加速康复外科策略对妇科恶性肿瘤手术患者术后早期恢复的影响

Impact of enhanced recovery after surgery strategy on early postoperative quality of recovery in patients undergoing laparoscopic surgery for gynecologic malignancy

目的探讨应用加速康复外科(ERAS)策略优化围手术期麻醉管理对妇科恶性肿瘤腹腔镜手术患者术后早期恢复的影响。方法选择2018年4月至2019年4月在北京朝阳医院行妇科恶性肿瘤腹腔镜手术患者90例,年龄18~65岁,美国麻醉医师协会(ASA)分级Ⅰ~Ⅱ级。采用随机数字表法分为加速组和常规组(n=45)。加速组采取全身麻醉复合腹横肌平面阻滞及多项优化措施进行围手术期麻醉管理。常规组采用常规围手术期管理方案。分别于术前1 d、术后24 h和术后48 h采用40项恢复质量评分量表(QoR-40)综合评价患者术后恢复情况。检测术前和术后24、72 h血清C反应蛋白(CRP)浓度。记录术后恶心呕吐和寒战发生情况,比较2组患者术后首次排气时间、下地时间、恢复普食时间、术后住院日及并发症发生率等。结果加速组术后24、48 h时QoR-40量表评分[M(Q1,Q3)]为175(171,179)分与185(183,189)分,均高于常规组的162(160,167)分与180(179,183)分(均P<0.01)。2组患者术后24、72 h CRP均较术前升高,加速组术后24、72 h CRP分别为(13.4±6.3)、(6.7±2.5)mg/L,常规组分别为(39.8±18.0)、(16.6±8.6)mg/L,常规组升高幅度高于加速组(均P<0.01)。加速组术后恶心严重程度评分为0(0,2)分,低于常规组的3(0,5)分(P<0.01);术后24 h内加速组呕吐、寒战发生率分别为8.9%(4/45)、11.1%(5/45),均明显低于常规组的26.7%(12/45)、31.1%(14/45),差异均有统计学意义(均P<0.05)。加速组和常规组术后首次排气时间分别为(14±6)、(25±10)h,下地时间分别为6(6,13)、21(19,27)h,恢复普食时间为1(1,2)、3(2,3)d,差异均有统计学意义(均P<0.01)。加速组术后住院时间为7(5,11)d,较常规组的10(7,14)d明显缩短(P<0.01)。加速组和常规组总并发症发生率分别为17.8%(8/45)、37.8%(17/45),差异有统计学意义(P<0.05)。结论应用ERAS策略对妇科恶性肿瘤腹腔镜手术患者围手术期麻醉管理进行优化,可减轻患者不适,降低手术应激,改善术后早期恢复质量。

Objective To investigate the impact of perioperative anesthesia management with enhanced recovery after surgery(ERAS)strategy on postoperative recovery in patients undergoing laparoscopic surgery for gynecologic malignancy.Methods Ninety patients undergoing laparoscopic surgery for gynecologic malignancies from April 2018 to April 2019,aged 18-65 years,with American Society of Anesthesiologists(ASA)physical statusⅠorⅡ,were recruited and randomly divided into two groups(n=45)using a random number table:ERAS group(group E)and control group(group C).Patients in group E received general anesthesia combined with transverses abdominis plane block and a series of interventions to optimize anesthetic and perioperative management,while patients in group C were treated with routine anesthesia management.Quality of Recovery-40 questionnaire(QoR-40)was administered to assess the early postoperative quality of recovery on 1 day before surgery,and at 24 and 48h after surgery.C-reactive protein(CRP)before and after the operation were evaluated.The incidence of nausea,vomiting and shivering,the time of first exhaust,ambulation,resumption of normal diet,postoperative hospital stay and complications were recorded.Results The scores of QoR-40[M(Q1,Q3)]in Group E were 175(171,179)and 185(183,189)at 24 h and 48 h after operation,which were higher than those in group C[162(160,167)and 180(179,183)](both P<0.01).The levels of CRP in both group E and group C increased at 24 h and 72 h after operation.Moreover,the extent of increasing level of CRP in group C was much higher than that in group E[(39.8±18.0)mg/L vs(13.4±6.3)mg/L,(16.6±8.6)mg/L vs(6.7±2.5)mg/L]at 24 h and 48 h after operation(both P<0.01).Compared with group C,the numerical rating scale(NRS)for nausea decreased significantly in group E[0(0,2)vs 3(0,5),P<0.01].Meanwhile,the incidence of vomiting and shivering in group E was lower than that in group C[8.9%(4/45)vs 26.7%(12/45);11.1%(5/45)vs 31.1%(14/45);both P<0.05].The time of first exhaust,ambulation and resumption of normal diet in group E was(14±6)h,6(6,13)h and 1(1,2)d,respectively,which was markedly shorter than that in group C[(25±10)h,21(19,27)h and 3(2,3)d](all P<0.01).Overall,the postoperative length of hospital stay reduced significantly for patients who followed the ERAS protocol[7(5,11)d vs 10(7,14)d,P<0.01].The incidence of postoperative complications was 17.8%(8/45)and 37.8%(17/45)in group E and group C,respectively,with a significant difference(P<0.05).Conclusion Implementation of ERAS anesthesia management in gynecologic oncology patients undergoing minimally invasive surgery alleviates perioperative discomfort,decreases surgical stress response,and improves the early postoperative quality of recovery.