加速康复外科联合腹腔镜胆总管探查术治疗胆总管结石的前瞻性研究
Enhanced recovery after surgery combined with laparoscopic common bile duct exploration in the treatment of choledocholithiasis: a prospective study
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摘要: 目的:探讨加速康复外科(ERAS)联合腹腔镜胆总管探查术(LCBDE)在胆总管结石患者治疗中的临床疗效。
方法:选取2011年1月至2013年12月皖南医学院附属弋矶山医院收治的84例胆总管结石患者进行前瞻性研究。采用随机、单盲对照法，通过随机数字表法将入组患者分为对照组和加速康复组。两组均行LCBDE，对照组患者围术期采用传统处理方案；加速康复组患者围术期采用ERAS处理方案。采用门诊随访，了解患者术后临床表现、肝功能和是否有结石残留，随访时间截至术后6个月。比较两组患者手术时间、术中出血量、术后并发症、肠功能恢复时间、住院时间、住院总费用和随访情况等指标。正态分布的计量资料以±s表示，两两比较采用独立样本t检验，计数资料比较采用χ2检验。
结果:筛选出符合研究条件的患者75例，对照组35例，加速康复组40例。两组患者手术均顺利完成。对照组和加速康复组患者手术时间和术中出血量分别为(185±46)min、(124±28)mL和(178±37)min、(114±32)mL，两组比较，差异无统计学意义(t=0.729，1.431，P>0.05)。对照组患者分别有12、14、10例发生术后切口疼痛、呕吐和各类感染，加速康复组分别有5、6、4例，两组比较，差异有统计学意义(χ2=5.054，5.966，4.241，P<0.05)。对照组和加速康复组患者术后第1天WBC、ALT、DBil分别为(11.4±3.5)×109/L、(128±33)U/L、(38±14)μmol/L和(10.6±3.0)×109/L、(135±35)U/L、(44±16)μmol/L，第4天分别为(7.8±2.9)×109/L、(48±14)U/L、(21±8)μmol/L和(6.9±2.1)×109/L、(43±13)U/L、(20±7)μmol/L，两组比较，差异无统计学意义(t=1.018，-0.872，-1.767，1.553，1.836，1.044，P>0.05)。对照组和加速康复组患者肛门排气时间、开始进食时间、术后输液时间、住院时间分别为(42±13)h、(45±14)h、(6.8±2.3)d、(11.3±4.5)d和(35±11)h、(19±7)h、( 4.2±1.8)d、(9.6±2.4)d，两组比较，差异有统计学意义(t=2.741，10.524，5.485，2.077，P <0.05)。对照组和加速康复组患者住院总费用分别为(18 729±3 127)元和(16 981±2 756)元，两组比较，差异有统计学意义(t=2.574，P<0.05)。术后1个月，所有患者肝功能恢复正常，T管胆道造影检查发现两组患者各有4例结石残留，经胆道镜取石痊愈；至随访结束，所有患者未再次出现腹痛、黄疸和发热等胆道并发症。
结论:ERAS联合LCBDE治疗胆总管结石安全，具有并发症发生率低、术后恢复快、住院时间短、总费用少等优点。Abstract:Objective:To investigate the application value of perioperative enhanced recovery after surgery (ERAS) combined with laparoscopic common bile duct exploration (LCBDE) in the treatment of choledocholithiasis.
Methods The clinical data of 84 patients with choledocholithiasis who were admitted to the Yijishan Hospital from January 2011 to December 2013 were prospectively analyzed. A singleblind, randomized, controlled study was performed in the 75 patients who were allocated into the control group and the enhanced recovery after surgery group (ERAS group) based on a random number table. All the patients underwent LCBDE, the patients in the control group received conventional perioperative management and the patients in the ERAS group received perioperative management according to enhanced recovery rehabilitation program. All the patients were followed up by outpatient interview till postoperative month 6. The clinical features, liver function and residual stones in the patients were observed. The operation time, postoperative complications, postoperative intestinal function recovery, duration of hospital stay and hospital expenses in the two groups were compared. Measurement data with normal distribution were presented as ±s. Comparison between groups were evaluated with an independant sample t test. Count data were analyzed using the chisquare test.
Results:All the 75 eligible patients undergoing successful operation were randomly divided into the control group (35 patients) and the ERAS group (40 patients). The operation time and volume of intraoperative blood loss in the control group and the ERAS group were (185±46)minutes and (124±28)mL, (178±37)minutes and (114±32)mL, respectively, with no significant difference (t=0.729, 1.431, P>0.05). There were 12, 14 and 10 patients in the control group and 5, 6 and 4 patients in the ERAS group with postoperative incision pain, vomit and infection, showing a significant difference (χ2=5.054, 5.966, 4.241, P<0.05). The level of white blood cell, alanine aminotrausferase and direct bilirubin in the control group and in the ERAS group were (11.4±3.5)×109/L, (128±33)U/L, (38±14)μmol/L and (10.6±3.0)×109/L, (135±35)U/L, (44±16)μmol/L at postoperative day 1, compared with (7.8±2.9)×109/L, (48±14)U/L, (21±8)μmol/L and (6.9±2.1)×109/L, (43±13)U/L, (20±7)μmol/L in the 2 groups at postoperative day 4, respectively, showing no significant difference between the 2 groups (t=1.018,-0.872,-1.767, 1.553, 1.836, 1.044, P>0.05). The postoperative first flatus day, time of food intake, time of postoperative infusion and duration of hospital stay were (42±13)hours, (45±14)hours, (6.8±2.3)days and (11.3±4.5)days in the control group, and (35±11)hours, (19±7)hours, (4.2±1.8)days and (9.6±2.4)days in the ERAS group, with a significant difference between the 2 groups (t=2.741, 10.524, 5.485, 2.077, P<0.05). The total hospital expenses was (18 729±3 127)yuan in the control group, which was significantly greater than (16 981±2 756)yuan in the ERAS group (t=2.574, P<0.05). The liver function of all the patients was recovered at the postoperative month 1. Four patients with residual stones in the 2 groups were detected by Ttube cholangiography, and were cured by removal of gallstones by choledochoscopy. There were no complications of the abdominal pain, jaundice and fever in all the patients till the end of followup.
Conclusion:ERAS combined with LCBDE for the treatment of choledocholithiasis is safe and feasible, with the advantages of low morbidity, quick recovery, short duration of hospital stay and less hospital expenses. -
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