加速康复外科在胰十二指肠切除术中的应用

Application of enhanced recovery after surgery in patients with duodenopancreatectomy

目的本研究旨在评估加速康复外科(ERAS)在胰十二指肠切除术中应用的安全性和有效性。方法将2014年1月至2015年12月我院54例胰十二指肠切除术患者随机为传统组(39例)和加速康复组(ERAS组,15例)两组。传统组按传统方法进行围手术期处理。ERAS组接受加速康复外科策略的围手术期处理,主要包括:术前教育、术前减黄、术前营养支持、术中保温、术后强化镇痛、术后早期肠内营养支持及早期恢复口服饮食、术后早期下床活动、术后强化血糖控制等。观察比较两组患者病死率、再手术率、术后平均住院日、治疗费用,以及胰瘘、胃排空延迟和其他腹腔并发症的发生率。结果两组患者的平均年龄、性别、原发病构成以及术前黄疸或糖尿病构成比例差别无统计学意义(P>0.05)。传统组死亡2例,再手术1例,1周内再入院1例。ERAS组没有死亡、再手术及再入院病例。传统组共发生胰瘘12例,ERAS组2例(30.8%vs 13.3%,P=0.191)。其中传统组有B级胰瘘2例,C级胰瘘3例,A级胰瘘7例;ERAS组均为A级胰瘘。传统组胃延迟排空发生率显著高于ERAS组(35.9%vs 6.7%,P=0.031)。包括腹腔出血、腹腔积液等其他腹腔并发症的发生率两组间没有明显统计学差异(P>0.05)。ERAS组术后胃肠道功能恢复时间、平均住院日(21 d vs 17 d,P=0.046)和住院费用(97 130元vs 80 963元,P=0.047)明显少于传统组。结论结合胰十二指肠切除手术特点所制定的加速康复外科策略在胰十二指肠切除术中的应用是安全的,并且可以有效降低患者术后胰瘘、胃排空延迟的发生率,减少术后住院时间和住院费用,有利于患者更快更好地康复。

Objective To evaluate the safety and efficacy of enhanced recovery after surgery （ERAS） in patients with duodenopancreatectomy. Methods A total of 54 patients of Jinling Hopsital from Jan. 2014 to Dec. 2015 were randomly divided into two groups, the traditional group （39 cases） and ERAS group （15 cases）. Traditional group received perioperative management by conventional method. ERAS group received ERAS perioperative management, mainly including preoperative education, preoperative jaundice, preoperative nutritional support, intraoperative warming, postoperative enhance the analgesic and postoperative early enteral nutrition support and early oral diet recovery and postoperative early ambulation, postoperative enhanced blood glucose control. The mortality rate, reoperation rate, average hospitalization duration, treatment cost, pancreatic fistula, delayed gastric emptying, and other complications were observed and compared between the two groups. Results The average age, gender, primary disease composition, and the proportion of preoperative jaundice or diabetes mellitus had no obvious difference between the two groups （P〉0.05）. In the traditional group, 2 patients died, 1 patient was reoperated and 1 patient was admitted to hospital within 1 weeks. Patients in the ERAS group had no death, reoperation, and readmission. In the traditional group, there were 12 cases of pancreatic fistula, and only 2 cases was found in ERAS group （30.8% vs 13.3%, P=0.191）. In the traditional group, there were 2 cases of B grade pancreatic fistula, 3 cases of C grade , and 7 cases of grade A. While in ERAS group, pancreatic fistula cases were all grade A. The incidence of delayed gastric emptying in the traditional group was significantly higher than that in the ERAS group （35.9% vs 6.7%, P=0.031）. There was no significant difference between two groups in the incidence of other complications, such as abdominal bleeding, ascites （P〉0.05）. But the postopera- tive gastrointestinal fimction recovery time,the average hospital stay （21 d V5 17 4 X）.046） and hospital costs （97 130 yuan vs 80 963 yuan, P=0.047） in ERAS group were significantly less than those in the traditional group. Conclusion It＇s safe for ERAS in duodenopancreatectomy according to its surgery characteristics. ERAS can effectively reduce postoperative pancreatic fistula, the incidence of delayed gastric emptying, and can reduce the postoperative hospitalization time, cost of hospitalization, which is favorable for the faster and better rehabilitation of patients.