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加速康复外科理念在肝切除术围手术期管理的应用研究
中文摘要

背景及目的 肝切除术主要应用于肝脏原发或继发的恶性肿瘤,以原发性肝细胞肝癌和结直肠癌肝转移癌为主。肝切除术一直被认为是一种有着高并发症与死亡率的高风险腹部大手术,随着外科技术水平的提高与设备的改进,肝切除术的并发症与死亡率已经较前明显下降,但仍有相当高的风险。 加速康复理念(Enhanced Recovery After Surgery,ERAS)在1997年由Kehlet提出,近年来,快速康复理念已经逐渐广泛应用于各外科围手术期管理中。ERAS包含了一系列的围手术期处理,它包括了术前充分沟通、术中优化麻醉理念、术后加快康复等措施,以减少手术应激,达到减少术后并发症、术后病死率,加速患者康复的目的。目前已经有大量的临床研究证明,ERAS应用在胃肠道手术、泌尿道等手术中可以明显获益,但在肝切除术的应用仅在于尝试阶段。本研究通过对比ERAS和传统方法行肝切除术的病人的临床指标,探讨ERAS策略对肝脏手术围手术期管理的临床应用价值。 方法 回顾性分析2015年1月至2016年9月南方医科大学南方医院收治的121例行肝切除术的病例,其中62例采用ERAS理念行围手术期管理,59例按照传统方式行围手术期管理。比较两组患者手术方式、手术类别、手术时长、术中出血,以及术后康复情况:术后病理结果、肛门排气时间、尿管拔除时间、腹腔引流管拔除时间、术后住院日、并发症发生情况、30天返院率,同时比较两组患者术前及术后第1、3、5天炎症指标:(C反应蛋白、血白细胞、血中性粒细胞百分比)、肝功能(TBIL、AST、ALT)、肾功能(CR、BUN)的变化情况。采用SPSS 20.0软件进行数据分析,计量资料服从正态分布的组间比较采用两独立样本t检验,采用〓+s描述;服从偏态分布的组间采用秩和检验,采用M(Q)描述。计数资料组间比较采用卡方检验χ²或Fisher精确检验。p<0.05为差异有统计学意义。 结果 两组病人均治愈出院,无围手术期死亡。ERAS组病人的术后1、3、5天的血白细胞、血中性粒细胞百分比及术后第3、5天的C反应蛋白和传统组病人相比,显著降低,差异有统计学意义(p<0.05)。ERAS组病人的术后第1、3天的ALT、AST、TBIL与传统组的对比,显著降低,差异有统计学意义(p<0.05)。与传统组对比,ERAS组病人的术后腹腔引流管拔除时间、尿管拔除时间、排气时间显著提前,术后住院日显著缩短,差异有统计学意义(p<0.05);在术后并发症及30天返院率方面,ERAS组与传统组对比差异无统计学意义(p>0.05)。 结论 ERAS理念应用于肝切除术围手术期的管理安全有效,可以在不增加术后并发症发生率与再返院率的前提下,有效缩短术后住院时间,加快肠道功能恢复,能有效减少患者术后炎症反应,加快患者术后康复。 关键词:肝切除术 加速康复外科 炎症反应 围手术期

英文摘要

Background and purpose Hepatectomy is mainly used in the benign and malignant liver tumors, including hepatocellular carcinoma and colorectal liver metastases. Hepatectomy is considered as a challenging major abdominal surgery with extreme impact on patient physiology, because of the complex procedures, large region of operation, long operation time, intraoperative tissue damage and overactive inflammation after surgery. Although the development of surgical techniques and the improvement of surgical instruments have reduced the mortality of hepatectomy, but the postoperative morbidity and mortality rates still remain high. The concept of Enhanced recovery after surgery (ERAS) was first introduced by Kehlet in 1997 and then has widely implemented in the perioperative period of multiple surgeries. ERAS contains a series of effective methods, mainly including preoperative counseling, perioperative anesthesia administration and postoperative mobilization, to reduce the inflammatory response and promote functional recovery. ERAS can effectively alleviate the psychological and physiological trauma; reduce the surgical stress response; accelerate intestine functional recovery, thus to reduce the postoperative morbidity and mortality rates; shorten the duration of postoperative hospital stay; reduce hospital cost. Is has been proved that ERAS is beneficial in colorectal, gastric and urologic surgeries. However, data on the implementation of ERAS in hepatectomy still remains rare. In this study, we conducted a retrospective study of 121 patients undergoing hepatectomy in Nanfang Hospital to investigate the effects of enhanced recovery program(ERAS) implemented in the perioperative period of hepatectomy. Methods We retrospectively investigated the medical records of 121 patients who had undergone hepatectomy during the period of January 2015 to September 2016 in Nanfang Hospital.62 patients in the ERAS group were guided by ERAS principles, while 59 patients in the control group were managed with traditional methods. They were compared in terms of operation method, operation level, operation time, volume of intraoperative blood loss, pathology, time to flatus, time to drainage tube removal, time to urinary tube removal, duration of postoperative hospital stay, complications, 30-days readmissions. THE changes of C-reactive protein (CRP), leukocytes, polymorphonuclear leucocytes, total bilirubin, aspartate aminotransferase (AST), anineamiotransferase (ALT) were recorded. Comparison of categorical variables was performed using the Chi-square test or independent samples t-test. The median and ranges of continuous parameters were compared using the Mann-Whitney U test. Results All patients were cured without perioperative death. The leukocytes and polymorphonuclear leucocytes on postoperative day 1,3,5 in ERAS group were significantly less than in control group(p<0.05).The CRP on postoperative day 3,5 in ERAS group were significantly lower than in control group(p<0.05).The ALT on postoperative day 1,3,5 in ERAS group were significantly lower than in control group(p<0.05).The AST and TBIL on postoperative day1,3 in ERAS group were significantly lower than in control group(p<0.05).The time of first flatus , drainage tube removal , urinary tube removal, duration of postoperative hospital stay were significantly reduced in ERAS group than in control group(p<0.05). There is no difference in readmission rate or surgical complications between ERAS group and control group. Conclusion ERAS programs appear to be safe and feasible in the perioperative period of hepatectomy, which can effectively reduce inflammatory response and accelerated functional recovery. KEYWORDS : Hepatectomy ; Enhanced recovery after surgery ; Inflammatory response; Perioperative period

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