加速康复外科技术在肛门闭锁并直肠前庭瘘中的应用

Application of enhanced recovery after surgery in infants with anal atresia with rectovestibular fistula

目的探讨加速康复外科(enhanced recovery after surgery,ERAS)技术应用于小儿肛门闭锁并直肠前庭瘘的有效性及安全性。方法采用前瞻性研究方法,将2017年1月至2021年10月山西省儿童医院收治的50例肛门闭锁并直肠前庭瘘患儿随机分为ERAS组和非ERAS组,其中ERAS组25例,非ERAS组25例。ERAS组采用手术日清晨清洁灌肠1次,术前2 h口服12.6%碳水化合物液体,术中保温、目标导向性补液,术后不留置尿管及术后镇痛等措施;非ERAS组采用传统围术期处理方案。两组均采用经肛穴肛门成形术,比较两组患儿麻醉开始时血糖、术后24 h血糖、白细胞计数(white blood cell count,WBC)、C反应蛋白(C-reactive protein,CRP)、术后首次肛门排气排便时间、术中输液量、术后静脉输液时间、术后住院时间、住院费用、并发症发生率及出院后30 d内再入院率。结果两组患儿术前平均年龄、体重、WBC、CRP、血红蛋白、白蛋白、前白蛋白、入院时血糖比较,差异均无统计学意义(P>0.05)。ERAS组和非ERAS组患儿麻醉开始时血糖分别为(4.92±0.50)mmol/L和(4.53±0.42)mmol/L;术后24 h血糖分别为(5.03±0.66)mmol/L和(5.96±1.18)mmol/L,WBC分别为(9.97±3.24)×10^(9)/L和(8.28±3.51)×10^(9)/L,CRP分别为(3.63±4.00)mg/L和(9.03±15.77)mg/L;术后首次肛门排气排便时间分别为(12.10±6.40)h和(14.00±9.30)h;术中输液量分别为(83.10±32.20)mL和(136.10±68.40)mL;术后静脉输液时间分别为(4.68±1.25)d和(6.60±1.68)d;术后住院时间分别为(7.12±1.56)d和(10.56±3.58)d;住院费用分别为(13314.34±2856.86)元和(16088.69±3282.34)元;两组并发症发生例数分别为3例(12%)和6例(24%);两组总体满意度分别为88%(22/25)和60%(15/25),均痊愈出院,无一例出院后30 d内再入院患儿。两组患儿术后首次肛门排气排便时间、术后24 h WBC、CRP比较,差异无统计学意义(P>0.05)。非ERAS组麻醉开始时血糖降低,术后24 h血糖水平升高,差异有统计学意义(P<0.05)。ERAS组较非ERAS组术中输液量减少、术后静脉输液时间及住院时间缩短、住院费用减少,差异有统计学意义(P<0.05)。两组并发症发生率差异无统计学意义(P>0.05)。ERAS组总体满意度高于非ERAS组,差异有统计学意义(P<0.05)。结论加速康复外科技术应用于肛门闭锁并直肠前庭瘘患儿安全、有效,能有效缩短平均住院日和术后住院时间,降低住院费用。

Objective To explore the efficacy and safety of enhanced recovery after surgery(ERAS)in children with anal atresia and rectal vestibular fistula.Methods From January 2017 to October 2021,prospective review was conducted for 50 children with anal atresia and rectal vestibular fistula undergoing transanal analoplasty.They were randomized into two groups of ERAS and non-ERAS(n=25 each).ERAS group received enema once in the morning of operation day,oral 12.6%carbohydrate liquid 2 h pre-operation,intraoperative heat preservation,target-oriented rehydration,no indwelling catheter post-operation,postoperative analgesia and other new measures;non-ERAS group had traditional perioperative treatment.Blood glucose at the beginning of anesthesia,blood glucose 24 h post-operation,white blood cell count(WBC),C-reactive protein(CRP),time of initial exhaust and defecation post-operation,amount of intraoperative infusion,time of postoperative intravenous infusion,time of postoperative hospitalization,expenditure of hospitalization,incidence of complications and readmission rate at Day 30 post-discharge were compared between two groups.Results No significant inter-group differences existed in average age,weight,preoperative WBC,CRP,hemoglobin,albumin,prealbumin or blood glucose at admission.Blood glucose at the beginning of anesthesia in ERAS and non-ERAS groups was(4.92±0.50)and(4.53±0.42)mmol/L,blood glucose(5.03±0.66)and(5.96±1.18)mmol/L at 24 h post-operation.WBC at 24h post-operation(9.97±3.24)×10^(9)/L and(8.28±3.51)×10^(9)/L;CRP at 24 h post-operation(3.63±4.00)and(9.03±15.77)mg/L;initial postoperative exhaust and defecation time(12.1±6.4)and(14.0±9.3)h;intraoperative infusion volume(83.1±32.2)and(136.1±68.4)mL;postoperative intravenous infusion time(4.68±1.25)and(6.6±1.68)days;postoperative hospital stay(7.12±1.56)and(10.56±3.58)days;hospitalization expense(13314.34±2856.86)and(16088.69±3282.34)CNY;complications occurred(n=3,12%)and(n=6,24%);overall satisfaction was 88%and 60%.Both groups were cured and discharged and there was no re-admission within 30 days post-discharge.No inter-group differences existed in initial exhaust or defecation time,WBC and CRP at 24 h post-operation(P>0.05).In non-ERAS group,blood glucose declined at the beginning of anesthesia while postoperative blood glucose level rose with statistical difference(P<0.05);overall satisfaction of ERAS group was higher than that of non-ERAS group with statistical difference(P<0.05).Conclusion Conceptual application of ERAS is both safe and effective in children with anal atresia with rectovestibular fistula.It can effectively shorten the average time of hospital stay,curtain the length of postoperative hospitalization and lower hospitalization expenditure.A wider popularization is worthy.