组（P〈0．05）；术中和术后第1、2天三酰甘油水平明显高于对照组（P〈0．05）。两组术前氮平衡差异无统计学意义（P〉0．05），手术当天和术后第6天ERAS组负氮平衡明显低于对照组（P〈0．05），但术后第2天ERAS组负氮平衡明显高于对照组，差异有统计学意义（P〈0．05）。ERAS组术后排气和排便时间、恢复进食时间、每天离床时间和活动时间、住院天数和并发症发生率等均明显好于对照组，差异有统计学意义（P〈0．05）。ERAS组手术后住院费用明显低于对照组（P〈0．05）。结论ERAS方案整合围手术期一系列干预措施，减少机体创伤应激反应．促进结直肠癌患者术后早日康复疗效显著；且安全可行，并可减少术后并发症的发生。     

Enhanced recovery in intestinal surgery

Enhanced recovery after surgery (ERAS) programmes utilize a multi-modal and multidisciplinary approach to surgical care. The aim of ERAS is to reduce the surgical stress response, to maintain physiological function and metabolic homeostasis and to expedite patients’ recovery to their baseline status. Following its success in colorectal surgery, ERAS is increasingly adopted by other surgical specialities. A good ERAS programme involves integrated preoperative, intra-operative and postoperative evidence-based practice. Successful ERAS programmes translate to a standardized patient care pathway, improved clinical outcomes and shorter hospital stay, all of which will help facilitate the increasing demand on healthcare and bed pressure. Its principles and many components are not only transferable to other surgical specialities, but may also allow medical specialities to improve patient care and recovery. ERAS is therefore expected to become the standard of care for the majority of hospital inpatients.     

Enhanced recovery in intestinal surgery

Enhanced recovery after surgery (ERAS) programmes utilize a multi-modal and multidisciplinary approach to surgical care. The aim of ERAS is to reduce the surgical stress response, to maintain physiological function and metabolic homeostasis and to expedite patients' recovery to their baseline status. Following its success in colorectal surgery, ERAS is increasingly adopted by other surgical specialities. A good ERAS programme involves integrated preoperative, intra-operative and postoperative evidence-based practice. Successful ERAS programmes translate to a standardized patient care pathway, improved clinical outcomes and shorter hospital stay, all of which will help facilitate the increasing demand on healthcare and bed pressure. Its principles and many components are not only transferable to other surgical specialities, but may also allow medical specialities to improve patient care and recovery. ERAS is therefore expected to become the standard of care for the majority of hospital inpatients.     

加速康复外科在妇科腔镜手术中的应用体会

目的:探讨加速康复外科(enhanced recovery after surgery,ERAS)策略用于妇科腔镜手术中的安全性与有效性。方法:将拟行腹腔镜妇科手术的200例患者随机分为ERAS组与对照组。ERAS组围手术期采用ERAS策略处理,对照组采用传统围手术期方案处理。术后2 h、6 h、12 h、24 h采用视觉模拟评分法观察两组患者疼痛程度,对比分析两组术后肛门首次排气时间、术后恶心呕吐发生率、术后住院时间、住院总花费及其他并发症发生情况。结果:与对照组相比,ERAS组术后2 h、6 h、12 h疼痛评分及术后恶心呕吐发生率明显降低(P0.05);术后肛门首次排气时间缩短(P0.05);术后住院时间、住院总费用减少(P0.05)。两组患者术后其他并发症发生率差异无统计学意义。结论:ERAS策略可安全地用于妇科腔镜手术,能有效促进术后恢复、缩短住院时间、降低医疗费用。     

