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。     

Meta-analysis of short-term outcomes after laparoscopic resection for colorectal cancer

BACKGROUND: The safety and efficacy of laparoscopic resection (LR) for colorectal cancer remains to be established. METHODS: A meta-analysis of randomized clinical trials comparing the short-term outcomes of laparoscopic with those of open resection for colorectal cancer was undertaken. A literature search was performed for relevant articles published by the end of 2002. Two reviewers independently appraised the trials using a predetermined protocol. Results were analysed using Comprehensive Meta-analysis. RESULTS: The outcomes of 2512 procedures from 12 trials were analysed. LR took on average 32.9 per cent longer to perform than open resection but was associated with lower morbidity rates. Specifically, wound infection rates were significantly lower (odds ratio 0.47 (95 per cent confidence interval 0.28 to 0.80); P = 0.005). In patients undergoing LR, the average time to passage of first flatus was reduced by 33.5 per cent, that to tolerance of a solid diet by 23.9 per cent and that to 80 per cent recovery of peak expiratory flow by 44.3 per cent. Early narcotic analgesia requirements were also reduced by 36.9 per cent, pain at rest by 34.8 per cent and during coughing by 33.9 per cent, and hospital stay by 20.6 per cent. There were no significant differences in perioperative mortality or oncological clearance. CONCLUSION: LR for colorectal cancer is associated with lower morbidity, less pain, a faster recovery and a shorter hospital stay than open resection, without compromising oncological clearance.     

Impact of intraoperative blood loss on the short-term outcomes of laparoscopic liver resection

Background

Intraoperative blood loss is one of the predictors of outcome of open hepatectomy. But the impact of blood loss in laparoscopic hepatectomy (LH) on postoperative outcomes is poorly understood. The aim of this study is to analyze the association between blood loss and postoperative outcomes after LH.

Methods

A retrospective analysis of prospectively maintained database of patients undergoing LH from 1995 to 2016 was performed. The data were divided into two groups based on the extent of blood loss: Group 1 (<250 ml) and Group 2 (≥250 ml). The basic characteristics and postoperative outcomes were compared between these groups.

Results

A total of 504 patients underwent 611 LH (Group 1: 414 and Group 2: 197). The mean age was 62.4 years. The most common indication was liver secondaries (71.7%). Major hepatectomy was performed in 37% cases. Mean operative time was 225?±?110.5 min and estimated blood loss was 239?±?399.4 ml (range 0–4500 ml). Group 2 had significantly higher number of patients with malignant lesions undergoing major hepatectomy, anatomical resection with higher requirement for blood transfusion, and longer hospital stay. The incidence of conversion rate, overall complications including liver failure, renal failure, and postoperative mortality, was significantly higher in Group 2. However, the bile leak rate was similar in the two groups.

Conclusion

Intraoperative blood loss is most frequent in patients undergoing major LH. Blood loss ≥250 ml during LH may adversely affect the postoperative outcomes.

     

加速康复外科在腹腔镜胰十二指肠切除术中的应用

目的探讨加速康复外科(enhanced recovery after surgery, ERAS)在腹腔镜胰十二指肠切除术(laparoscopic pancreaticoduodenectomy,LPD)围手术期中的临床价值及方法。 方法回顾性分析2017年1月至2021年6月期间,河北医科大学第二医院肝胆外科收治的行LPD患者的临床资料,其中常规理念组(对照组)255例、以ERAS理念为指导的试验组(ERAS组)276例。观察比较两组的术后恢复情况。 结果ERAS组与对照组一般资料比较,差异无统计学意义(P>0.05),具有可比性。全部病例均顺利完成手术,手术时间[(354.89±93.02)min比(362.90±95.62)min]及术中出血量[300 ml(100,500)ml比300 ml(200,500)ml]比较,差异无统计学意义(P>0.05)。相较于对照组,ERAS组术后首次肛门排气时间[(2.61±0.62)d比(2.76±0.72)d,P<0.05]、胃管拔除时间[(3.07±0.82)d比(3.52±0.66)d,P<0.001] 、腹腔引流管拔除时间[(2.77±1.08)d比(5.58±2.14 )d,P<0.001]更早;术后疼痛视觉模拟评分[(3.31±1.07)分比(4.90±2.00)分,P<0.001]更低;胃排空障碍[4.3%(12/276)比8.6%(22/255),P<0.05]、术后腹腔感染[1.4%(4/276)比4.3%(11/255),P<0.05]、术后肺部感染[0.7%(2/276)比3.9%(10/255),P<0.05]发生率更低;术后住院时间[(15.36±3.26)d比(17.90±5.66)d,P<0.001]更短;住院费用[124 153.00元(112 437.75,136 604.50)元比133 604.00元(115 086.00,150 758.00)元,P<0.05]更少。两组其他观察指标比较,差异无统计学意义(P>0.05)。 结论在熟练掌握LPD的基础上,围手术期实施ERAS安全、有效,能够有效促进LPD患者术后康复,缩短住院时间,减少住院费用。     

