加速康复外科理念在腹腔镜肝切除术中的应用

Clinical effect and safety of enhanced recovery after surgery in laparoscopic hepatectomy

目的初步探讨加速康复外科(ERAS)应用于腹腔镜肝切除中的安全性及效果。方法选取2014年1月-2016年12月在南京大学医学院附属鼓楼医院肝胆外科接受腹腔镜肝切除的患者55例,随机分为ERAS组(27例)和围手术期常规处理组,即对照组(28例),比较2组患者术后肝功能恢复情况、CRP、术后并发症发生率、术后康复情况、术后康复体力评分及生活状况。计量资料2组间比较采用独立样本t检验,2组间指标变化趋势的比较采用重复测量方差分析,计数资料组间比较采用χ~2检验。结果2组患者术前术中各方面指标差异无统计学意义(P值均>0.05)。与对照组相比,ERAS组除术后第5天AST、CRP水平显著低于对照组,差异均有统计学意义(t值分别为2.168、2.291,P值均<0.05),其余肝功能指标差异均无统计学意义(P值均>0.05)。ERAS组术后非手术部位并发症发生率显著低于对照组,差异有统计学意义(χ~2=4.150,P<0.05),并发症总发生率、手术部位并发症发生率以及Clavien-Dindo并发症分级差异无统计学意义(P值均>0.05)。术后康复评分中综合评分、疼痛评分、活动评分ERAS组均显著优于对照组,差异均有统计学意义(t值分别为1.297、2.777、3.009,P值均<0.05),且排气时间、排便时间和术后住院时间均明显短于对照组,差异均有统计学意义(t值分别为6.291、2.577、4.229,P值均<0.05)。结论 ERAS应用于腹腔镜肝切除可减少手术应激,降低非手术部位并发症发生,加速患者术后康复。

Objective To investigate the clinical effect and safety of enhanced recovery after surgery（ ERAS） in laparoscopic hepatectomy.Methods A total of 55 patients who underwent laparoscopic hepatectomy in Department of Hepatobiliary Surgery,Affiliated Drum Tower Hospital of Nanjing University Medical School,from January 2014 to December 2016 were enrolled and randomly divided into ERAS group with 27 patients and control group with 28 patients（ conventional perioperative treatment）. The two groups were compared in terms of recovery of liver function after surgery,C-reactive protein（ CRP）,incidence of postoperative complications,postoperative recovery,postoperative physical recovery score,and quality of life. The independent samples t-test was used for comparison of continuous data between groups,an analysis of variance with repeated measures was used for comparison of change trends of indices between the two groups,and the chi-square test was used for comparison of categorical data between groups. Results There were no significant differences in related indices before and during surgery between the two groups（ all P 0. 05）. Compared with the control group,the ERAS group had significantly lower aspartate aminotransferase and CRP on day 5 after surgery（ t = 2. 168 and 2. 291,both P 0. 05）,and there were no significant differences in other liver function parameters between the two groups（ all P 0. 05）. The ERAS group had significantly lower incidence rates of postoperative non-surgical site complications than the control group（ χ~2= 4. 15,P 0. 05）,and there were no significant differences in the overall incidence of complications,incidence rates of surgical site complications,and the Clavien-Dindo classification of complications between the two groups（ all P 0. 05）. As for postoperative recovery scores,the ERAS group had significantly better comprehensive score,pain score,and activity score than the control group（ t = 1. 297,2. 777,and 3. 009,all P 0. 05）. Compared with the control group,the ERAS group had significantly shorter time to first flatus,time to first defecation,and length of postoperative hospital stay（ t =6. 291,2. 577,and 4. 229,all P 0. 05）. Conclusion When applied in patients undergoing laparoscopic hepatectomy,ERAS can reduce surgical stress and incidence of non-surgical site complications and accelerate postoperative recovery.