加速康复外科策略对腹腔镜结直肠癌手术患者术后恢复的影响

目的探讨围术期实施加速康复外科(enhanced recovery after surgery,ERAS)策略对腹腔镜结直肠癌根治术患者术后恢复的影响。方法选择2015年3月至2016年6月择期行腹腔镜结直肠癌根治术患者84例,男55例,女29例,年龄36~78岁,ASAⅠ或Ⅱ级,随机分为两组,每组42例。E组采用硬膜外阻滞联合全麻,加强术前宣教,术中保温,限制性补液,术中、术后完善镇痛等一系列ERAS策略进行围术期管理,C组采用常规围术期处理。记录补液量、术毕鼻咽温度、术后首次肠鸣音时间、首次排气时间、首次进流体食物时间、首次下床活动时间及导尿管拔出时间;记录术后PACU停留时间、总住院时间及总住院费用等。结果 E组补液量[(1 328±64)ml vs.(2 463±135)ml]明显少于C组(P0.05),术毕鼻咽温度[(36.2±0.2)℃vs.(35.1±0.5)℃]明显高于C组(P0.05),术后首次肠鸣音时间[(33.4±12.5)h vs.(42.8±14.3)h]、首次排气时间[(43.6±13.9)h vs.(60.7±15.4)h]、首次进流体食物时间[(26.8±4.1)h vs.(67.4±13.5)h]、首次下床活动时间[(7.4±1.6)h vs.(26.5±3.8)h]、导尿管拔出时间[(29.2±6.1)h vs.(51.8±7.6)h]、术后PACU停留时间[(26.4±8.5)min vs.(37.2±11.6)min]和总住院时间[(7.5±0.9)d vs.(9.7±1.2)d]明显短于C组(P0.05),总住院费用[(2.1±0.6)万元vs.(2.6±0.8)万元]明显少于C组(P0.05),术后恶心呕吐(2.4%vs.21.4%)、躁动(4.8%vs.26.2%)、皮肤瘙痒(7.1%vs.23.8%)及寒战(0%vs.19.0%)的发生率明显低于C组(P0.05)。结论加速康复外科策略应用于腹腔镜结直肠癌患者围术期管理,可减少术中舒芬太尼用量,防止术后低体温的发生,胃肠功能恢复更快,明显缩短住院时间和降低医疗费用。     

加速康复外科对老年病人结直肠癌根治术后氧化应激状态影响的研究

目的探讨加速康复外科(enhanced recovery after surgery,ERAS)理念在老年结直肠癌根治术后病人围术期的应用疗效及其对氧化应激状态的影响。方法回顾性分析2014年6月至2016年6月收治的年龄大于或等于65岁行结直肠癌根治术病人的临床资料。将行加速康复治疗的71例病人作为观察组,行传统模式治疗的74例病人作为对照组。比较两组病人术后疼痛视觉模拟评分(visual analogue score,VAS)以及氧化应激状态。结果术后1 d,观察组病人的丙二醛(malondialdehyde,MDA)水平为(20.05±2.81)nmol/ml,较对照组的(25.36±3.02)nmol/ml明显降低(P0.05);观察组病人的氧自由基(reactive oxygen species,ROS)水平为5 536.8±717.3,较对照组的6 925.1±826.7明显降低(P0.05)。术后2周,观察组病人的MDA水平为(6.27±1.80)nmol/ml,较对照组的(11.46±3.55)nmol/ml明显降低(P0.05);观察组病人的ROS水平为3 185.4±414.6,较对照组(3 713.6±553.2)明显降低(P0.05)。对两组人群术后2周的抗氧化剂水平进行比较发现,观察组病人的超氧化物歧化酶(superoxide dismutase,SOD)水平为(82.7±14.9)U/ml,较对照组的(40.5±12.3)U/ml明显升高(P0.05);观察组病人的谷胱甘肽(glutathione,GSH)水平为(62.8±12.6)μg/ml,较对照组的(36.0±10.2)μg/ml明显升高(P0.05);观察组病人的维生素C水平为(36.2±13.1)mg/L,较对照组的(18.8±8.0)mg/L明显升高(P0.05);观察组病人的维生素E水平为(12.1±4.5)mg/L,较对照组的(5.4±2.6)mg/L明显升高(P0.05)。术后2周,观察组病人静息状态的VAS评分为(4.0±0.9)分,较对照组的(4.8±1.2)分明显降低(P0.05);观察组运动状态的VAS评分为(4.5±1.2)分,较对照组的(5.7±1.3)分明显降低(P0.05)。观察组的并发症发生率较对照组明显降低(P0.05),观察组的恢复情况较对照组明显加快(P0.05)。结论在行结直肠癌根治术后应用ERAS能够减低病人氧化应激状态,可以有效减少病人术后疼痛,促进病人生活质量提高。     

Enhanced recovery after surgery (ERAS) in one-anastomosis gastric bypass surgery: a matched-cohort study

Background

One-anastomosis gastric bypass (OAGB) is considered new from the bariatric standpoint.

