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。     

Hypoxaemia during recovery after surgery for colorectal cancer: a prospective observational study

Episodic and ongoing hypoxaemia are well-described after surgery, but, to date, no studies have investigated the occurrence of episodic hypoxaemia following minimally-invasive colorectal surgery performed in an enhanced recovery setting. We aimed to describe the occurrence of postoperative hypoxaemia after minimally-invasive surgery in an enhanced recovery setting, and the association with morphine use, incision site, fluid intake and troponin increase. We performed a prospective observational study of 85 patients undergoing minimally-invasive surgery for colorectal cancer between 25 August 2016 and 17 August 2017. We applied a pulse oximeter with a measurement rate of 1 Hz immediately after surgery either until discharge or until two days after surgery, and recorded the oxygen saturation. We measured troponin I during the first four days after surgery, or until discharge. The median (IQR [range]) length of stay was 3 (2–4 [1–38]) days. Thirty-six percent of patients spent more than 1 h below an oxygen saturation of 90% (4.2% of the day), and with a median (IQR [range]) proportion of 1.3 (0.2–11.1 [0.0–21.4])% of the day spent with an oxygen saturation below 88%. We found no associations between time spent below an oxygen saturation of 88% and morphine use (p = 0.215), fluid intake (p = 0.446), complications (p = 0.808) or extraction site (p = 0.623). Postoperative increases in troponin I were associated both with time spent below an oxygen saturation of 88% (p = 0.026) and hypopnoea episodes (p = 0.003). Even with minimally-invasive surgery and enhanced recovery after surgery, episodic hypoxaemia and hypopnoea episodes are common, but are not associated with morphine use, fluid intake or incision site. Further studies should investigate the relationship between hypoxaemia and troponin increase.     

加速康复外科策略对腹膜后恶性肿瘤患儿体液免疫功能及术后恢复的影响

目的:探讨围手术期麻醉管理应用加速康复外科（enhanced recovery after surgery, ERAS）策略对腹膜后恶性肿瘤患儿体液免疫功能及术后恢复的影响。方法:选择择期行腹膜后恶性肿瘤切除术患儿70例,年龄1~4岁,ASA分级Ⅱ、Ⅲ级。按照随机数字表法将患儿分为常规组（C组）和ERAS组（E组）,每...     

加速康复外科理念对髋关节置换术病人术后并发症预防效果的观察

目的 分析加速康复外科（enhanced recovery after surgery, ERAS）理念对髋关节置换术（total hip arthroplasty, THA）病人术后并发症的预防效果。方法 回顾性分析我院2014年1月至2018年12月收治的200例行THA病人的临床资料,将术后采用常规护理的病人纳入对照组（100例）,术后采用ERAS理念护理的病人纳入观察组（100例）。观察两组病人术后并发症发生情况、髋关节功能康复情况和功能独立性。结果 术后6个月,观察组并发症发生率为4.00%,明显低于对照组的14.00%,差异有统计学意义（P＜0.05）;观察组Harris髋关节功能评分（Harris hip score, HHS）为（93.86±4.37）分,高于对照组的（77.64±8.74）分,差异有统计学意义（P＜0.05）;观察组功能独立性评定量表（functional independence measure, FIM）评分为（116.78±3.99）分,高于对照组的（94.09±6.82）分,差异有统计学意义（P＜0.05）。结论 ERAS理念可有效预防THA病人术后并发症,并且有助于提升病人髋关节功能康复效果及功能独立性。     

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。     

加速康复外科程序在肝胆管结石肝切除术中的应用

目的:探讨加速康复外科(ERAS)程序在肝胆管结石肝切除术中的应用价值。方法:回顾性分析2013年1月—2016年12月178例采用ERAS处理行肝切除术治疗的肝胆管结石患者(ERAS组)和2009年1月—2012年12月218例按传统方法进行围手术期处理行肝切除术治疗的肝胆管结石患者(常规组)的临床资料。比较两组患者的相关临床指标。结果:与常规组比较,ERAS组术后肝功能指标恢复较好(部分P0.05),术后住院时间明显缩短、首次排气时间明显提前、体质量下降明显减少、治疗总费用明显下降(均P0.05)。两组术后总并发症与各并发症发生率差异均无统计学意义(均P0.05)。两组均无死亡病例。结论:肝胆管结石肝切除术中采用ERAS程序安全、可行,既加速患者术后器官功能的恢复,又可以减少住院时间与治疗费用。     

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.     