Impact of an enhanced recovery program for cesarean delivery on postoperative opioid use

BackgroundCesarean delivery is one of the most common surgeries performed worldwide and the adoption of enhanced recovery programs for cesarean delivery is gaining popularity. We tested the hypothesis that implementation of an enhanced recovery program for cesarean delivery would be associated with a decrease in postoperative opioid consumption.MethodsWe compared a retrospective cohort of women delivered by elective cesarean delivery (January 1, 2017 to June 30, 2018) to a prospective cohort exposed to the enhanced recovery protocol (July 1, 2018 to December 31, 2018). The primary outcome was inpatient maternal opioid use, measured as total oral morphine equivalents. Secondary outcomes included postoperative 0–10 pain scores, length of stay, 30-day postoperative complication rates, and hospital re-admissions.ResultsData from 541 patients were analyzed. The enhanced recovery cohort used significantly less oral morphine equivalents compared with the pre-enhanced recovery cohort (60.3 mg vs 104.3 mg, P <0.001). The number of patients who required opioid medication within 24 h of discharge was significantly reduced in the enhanced recovery cohort (41.1% vs 74.6%, P <0.001). There were no significant differences in average pain scores (1.6 vs 1.9, P=0.037).ConclusionsThe implementation of an enhanced recovery program for cesarean delivery was associated with a significant reduction in postoperative opioid consumption throughout hospitalization, with average pain scores remaining <2. Implementation of this program was also associated with an increase in the number of patients who were opioid-free 24 h prior to discharge.     

腹腔镜胃癌根治术中应用加速康复外科对术后近期营养指标的影响

目的观察加速康复外科(enhanced recovery after surgery,ERAS)对腹腔镜胃癌根治术病人术后近期营养指标的影响。方法将以2016年1~7月期间收治的胃癌病人为研究对象,按腹腔镜胃癌手术操作指南进行腹腔镜辅助下D2根治术的65例胃癌病人随机分为2组,常规组(n=32)应用传统围手术期处理行腹腔镜手术,观察组(n=33)在ERAS理念指导下行腹腔镜手术。2组病人分别于术前、术后第1天、术后第3天、术后第7天抽取外周血测定白蛋白(ALB)、前白蛋白(PRE)、转铁蛋白(TRF)、视黄醇结合蛋白(RbP)、血红蛋白(Hb),监测术后第1天、术后第7天和术后第30天的体重与术前体重的比值(WR),并进行对比分析。结果术前各项指标2组间差异均无统计学意义。术后第1天,各组指标均较术前降低,2组之间差异无统计学意义(P0.05);术后2组病人ALB、PRE、TRF水平逐渐上升,与常规组相比,术后第7天时观察组ALB水平为(38.6±2.0)g/L、PRE水平为(192.2±16.1)mg/L,升高更明显,差异有统计学意义(P0.05)。常规组术后第1天、术后第3天RbP水平均低于术前(P0.05),而观察组术后RbP水平与术前无明显差异。2组病人术后Hb水平均低于术前(P0.05),术后第7天2组均恢复至术前水平,2组之间Hb水平分别为(109.4±7.11)g/L和(108.7±8.11)g/L,差异无统计学意义。2组病人术后WR逐渐下降,术后第7天时常规组为0.93±0.053,低于观察组的0.96±0.028,差异有统计学意义(P0.05)。结论腹腔镜胃癌根治术中应用ERAS理念,可维持病人术后营养状态。     