促进术后恢复综合方案在结直肠癌根治术患者中的应用

目的评价围手术期应用促进术后恢复综合方案（ERAS）对结直肠癌根治术患者术后恢复的促进作用。方法2007年7月至2010年5月间复旦大学附属中山医院普通外科结直肠专业组收治的597例结直肠癌根治术患者被前瞻性纳入研究．按随机数字表法分为ERAS组（299例）和对照组（298例）。ERAS组患者围手术期采用ERAS方案,包括一系列被证明有效的围手术期处理措施,而对照组患者围手术期采用传统方案。记录两组患者的营养代谢指标、应激指标及临床恢复指标。结果两组患者一般资料和手术方式的差异均无统计学意义（均P〉0．05）。ERAS组患者术后营养代谢指标（白蛋白、前白蛋白及转铁蛋白）均优于对照组（均P〈0．05）。ERAS组患者术后第1天胰岛素抵抗指数低于对照组患者（3．31±2．92比6．58±3．86,P〈0．01）。对照组患者术后第1天和第5天皮质醇水平均较术前显著升高（均P〈0．01）,而ERAS组患者直至术后第5天才较术前升高（P〈0．01）。ERAS组患者术后住院时间[（5．7±1．6）d比（6．6±2．4）d,P〈0．01]和住院费用[（15998±2655）元比（17763±3059）元,P〈0．01]均少于对照组患者;两组患者术后并发症发生率的差异无统计学意义[9．7％（29／299）比9．4％（28／298）,P〉0．05]。结论ERAS方案可减轻手术应激,加快术后恢复。且不增加术后并发症的发生。     

加速康复外科理念在腹腔镜下宫颈癌根治术中的管理实践及效果评价

目的:制定适用于腹腔镜下宫颈癌根治术的妇科加速康复外科(Enhanced recovery after surgery,ERAS)方案,评价该方案临床应用效果.方法:组建妇科ERAS多学科团队,筛选最佳实施策略,确立妇科ERAS方案,进行人员培训和方案实施,固化有效措施,并在院内交流实施经验.选择方案实施前146例宫颈癌患者为对照组,实施后128例宫颈癌患者为试验组,比较两组患者术后恢复情况.结果:试验组术后并发症总发生率为21.09％,显著低于对照组(38.36％),差异有统计学意义(P<0.05).两组患者术后住院日、住院费用和术后30d再入院率差异无统计学意义(P>0.05).试验组术后初次下床活动时间、胃肠功能恢复时间均显著低于对照组(P<0.05).结论:将细节落至实处的妇科加速康复外科方案可安全应用于腹腔镜下宫颈癌根治术,缩短患者术后身体功能恢复时间.     

Enhanced recovery in major colorectal surgery: Safety and efficacy in an unselected surgical population at a UK district general hospital

Background

Enhanced Recovery Programmes (ERPs) have been shown to benefit recovery following major surgery in selected centres and patient groups, but their wider applicability requires continued evaluation. The aims of this study were to assess the outcomes of the first 400 consecutive, non-selected patients, undergoing major elective colorectal surgery within an Enhanced Recovery programme at a UK District General hospital and to examine the effects of patient risk factors and operative approach on outcomes.

Methods

Since September 2005 all patients undergoing major elective colon and rectal surgery at our hospital have been treated within an ERP and their data recorded prospectively on a database. Safety and efficacy outcomes for the first 400 patients were compared using SPSS v14.0 with both a retrospective, pre-ERP group; and according to patient risk factors and operative approaches.

Results

Median length of stays (LOS) reduced from 9 days (IQR 7–11) to 6 days (IQR 5–10) after introduction of the ERP (p < 0.001). No statistically significant differences in LOS were observed between elderly (≥80 years) and younger patients or between different BMI groups. American Society of Anesthesiologists (ASA) grade 3 patients demonstrated significantly longer median LOS than those with ASA grades 1 and 2. Patients undergoing laparoscopic surgery had median LOS of 6 days (IQR 4–8) compared to 7 days (IQR 5–10) for open procedures (p < 0.001). No differences in morbidity or mortality were observed between the groups.