Institutional factors associated with adherence to enhanced recovery protocols for colorectal surgery: Secondary analysis of a multicenter study

IntroductionAdherence to Enhanced Recovery Protocols (ERPs) is associated with faster functional recovery, better patient satisfaction, lower complication rates and reduced length of hospital stay. Understanding institutional barriers and facilitators is essential for improving adherence to ERPs. The purpose of this study was to identify institutional factors associated with adherence to an ERP for colorectal surgery.MethodsA secondary analysis of a nationwide study was conducted including 686 patients who underwent colorectal surgery across twenty-one institutions in Spain. Adherence to ERPs was calculated based upon the components recommended by the Enhanced Recovery After Surgery (ERAS®) Society. Institutional characteristics (i.e., case volume, ERP duration, anesthesia staff size, multidisciplinary meetings, leadership discipline) were captured from each participating program. Multivariable regression was performed to determine characteristics associated with adherence.ResultsThe median adherence to ERAS was 68.2% (IQR 59.1%–81.8%). Multivariable linear regression revealed that anesthesiologist leadership (+5.49%, 95%CI +2.81% to +8.18%, P < 0.01), duration of ERAS implementation (+0.46% per year, 95%CI +0.06% to +0.86%, P < 0.01) and the use of regular multidisciplinary meetings (+4.66%, 95%CI +0.06 to +7.74%, P < 0.01) were independently associated with greater adherence. Case volume (−2.38% per 4 cases weekly, 95%CI -3.03 to −1.74, P < 0.01) and number of anesthesia providers (−1.19% per 10 providers, 95%CI +2.23 to −8.18%, P < 0.01) were negatively associated with adherence.ConclusionAdherence to ERPs is strongly associated with anesthesiology leadership, regular multidisciplinary meetings, and program duration, whereas case volume and the size of the anesthesia staff were potential barriers. These findings highlight the importance of strong leadership, experience and establishing a multidisciplinary team when developing an ERP for colorectal surgery.     

区域麻醉在心脏手术快速康复中的应用进展

正中劈开胸骨的心脏手术创伤大,术后加速康复一直是手术和麻醉的重点和难点。目前,由于区域麻醉可以阻断疼痛的传导通路,减少手术应激,有益于术后镇痛,因此已广泛应用于普通外科手术的辅助麻醉。由于心脏手术中心肺转流需要全身肝素化,区域麻醉的应用一直存在争议。本文对几种常见的应用于正中劈开胸骨的心脏手术的区域麻醉方式及其并发症等研究状况进行综述,为开胸心脏手术麻醉管理提供参考。     

Enhanced recovery after surgery protocols - compliance and variations in practice during routine colorectal surgery

Aim Although there are numerous studies on the efficacy of enhanced recovery after surgery (ERAS) protocols in reducing length of stay, the long‐term compliance to such protocols in routine clinical practice has not been well documented. The aim of this study was to review the published literature on compliance to ERAS in patients undergoing colorectal surgery in routine clinical practice. Method Medline, Embase and PubMed databases were searched to identify studies that focused on compliance to ERAS protocols during routine clinical practice. Fourteen studies fulfilled the inclusion criteria and a total of 19 perioperative ERAS modalities were identified across these studies. Results None of the studies used all 19 ERAS modalities within their ERAS protocols. Compliance to the various modalities varied considerably between studies and, in general, was poorest during the postoperative period. The use of epidural had the highest compliance (between 67 and 100%), whereas the use of transverse incisions (25%) had the lowest compliance. Length of stay in hospital ranged from 2 to 13 days. Higher compliance was associated with a reduced length of hospital stay. However, reduced length of hospital stay was associated with a high rate of readmission. Conclusion There is significant variation in the components of, as well as in compliance to, ERAS protocols in daily practice. This may contribute to the observed variation between the studies in length of hospital stay. A standardized and practically feasible ERAS protocol should be established in order to improve the implementation and optimal outcome.     

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。     

Successful enhanced recovery program after colorectal surgery in a county institution

Enhanced recovery programs after colorectal surgery have gained acceptance recently as they have shown a decrease length of hospital stay. However, these pathways require strict adherence to standardized programs with patient education and high compliance. This study was designed to assess the feasibility of such a program in a large county hospital. A retrospective review was performed of 54 consecutive patients who underwent laparoscopic or open segmental colorectal resection without an ostomy. The first 27 patients were treated in a conventional manner, whereas the latter 27 were treated using a protocol promoting early feeding and ambulation with decreased intravenous fluids and narcotic use. There were no baseline differences between the groups, however, there was a significant difference in the patients treated with the enhanced recovery program in terms of less intravenous fluids administered in surgery (P = 0.001), and over the subsequent 3 days (P = 0.0017), with a decrease in length of hospital stay of 4 compared with 6 days (P = 0.003). There were no differences in terms of complication and readmission rates. Based on this study, we conclude that strict adherence to a standard enhanced recovery program was effective in reducing hospital stay in patients undergoing colorectal resection without any increase in complications.