加速康复外科在胰腺手术中的应用价值

Application value of enhanced recovery after surgery in the pancreatic surgery

目的：探讨加速康复外科（ERAS）在胰腺手术中应用的安全性和可行性。 方法：采用回顾性队列研究方法。收集2014年10月至2015年3月南京医科大学第一附属医院135例施行胰腺手术患者的临床资料。其中，2015年1-3月收治的47例患者围术期采用ERAS处理方案，设为ERAS组；2014年10-12月收治的88例患者围术期采用传统处理方案，设为对照组。观察指标：（1）术后临床指标：首次饮水时间、首次下床时间、首次通便时间、胃管拔除时间（单纯胃肠减压和输入襻减压）、导尿管拔除时间、腹腔引流管拔除时间、术后住院时间、无并发症患者术后住院时间、住院费用。（2）术后并发症情况：胰瘘、胃排空障碍、出血、胆瘘、乳糜漏、腹腔感染、再手术率、病死率、并发症发生率、90 d再住院率。采用电话或门诊随访，随访内容包括术后恢复情况和进一步治疗情况。随访时间截至2016年7月1日。正态分布的计量资料以±s表示，采用成组t检验进行分析。计数资料采用χ2检验。 结果：（1）术后临床指标：ERAS组首次饮水时间、首次下床时间、导尿管拔除时间和术后住院时间分别为（20±5）h、（53±11）h、（2.2±1.3）d、（15.6±8.2）d，对照组上述指标分别为（25±3）h、（59±8）h、（3.8±1.7）d、（20.0±13.8）d，两组比较，差异均有统计学意义（t=7.00，3.75，5.63，2.00， P〈0.05）。（2）术后并发症情况：ERAS组和对照组术后并发症总体发生率分别为25.5%（12/47）和34.1%（30/88），两组比较，差异无统计学意义（χ2=1.05，P〉0.05）。ERAS组无死亡及再手术患者，有2例患者出院后因腹腔积液再次入院，2例患者发生腹腔出血， 1例患者发生腹腔感染，1例患者发生乳糜漏。对照组无90 d内再入院患者，有1例患者因术后当晚腹腔出血抢救无效死亡，5例患者发生腹腔感染，4例患者出血，3例患者发生胆瘘，1例患者因腹腔出血行二次手术，1例患者发生乳糜漏。B级和C级胰瘘发生率ERAS组为10.6%（5/47），对照组为22.7%（20/88）。ERAS组B级和C级胃排空障碍发生率为8.5%（4/47）,对照组为4.5%（4/88）。两组患者胰瘘和胃排空障碍发生率比较，差异均无统计学意义（χ2=2.97，0.86，P〉0.05）。 结论：胰腺手术围术期应用ERAS模式可显著缩短住院时间、提高患者生命质量及满意度，具有较良好的可行性、安全性及有效性，值得推广应用。

Objective：To evaluate the feasibility and safety of enhanced recovery after surgery （ERAS） in the pancreatic surgery. Methods：The retrospective casecontrol study was adopted. The clinical data of 135 patients who underwent pancreatic surgery at the First Affiliated Hospital of Nanjing Medical University from October 2014 to March 2015 were collected. Fortyseven patients receiving ERAS management between January 2015 and March 2015 were allocated into the ERAS group and 88 patients receiving traditional perioperative management between October 2014 and December 2014 were allocated into the control group. Observation indicators included （1） postoperative clinical indexes： time for initial water intake, time for outofbed activity, time to initial defecation, time of gastric tube removal, time of urinary catheter removal, time of abdominal drainagetube removal, duration of hospital stay, duration of hospital stay of patients without complications and hospital expenses, （2） postoperative complications： pancreatic fistula, delayed gastric emptying, bleeding, biliary fistula, chyle leakage, intraabdominal infection, reoperation rate, mortality, incidence of complications and readmission rate within 90 days. The followup using telephone interview and outpatient examination was performed to detect postoperative recovery and further treatment of patients up to July 1, 2016. Measurement data with normal distribution were presented as ±s and analyzed by t test. Count data were analyzed by the chisquare test. Results：（1） Postoperative clinical indexes： time for initial water intake, time for outofbed activity, time of urinary catheter removal and duration of hospital stay were （20±5）hours, （53±11）hours, （2.2±1.3）days, （15.6±8.2）days in the ERAS group and （25±3）hours, （59±8）hours, （3.8±1.7）days, （20.0± 13.8）days in the control group, respectively, with statistically significant differences between the 2 groups （t= 7.00, 3.75, 5.63, 2.00, P〈0.05）. （2） Postoperative complications： overall incidence of postoperative complications was 25.5%（12/47） in the ERAS group and 34.1%（30/88） in the control group, with no statistically difference （χ2=1.05, P〉0.05）. There was no occurrence of death and reoperation in the ERAS group, 2 patients had readmission due to peritoneal effusion, and 2, 1 and 1 patients were respectively complicated with abdominal bleeding, intraabdominal infection and chyle leakage. There was no occurrence of reoperation in the control group and 1 patient died of abdominal bleeding, and 5, 4, 3, and 1 patients were respectively complicated with intraabdominal infection, bleeding, biliary fistula and chyle leakage as well as 1 patient received reoperation due to abdominal bleeding. The incidences of pancreatic fistula in grade B/C and delayed gastric emptying in grade B/C were 10.6%（5/47）, 8.5%（4/47） in the ERAS group and 22.7%（20/88）, 4.5%（4/88）in the control group, showing no statistically significant difference in the pancreatic fistula and delayed gastric emptying between the 2 groups （χ2=2.97, 0.86, P〉0.05）. Conclusion：The perioperative ERAS program in the pancreatic surgery is safe and effective and should be popularized, meanwhile, it can also reduce duration of hospital stay and improve the quality of life and satisfaction of patients.