Conclusions

Unselected application of an ERP in our unit has been associated with reductions in post-operative LOS. The ERP was safe and effective when applied to all our study patients independent of age and BMI. Despite LOS being longer in ASA grade 3 patients, application of the ERP to this higher risk group was not associated with significantly increased morbidity or mortality. Laparoscopic surgery resulted in additional modest reductions in LOS compared to open surgery within the ERP.     

加速康复外科在腹腔镜胰十二指肠切除术围手术期管理中的临床应用

目的:探讨加速康复外科(ERAS)在腹腔镜胰十二指肠切除术围手术期管理中的临床应用价值。方法:选取2016年1月至2019年1月收治的168例行腹腔镜胰十二指肠切除术的患者,采用随机数字法分为ERAS组与对照组,ERAS组围手术期采取ERAS措施,对照组采取常规围手术期处理。对比分析两组术后恢复情况、术后并发症发生情况、术后住院时间、住院费用、再次手术率及病死率。结果:ERAS组首次肛门排气时间、进食时间、胃管留置时间、腹腔引流管与尿管拔除时间、疼痛、住院费用、身体质量指数优于对照组,差异均有统计学意义(P<0.05),两组术后总体并发症发生率、胰瘘与腹腔出血情况、再手术、再入院、病死率差异无统计学意义(P>0.05)。结论:腹腔镜胰十二指肠切除术围手术期应用ERAS措施可促进患者术后快速康复,缩短住院时间,降低住院费用,安全性高。     

Deviation and failure of enhanced recovery after surgery following laparoscopic colorectal surgery: early prediction model

Aim Enhanced recovery after surgery (ERAS) programmes are well established, but deviation from the postoperative elements may result in delayed discharge. Early identification of such patients may allow remedial action to be taken. The aims of this study were to investigate factors associated with delayed discharge and to produce a predictive scoring system for ERAS failure. Method A retrospective review was carried out of case notes of patients who underwent elective laparoscopic colorectal resection and ERAS at Yeovil District Hospital between 2002 and 2009. Univariate and multivariate analyses were performed and binary logistic regression was used to model a predictive scoring system. Results In all, 385 patient records were reviewed with a median length of stay of 6 days; 122 (31%) patients stayed longer than 1 week (delayed discharge) and 159 (41%) deviated in up to two postoperative ERAS factors. Patient demographic factors were not predictive of delayed discharge. Deviation from ERAS factors at the end of the first postoperative day, including continued intravenous fluid infusion, lack of functioning epidural, inability to mobilize, vomiting requiring nasogastric tube insertion and re‐insertion of urinary catheter, were strongly associated with delayed discharge. A five‐element predictive scoring system for ERAS failure and delayed discharge was formulated. Conclusion Enhanced recovery failure and delayed discharge after laparoscopic colorectal surgery can be predicted by the early deviation from postoperative factors of an ERAS programme.     

Enhanced recovery for colorectal surgery: Practical hints, results and future challenges

Enhanced recovery after surgery (ERAS) protocols are now achieving worldwide diffusion in both university and district hospitals with special interest in colorectal surgery. The optimization of the patient’s preoperative clinical conditions, the careful intraoperative administration of fluids and drugs and the postoperative encouragement to resume the normal physiological functions as early as possible has produced results in a large amounts of studies. These approaches successfully challenged long-standing and well-established perioperative managements and finally achieved the status of gold standard treatments for the perioperative management of uncomplicated colorectal surgery. Even more important, it seems that the clinical improvement of the patient’s clinical management through ERAS protocols is now reaching his best outcomes (length of stay of 4-6 d after the operation) and therefore any further measures add little to the results already established (i.e., the adjunct of laparoscopic surgery to ERAS). Still dedicated meetings and courses around the world are exploring new aspects including the improvement the preoperative nutrition status to provide the energy necessary to face the surgical stress, the preoperative individuation of special requirements that could be properly addressed before the date of surgery and therefore would reduce the number of unnecessary days spent in hospital once fully recovered (i.e., rehabilitation, social discharges), and finally the development of an important web of out-of-hours direct access in order to individuate alarm symptoms in those patients at risk of complications that could prompt an early readmission.