Impact of obesity on short-term results of laparoscopic rectal cancer resection

Introduction  The influence of obesity [body mass index (BMI) ≥ 30 kg/m²] on the outcome of laparoscopic colorectal surgery remains controversial. The complexity of rectal laparoscopic resections requires a specific assessment of the impact of obesity on the feasibility and short-term results of the surgery. Methods  Between February 2002 and May 2007, 210 laparoscopic mesorectal excisions were performed. Demographic, oncologic and perioperative data were entered in a prospective database. Twenty-four patients (11.4%) with BMI over 30 kg/m² formed the obese group (OG). The outcomes in the OG and the nonobese group (NOG) were compared. Results  There were significantly more American Society of Anesthesiologists (ASA) score 3 patients (26% in OG versus 9% in NOG; p = 0.03) in the obese group. Obese patients experienced longer operative times (513 min in OG vs. 421 min in NOG; p < 0.01) and more frequent conversion to laparotomy (46% in OG vs. 12% in NOG; p < 0.001). Morbidity grade 1 was higher in the obese group (29.2% vs. 9.7% in NOG; p = 0.01), but there was no difference in regards to morbidity grade 2 or more (33.3% in OG vs. 32.3% in NOG). In addition, conversion to laparotomy among the obese did not increase significantly morbidity grade 2 or higher (5 of 11 for OG converted vs. 3 of 13 for OG nonconverted; p = 0.39). Regarding the oncological parameters (e.g. number of lymph nodes removed, distal and lateral margins) there was no difference between groups. Conclusion  Obesity increases operative duration and conversion rate of rectal laparoscopic resection for cancer. Although obesity is associated with a worse preoperative evaluation, there is no increase in relevant morbidity and no impairment of oncological safety.     

Oncological outcomes of laparoscopic colon resection for cancer after implementation of a full-time preceptorship

Background  

The learning curve for laparoscopic colectomy (LC) is considered long and difficult. The presence of a preceptor may shorten the learning curve of LC and ensure adequate oncologic and short-term results. City of Hope implemented a full-time LC preceptorship between September 2004 and March 2006 with one experienced surgeon assisting other surgeons. We review our outcomes with laparoscopic colon resection for colon adenocarcinoma after implementation of this preceptorship.     

Impact of implementation of an enhanced recovery after surgery (ERAS) program in laparoscopic Roux-en-Y gastric bypass: a prospective randomized clinical trial

Background

The essence of enhanced recovery after surgery (ERAS) program is the multimodal approach, and many authors have demonstrated safety and feasibility in fast-track bariatric surgery.

Implementation of an enhanced recovery after surgery program including a patient school: Impact on quality of life results

IntroductionEnhanced Recovery After Surgery (ERAS) protocols and educational programmes have been shown to accelerate orthopaedic surgery recovery with fewer complications, and improve patient-reported outcomes (PROs) for different types of surgery. The objective was to evaluate the impact of an ERAS programme including a patient school on health outcomes and PROs for Total Knee Replacement (TKR) surgery.Material and methodsA multidisciplinary group created the programme and the patient school (preoperative consultations where the patients’ surgical processes are explained and are also given instructions for an appropriate perioperative care management). An observational, prospective study was conducted on all patients operated for TKR from March 2021 to March 2022. Main health outcomes were: hospital stay length, surgical complications and surgery cancellations due to a wrong preoperative medication management. PROs evaluated were: patient satisfaction with pain management, the school, and quality of life before and after surgery (EQ-5D).ResultsOne hundred thirty-three patients were included. Median hospital stay length was 3 days (IQR 3-5). Rate of surgical complications was 25.6%. No surgery was cancelled. Patient satisfaction rates with pain management and with the school were 8.10/10 and 9.89/10, respectively. Concerning quality of life, mean improvement in mobility and knee pain after the surgery was 0.66 (p < 0.05) and 0.84 (p < 0.05), respectively.ConclusionsThe ERAS programme including a patient school was highly successful with a fast recovery, a short hospital stay length, no surgery cancellations, and improved PROs.     

