我国胃肠道肿瘤围手术期加速康复外科路径管理的思考与建议

Thinking and suggestions on pathway management of perioperative enhanced recovery after surgery in gastrointestinal tumors in China

加速康复外科(ERAS)是一种多模式围手术期管理路径,通过多学科团队合作,旨在缩短住院时间、降低医疗并发症和再入院的风险,改善患者近期和长期临床结局,同时将手术应激反应降到最低水平。尽管取得了巨大成功,由于胃肠道肿瘤患者特殊的病理生理学和围手术期处理特点,针对此类患者ERAS方案仍需要进一步优化,提高条款执行率和依从性。患者宣教、术前预康复、多模式镇痛、精准外科、下床活动以及手术后早期饮食与口服营养补充等措施应视为核心条款。在ERAS的应用过程中,要充分理解围手术期器官功能及病理生理学改变,严格执行循证医学为基础的围手术期ERAS路径及方案;另外,需多学科团队的密切配合,提高患者ERAS的依从性和执行率,强调患者院前、术前、术中、术后及院后全程、动态、无缝隙管理,鼓励患者及家属参与整个医疗活动。除此之外,需关注特殊时期、特殊人群ERAS方案的调整。目前我国已经有多个胃肠道肿瘤手术相关ERAS管理共识和指南发布,但缺乏我国学者牵头进行的高质量临床研究文献支持,亟待根据胃肠道肿瘤代谢和围手术期管理的特点,以问题为导向,按照国际规范开展大规模随机对照试验来形成高级别循证医学证据以指导临床实践。

Enhanced recovery after surgery(ERAS)is a multimodal perioperative care program to decrease the risk of delayed hospitalization,medical complications,readmission and to improve patient short-and long-term outcomes with minimized level of surgical stress responses through multidisciplinary cooperation.Despite its huge success,the program has challenges for further optimization with a primary focus on modification according to the specific pathophysiology and perioperative management characteristics of patients with gastrointestinal tumors to improve the compliance and implementation rate of items.Patient education,prehabilitation,multimodal analgesia,precision surgery,early mobilization,early oral feeding and oral nutrition supplement(ONS)should be regarded as core terms suitable for all the patients.During the application of ERAS pathway management,it is necessary to fully understand the perioperative changes of organ function and pathophysiology,and to strictly implement the ERAS program and items based on evidence-based medicine.Moreover,the close collaboration of multidisciplinary teams is needed to improve the compliance and increase the adherence rate of ERAS protocol for patients,which emphasizes the dynamic,gap-free and whole course management that covers pre-hospital,pre-operative,intra-operative,post-operative and post-hospital periods.Concurrently,we encourage our patients and their families to participate in the whole healthcare activities.Even more concerning,it is indispensable to adjust ERAS program for special time and special patients.At present,several consensus and guidelines on the ERAS management of gastrointestinal tumor surgery have come out for clinical practice in China,which,however,still lacks a high-level evidence from more high-quality clinical trials conducted by Chinese researchers.It is urgent to carry out a series of large-scale randomized controlled studies in accordance with international standards to obtain high-level evidence-based medical evidence for clinical practice,which is problem-oriented and integrated with features of metabolism and perioperative management of gastrointestinal tumor surgery.