个体化快速康复措施对胰十二指肠切除术后围手术期并发症的影响

Influence of personal fast track surgery measures on the complications after pancreaticoduodenectomy during perioperative period

目的 研究胰十二指肠切除术后围手术期并发症的处理流程和改进措施.方法 收集2012年1月至2013年6月间在上海长海医院接受胰十二指肠切除术的635例患者病史资料及随访数据,对围手术期内并发症发生情况进行系统性回顾和分析,比较不同处理措施对其恢复效果的影响,分析并总结患者术后再入院的主要风险因素和规避策略.结果 相对于术后肠外营养或口服进食的患者,早期应用肠内营养、下床活动以及更改腹腔引流管等个体化快速康复措施的患者的术后排气、排便时间更早[（2.9±1.6）比（3.6±2.1）d],住院天数、住院费用显著降低[（13.9±7.5）比（17.6±7.7）d、（58 505±34 045）比（68 663±26 640）元],差异均有统计学意义（P值＜0.05或＜0.01）;上消化道排空障碍、腹腔内感染、胰瘘、胆瘘、腹腔内出血等并发症的发生率均下降,其中上消化道排空障碍及腹腔感染发生率的下降具有统计学意义（8.9％比16.8％、14.2％ 比22.3％,P值均＜0.05）.接受胰十二指肠切除术的患者术后再入院率显著高于保留幽门胰十二指肠切除术者（20.0％比11.9％,P=0.015）.结论 对于胰十二指肠切除术患者来说,个体化快速康复治疗是减轻手术应激,减少围手术期并发症,同时不增加患者术后再入院率的安全有效的处理策略。

Objective To evaluate the impact of personal fast track surgery （FTS） measures for complications of pancreaticoduodenectomy （PD） during perioperative period.Methods Between January 2012 and June 2013,there were 635 patients underwent PD or PPPD in our department,and the medical record and follow up data were collected and retrospectively systematically analyzed.The recovery effect by different measures was determined,and the risk factors for re-admission and management strategy was analyzed.Results Compared with patients with postoperative parenteral nutrition or oral intake,FTS group patients with early enteral nutrition,out of bed activity,change of abdominal drainage tube had shorter postoperative exhaust time [（2.9 ± 1.6） vs （3.6 ± 2.1） d],length of hospitalization [（13.9 ± 7.5） vs （17.6 ± 7.7） d],fewer expenses [（58 505 ± 34 045） vs （68 663 ± 26 640） Yuan],and the difference between the two groups was statistically significant （P 〈0.05 or 〈 0.01）.The incidence of delayed gastric emptying,intra-abdominal infection,pancreatic fistula,biliary fistula and.intra-abdominal bleeding was decreased,and the decrease of delayed gastric emptying and intra-abdominal infection was statistically significant （8.9% vs 16.8%,14.2% vs 22.3%,P〈0.05）.The patients underwent the routine pancreaticoduodenectomy procedure had higher risk of re-admission than patients with pylorus preserving pancreaticoduodenectomy （20.0% vs 11.9%,P =0.015）.Conclusions For patients undergoing pancreaticoduodenectomy,personal fast track surgery can alleviate surgical stress,decrease perioperative complication rate without increasing the risk of re-admission.