快速康复外科理念在腹腔镜小肝癌治疗中的应用

目的:探讨快速康复外科(ERAS)理念应用于腹腔镜小肝癌切除术患者围手术期的临床价值。方法:分析2016年1月—2017年12月50例腹腔镜小肝癌切除术患者的临床资料,其中24例围手术期采用ERAS方案(ERAS组),26例围手术期采用传统方案(对照组)。比较两组患者相关临床指标。结果:两组患者术前临床资料具有可比性。与对照组比较,ERAS组术中出血量、手术时间均无统计学差异(均P0.05),术后肛门排气时间与住院时间明显缩短、住院总费用明显减少、并发症发生率均明显降低(均P0.05);ERAS组术后1、3、5d的Qo R-15恢复质量评分与C反应蛋白水平均明显优于对照组(均P0.05)。结论:腹腔镜小肝癌切除术患者围手术期应用ERAS理念可以有效的减轻手术创伤应激、缩短住院时间、降低住院费用、减少手术并发症,从而加快患者的康复。     

Towards optimizing perioperative colorectal care: outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery pathways

BackgroundLearning curves and efficiency concerns have slowed the integration of laparoscopy into colorectal practice. We evaluated our experience with laparoscopic colorectal (LC) surgery using enhanced recovery pathways (ERPs).MethodsOne thousand consecutive LC procedures performed by 2 surgeons over a 5-year period using previously published, standardized ERPs were assessed.ResultsThe mean age was 59, and the mean body mass index was 29.5. Procedures included segmental colectomy (54%), proctectomy (19%), total colectomy (11%), ostomy (5%), and other procedures (11%). Diagnoses included malignancy (41%), diverticulitis (16%), inflammatory bowel disease (13%), and other (30%). The mean operative time was 151 minutes, and the mean blood loss was 55 mL. Conversion to an open surgery occurred in 5.8%, whereas 2.3% were performed using a hand-assist procedure. The mean hospital stay was 4.1 days (median 3), with a 6% readmission rate. Complications (20%) included mortality (0.3%), wound infection (4%), and anastomotic leak (1.4%).ConclusionsLC surgery with ERP offers excellent outcomes with efficient use of resources.     

Systematic review on the short-term outcome of laparoscopic resection for colon and rectosigmoid cancer

OBJECTIVE: Several large randomized controlled trials on laparoscopic resection for colon and rectosigmoid cancer have recently been published. There is a need to provide an up-to-date systematic review in this subject. METHODS: A literature search of all published randomized trials in English between January 1991 and September 2005 was obtained, from Ovid MEDLINE, EMBASE, CINAHL, and All EBM Reviews (Cochrane Central Register of Controlled Trial, Cochrane Database of Systemic Review, and Database of Abstracts of Reviews of Effects), including e-links to the related articles. Two independent assessors reviewed the trials using a standardized protocol. Where means and standard deviations were available, meta-analysis was performed using the Forest plot review. Studies where medians and ranges were presented were separately analysed. RESULTS: A total of 17 randomized controlled trials with 4013 procedures were reviewed. The conversion rate varied widely between studies and was lowest in single-Centre trials. There were no significant differences in overall and surgical complication rate, anastomotic leak rate, re-operation rate and oncological clearance. However, laparoscopic resection has a significantly lower peri-operative mortality (odds ratio 0.33; P = 0.005), lower wound complications (odds ratio 0.65; P = 0.01), less blood loss (weighted mean difference 0.11 l; P < 0.00001) and reduced postoperative pain scores by 12.6% with reduction of requirements for narcotic analgesia by 30.7%. After laparoscopic surgery, patients passed flatus 38.8% earlier (weighted mean difference 27.6 h; P < 0.00001) and had bowel movement 21.0% earlier (weighted mean difference 23.9 h; P < 0.00001) and resumed oral diet 28.3% sooner than patients in the open group (weighted mean difference 27.3 h; P < 0.00001). Patients were discharged 19.1% earlier after laparoscopic surgery than open surgery (weighted mean difference 1.7 days; P < 0.00001). Laparoscopic resection took 28.7% longer (weighted mean difference 40.1 min; P < 0.00001) to perform. CONCLUSIONS: Laparoscopic resection for colon and rectosigmoid cancer is feasible, safe and has many short-term benefits.     

