加速康复外科在婴儿胆管扩张症围手术期的应用

Application of enhanced recovery after surgery in perioperative management of congenital cholangiectasis in infants

目的探讨婴儿先天性胆管扩张症围手术期采用加速康复外科管理模式的安全性及有效性。方法前瞻性研究加速康复外科管理模式在婴儿先天性胆管扩张症围手术期的优势及安全性。2016年03月至2017年04月,南京医科大学附属儿童医院外科收治的先天性胆管扩张症患儿23例,在围手术期采用加速康复外科管理模式(ERAS组);以2015年01月至2016年02月采用传统方法进行围手术期管理的患儿为对照组(18例)。比较两组患儿手术时间、术中出血量、术后第一天白细胞(WBC)计数和术后第一天C-反应蛋白(CRP)值、术后首次排便时间、术后首次经口喂水、喂奶时间、术后停止静脉补液时间、术后并发症(吻合口漏、出血、胆管炎、切口感染及呼吸道感染)发生率、术后住院时间及费用,以及术后再手术率、出院后30d再入院率。术后随访(6±2)个月。结果两组患儿在年龄、体重、手术时间、术中出血量、术后并发症发生率等方面两组差异均无统计学意义。ERAS组术后第一天白细胞和CRP值分别为(13.9±2.0)×10^9/L、(16.7±12.6)mg/L,比对照组(14.9±2.6)×10^9/L、(26.6±21.4)mg/L指标有所降低,但差异无统计学意义。而EARS组术后首次排便时间[(43.1±14.6)h比(59.3±15.2)h,P=0.001]、术后首次经口喂水[(39.3±6.5)h比(128.8±11.4)h,P<O.001]、喂奶时间[(63.3±7.O)h比(153.8±11.7)h,P<O.001],术后停止静脉补液时间[(7.6±0.6)d比(10.9±1.26)d,P<0.001],术后住院时间[(10.0±1.3)d比(12.9±2.6)d,P<0.001],对比对照组显著缩短或提前,差异均有统计学意义。ERAS组住院费用较对照组[(28548.1±2682.2)元比(32516.6±5134.2)元,P=O.003]显著减少,差异有统计学意义。两组术后相关并发症发生率差异无统计学意义,两组均无术后再手术、出院后30d再入院以及死亡患儿。结论婴儿先天性胆管扩张症围手术期采用加速康复外科管理模式,可以降低患儿创伤应激,促进术后康复,减少医疗费用,安全有效。

Objective To explore the safety and efficacy of employing the model of enhanced recovery after surgery (ERAS)in perioperative management of congenital cholangiectasis in infants. Methods Prospective study was conducted for the advantages and safety of ERAS model in perioperative management of congenital cholangiectasis in infants.From March 2016 to April 2017, infants with congenital cholangiectasis underwent ERAS model (ERAS group,n =23)during perioperative management.From January 2015 to February 2016,the perioperative management of infants with traditional methods was control group (n =18).Two groups were compared with regards to operative duration,intraoperative blood loss,leucocyte counts and C-reactive protein (CRP)values at postoperative Day 1,time to first defecation,time to first drink of water and feed of milk,time to stopping intravenous fluids,the incidence of postoperative complications (anastomotic leak,bleeding cholangitis,incision infection&respiratory infection),postoperative hospitalization time&cost, reoperative rate and re-admission rate within 30 days.The postoperative follow-up period was 6±2 months.Results No inter-group statistical difference existed in age,weight,operative duration, intraoperative blood loss or postoperative complications.The leukocyte counts and CRP values at the first postoperative day in ERAS group decreased as compared with control group [(13.9±2.0)×10^9/L、(16.7±12.6)mg/L)vs (4.9±2.6)×10^9/L、(26.6±21.4)mg/L)].However,it failed to show statistical difference.While,time to first defecation,time to first drink or feed of milk,time to stopping intravenous fluids and postoperative hospital stay all significantly decreased in ERAS group [(43.1±14.6)vs (59.3±15.2)h,(39.3±6.5)vs (128.8±11.4)h,(63.3±7.0)vs (153.8± 11.7)h,(7.6±0.6)vs (10.9±1.26)d,(10.0±1.3)vs (12.9±2.6)d].P values were P =0.001, P<0.001,P<0.001,P<0.001and P<0.001respectively.The cost of hospitalization was significantly lower in ERAS group than that of control group [(2848.1±282.2)vs (3216.6± 534.2)yuan,P =0.003].No statistically significant inter-group differences existed in postoperative complications.No reoperation was performed.And there was neither mortality nor re-admission within 30days.Conclusions ERAS model may lower traumatic stress,promote postoperative recovery and reduce medical expenses.And it is both safe and effective during perioperative management of infants with congenital cholangiectasis.