快速康复外科在老年患者传统开腹与腹腔镜下胆囊切除加胆总管探查术围手术期中的应用

目的探讨快速康复外科(ERAS)理念在老年患者传统开腹与腹腔镜下胆囊切除加胆总管探查术围手术期的应用及其在临床中的使用价值。 方法选取2012年1月至2016年4月在内蒙古自治区人民医院肝胆胰脾外科择期行胆囊切除加胆总管探查术的老年患者共113例，按随机数字表法将113例患者分为行开腹胆囊切除加胆总管探查术患者60例(O-组)和腹腔镜下胆囊切除加胆总管探查术患者53例(L-组)，再用随机数字表法将两大组分为4个亚组，分别实施ERAS措施和传统措施，即分为O-ERAS组(30例)、O-Control组(30例)和L-ERAS组(27例)、L-Control组(26例)。O-组实施开腹胆囊切除术加胆总管探查术，L-组实施腹腔镜下胆囊切除术加胆总管探查术。而O-ERAS组和L-ERAS组采取ERAS相关措施进行处理，O-Control组和L-Control组应用传统方法处理，对不同组别病例的手术时间、术中出血量、术后排气时间、术后住院时间、住院费用等情况进行观察。对数据行t检验。 结果O-Control组手术时间为(2.3±0.7) h、术中出血量为(81.0±77.7) mL、术后排气时间为(3.4±1.0) d、术后住院时间为(12.9±4.0) d，与O-ERAS组的手术时间(1.9±0.5) h]、术中出血量(48.0±24.1) mL]、术后排气时间(2.8±0.9) d]、术后住院时间(10.5±4.1) d]相比，后者术中出血量减少，手术时间、术后排气时间、术后住院时间缩短，差异均有统计学意义(t＝－2.008、－2.099、－2.734、－2.233, P值均小于0.05)；而2组住院费用分别为(22 246.9±13 344.3)元、(20 194.4±2 828.2)，差异无统计学意义(P>0.05)。 L-Control组手术时间为(2.2±0.6) h、术中出血量为(54.0±32.1) mL、术后排气时间为(2.9±0.9) d、术后住院时间为(7.0±2.0) d，与L-ERAS组的手术时间(1.8±0.5) h]、术中出血量(37.0±26.3) mL]、术后排气时间(2.4±0.8) d]、术后住院时间(5.7±1.1) d]相比，后者术中出血量减少，手术时间、术后排气时间、术后住院时间缩短，差异均有统计学意义(t＝－2.179、－2.214、-2.197、－2.660，P值均小于0.05)；而2组住院费用分别为(22 672.6±5 446.9) 、(22 404.4±8 482.4)元，差异无统计学意义(P>0.05)。与O-ERAS组相比，L-ERAS组术中出血量减少，手术时间、术后排气时间和术后住院时间缩短，2组差异均有统计学意义(P值均小于0.05)；但2组住院费用差异无统计学意义(P>0.05)。 结论快速康复外科理念在老年患者胆囊切除加胆总管探查术中能促进老年患者术后康复，且腹腔镜胆囊切除术加胆总管探查术更有利于患者术后快速康复，临床应用效果明显，可在临床推广。

Application of enhanced recovery after surgery in perioperative period of traditional open surgery and laparoscopic cholecystectomy plus common bile duct exploration in elderly patients

ObjectiveTo analyze the application and value of enhanced recovery after surgery(ERAS) in the elderly patients with open cholecystectomy plus common bile duct exploration and laparoscopic cholecystectomy plus common bile duct exploration in the perioperative period. MethodsA total of 113 elderly patients undergoing cholecystectomy plus common bile duct exploration were selected from January 2012 to April 2016 in the Inner Mongolia People′s Hospital. All the patients were divided into 60 patients with open cholecystectomy and common bile duct exploration (O-group) and 53 patients with laparoscopic cholecystectomy and common bile duct exploration (L-group) according to random number table method. The two groups of patients were further divided into 4 subgroups by using random number table method, and the ERAS and traditional measures were respectively implemented, namely L-ERAS group(27 patients), O-ERAS group(30 patients)] and L-Control group(26 patients), O-Control group(30 patients)]. The O-group underwent open cholecystectomy plus common bile duct exploration, and the L-group underwent laparoscopic cholecystectomy plus common bile duct exploration. The patients in the ERAS group were treated with ERAS, and the control group was treated by traditional method. The operative time, intraoperative blood loss, postoperative exhaust time, the length of postoperative hospital stay, the hospitalization expenese in different groups were compared. Data were processed with t test. ResultsThe operative time of O-Control group was (2.3±0.7) h, the intraoperative bleeding volume was (81.0±77.7) mL, postoperative exhaust time was (3.4±1.0) d, postoperative hospital stay was(12.9±4.0) d. And the operative time of O-ERAS group was(1.9±0.5) h, the intraoperative bleeding volume was (48.0±24.1) mL, postoperative exhaust time was (2.8±0.9) d, postoperative hospital stay was(10.5±4.1) d. Compare with the O-Control group, the latter with less amount of bleeding, the operative time, the time of postoperative exhaust time, the time of post-operative hospitalization were shortened, and the differences were statistically significant(t=-2.008, -2.099, -2.734, -2.233; with P values below 0.05). The hospitalization expenses of the two groups were(22 246.9±13 344.3) , (20 194.4±2 828.2) yuan, the difference was not statistically significant(P>0.05). The operative time of L-Control group was(2.2±0.6) h, the intraoperative bleeding volume was (54.0±32.1) mL, postoperative exhaust time was (2.9±0.9) d, postoperative hospital stay was(7.0±2.0) d, the operative time of L-ERAS group was(1.8±0.5) h, the intraoperative bleeding volume was (37.0±26.3) mL, postoperative exhaust time was(2.4±0.8) d, postoperative hospital stay was(5.7±1.1) d. Compare with the L-Control group, the latter with less amount of bleeding, the operative time, the time of postoperative exhaust time, the time of post-operative hospitalization were shortened, and the differences were statistically significant(t=-2.179, -2.214, -2.197, -2.660; with P values below 0.05). The hospitalization expenses of the two groups were (22 672.6±5 446.9), (22 404.3±8 482.4) yuan, the difference was not statistically significant(P>0.05). Compared with the O-ERAS group, the L-ERAS group with less amount of bleeding , the operative time, the time of postoperative exhaust time, the time of post-operative hospitalization were shortened, and the differences were statistically significant(with P values below 0.05); however, there was no significant difference in hospitalization expenses between the two groups (P>0.05). ConclusionsERAS in elderly patients with cholecystectomy plus common bile duct exploration can promote the rehabilitation of elderly patients after surgery. And laparoscopic cholecystectomy plus common bile duct exploration is more conducive to rapid postoperative recovery, the effect of clinical application is obvious and can be promoted in clinic.