Impact of incision length on the short-term outcomes of laparoscopic colorectal surgery

Background

The recent introduction of hand-assist devices in laparoscopic colorectal surgery has renewed interest in the influence of incision length. This study aimed to define the impact of extraction incision length on the postoperative outcomes of laparoscopic left-sided colon and rectal resections.

Methods

Consecutive patients undergoing laparoscopic left-sided colorectal resection from 1991 to 2007 were retrieved from a prospectively collected database. The association between incision length and patient characteristics, diagnosis, and perioperative outcomes were analyzed using logistic regression, Spearman correlation, Wilcoxon test, and chi-square test.

Results

A total of 494 laparoscopic colorectal resections (left, sigmoid, anterior, and low anterior resections) were retrieved. Patients with conversions to open surgery (n = 59) and missing data (n = 53) were excluded. As a result, 382 cases were included in the study. A slight majority of the patients had malignant disease (n = 202, 53%). The median incision length was 5 cm (interquartile range, 4–6 cm). Increasing weight was positively correlated with incision length (p = 0.0001). Male patients had modestly larger mean incisions than female patients (5.5 vs. 5.0 cm; p = 0.0075). Age, previous surgery, diagnosis, days to resumption of normal diet, and days to discharge from hospital showed no significant relationship with incision length. No association was observed between the incision length and intraoperative or postoperative complications.

Conclusions

Patients undergoing laparoscopic colorectal surgery appear to achieve the same perioperative outcomes irrespective of their extraction incision lengths. To maintain the short-term benefits of laparoscopy, surgeons should consider pursuing a minimally invasive technique, even when a larger extraction incision will ultimately be required.     

Impact of obesity on surgical outcomes after colorectal resection

BACKGROUND: As the impact of obesity on surgical outcomes after colorectal resection is not well known, this study was designed to compare the results of colorectal resection in obese and nonobese patients. METHODS: From 1990 to 1997, 584 consecutive patients underwent elective colorectal resection in our department. Of these, 158 (27%) were obese (body mass index >27). Obese and nonobese patients were well matched for demographic data and surgical procedures. RESULTS: After right or left colectomy, no difference was noted between obese and nonobese patients for overall mortality, morbidity, or leakage rates. However, after left colectomy, postoperative intra-abdominal collections requiring treatment were significantly more frequent in obese than in nonobese patients (10% versus 2%; P <0.05). After proctectomy, the mortality rate was 5% (3 of 61) among obese patients and 0.5% (1 of 185) among nonobese patients (P <0.02). The anastomotic leakage rate was 16% (5 of 58) for obese patients and 6% (11 of 169) for nonobese patients (P <0. 05), and the corresponding proportions of transfused patients were 43% and 19%, respectively (P <0.02). After proctectomy, multivariate analysis showed that for obese patients, diabetes mellitus (P <0.05) and American Society of Anesthesiologists (ASA) status >2 (P <0.05) were significant risk factors for anastomotic leakage; age >60 years (P <0.01) and ASA status >2 (P <0.05) were significant risk factors for perioperative blood transfusions. CONCLUSIONS: Our study suggested that, for obese patients, (1) right colectomy can be performed in the same manner as for nonobese patients; (2) after left colectomy, abdominal drainage may be indicated, and (3) after proctectomy, a defunctioning stoma should be recommended when diabetes mellitus or ASA status >2 is present, and an autologous blood transfusion could be discussed for patients >60 years old or with ASA status >2.