肝胆胰外科术后加速康复实施单中心经验
Application of enhanced recovery after hepatopancreatobiliary surgery: a singlecenter experience
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摘要:
目的:探讨肝胆胰外科手术加速康复外科(ERAS)实施的临床价值和影响ERAS实施失败的相关因素。
方法:采用回顾性队列研究方法。收集2013年8月至2015年1月浙江大学医学院附属第二医院433例行中大型手术(肝脏或胰腺切除)患者的临床资料，其中2014年5月至2015年1月收治的216例采用ERAS围术期处理方案患者设为ERAS组，2013年8月至2014年4月收治的217例采用传统围术期处理方案患者设为传统组。收集患者下列指标进行分析：(1)一般资料：患者性别、年龄、美国麻醉医师协会(ASA)分级、伴发疾病、肝硬化史、原发病、BMI、吸烟史、饮酒史、TBil、ALT、Alb。(2)术中情况：手术类型(肝脏手术、胰腺手术、肝脏手术胆道重建情况、肝脏切除范围、胰腺手术方式)、腹腔镜手术、手术时间、术中出血量和术中输血情况。(3)术后疗效：并发症等级、非计划再手术患者例数、非计划再入院患者例数、术后ICU时间>24 h患者例数、术后住院时间、0～Ⅱ级并发症患者术后住院时间、Ⅲ～Ⅳ级并发症患者术后住院时间。正态分布的计量资料以
±s表示，采用Student′s t检验，偏态分布的计量资料以 M(范围)表示，采用MannWhitney检验，计数资料采用χ2检验或Fisher确切概率法检验。单因素分析采用〖HT2.〗〖HT5”SS〗χ2检验。多因素分析采用Logistic回归模型。
结果:(1)术中情况：ERAS组患者手术类型(小范围肝切除联合胆道重建、小范围肝切除无胆道重建、大范围肝切除联合胆道重建、大范围肝切除无胆道重建、胰十二指肠切除术、其他胰腺手术)、腹腔镜手术、手术时间、术中出血量和术中输血情况分别为29例、64例、 31例、26例、43例、23例、23例、(275±122)min、(308±254)mL、42例，传统组上述指标分别为27例、 67例、 34例、20例、47例、22例、20例、(281±124)min、(356±288)mL、45例，两组比较，差异无统计学意义(χ2=1.259，0.248，t=0.509，1.788，-χ2=0.113，P>0.05)。(2)术后疗效：ERAS组患者非计划再手术患者例数、非计划再入院患者例数、术后ICU时间>24 h患者例数、Ⅲ～Ⅳ级并发症患者术后住院时间分别为3例、11例、5例、(18±10)d，传统组患者上述指标分别为1例、6例、11例、(22±16)d，两组比较，差异无统计学意义(t=-1.279，P>0.05)；而ERAS组患者的Ⅰ～Ⅴ级并发症患者例数、术后住院时间、0～ Ⅱ级并发症患者术后住院时间分别为111例、(11±8)d、(9±6)d，传统组患者上述指标分别为136例、(13±10)d、(10±5)d，两组比较，差异有统计学意义(U=20 771.000，t=-2.547，-2.631，P<0.05)。(3)ERAS依从性：肝脏手术和胰腺手术患者预防性镇吐、早期胃管拔除、早期进食流质食物、早期进食固体食物、低分子肝素抗凝分别为48.7%和63.6%、77.3%和57.6%、76.7%和60.6%、72.7%和50.0%、36.7%和 51.5%，两者依从性比较，差异有统计学意义(χ2=4.126，8.743，5.834，10.455，4.171， P<0.05)。(4)单因素分析结果：ASA分级、手术类型、Alb是影响ERAS方案失败的危险因素(χ2=13.383，4.365，5.953，P< 0.05)。其中肝脏手术患者中，肝脏切除范围是影响ERAS方案失败的危险因素(χ2=14.104，P< 0.05)。(5)多因素分析结果：ASA Ⅲ、Ⅳ级和胰腺手术是ERAS方案失败的独立危险因素(RR=4.621，2.586，95%可信区间：1.709～12.490，1.010～6.615，P<0.05)。
结论:肝胆胰外科中大型手术［肝脏和(或)胰腺切除术］实施ERAS安全可行。它可以缩短术后住院时间，减少术后并发症的发生。肝胆胰手术中，ASA Ⅲ、Ⅳ级或胰腺手术的患者实施ERAS方案容易失败。Abstract:Objective:To investigate the clinical effect of enhanced recovery after surgery (ERAS) after hepatopancreatobiliary surgery and related factors associated with failure of the program.
Methods:The retrospective cohort study was adopted. The clinical data of 433 patients who underwent middlelarge surgery (hepatectomy or pancreatectomy) at the Second Affiliated Hospital of Zhejiang University School of Medicine between August 2013 to January 2015 were collected. Of the 433 patients, 216 patients managed with ERAS program in the middlelarge hepatic or pancreatic surgery between May 2014 and January 2015 were allocated to the ERAS group, 217 patients managed with traditional perioperative treatment between August 2013 and April 2014 were allocated to the traditional group. The following indexes of patients were collected and analyzed: (1) General information: gender, age, classification according to American Society of Anesthesiologists (ASA), concomitant disease, history of liver cirrhosis, primary disease, body mass index, smoking history, alcohol drinking history, total bilirubin (TBil), alanine aminotransferase (ALT), albumin (Alb). (2) Intraoperative status: surgical type (hepatic surgery, pancreatic surgery, biliary reconstruction in hepatic surgery, hepatic excision extension, method of pancreatic surgery), laparoscopic surgery, operation time, volume of intraoperative blood loss and intraoperative blood transfusion. (3) Postoperative efficacy: stage of complication, number of unplaned reoperation and readmission, number of patients with ICU care time>24 hours, durations of postoperative hospital stay, duration of postoperative hospital stay of patients with grade 0-Ⅱ complications and with grade Ⅲ-Ⅳ complication. Measurement data with normal distribution were presented as
±s and analyzed using the Student′s t test. Measurement data with skewed distribution were presented as M(range) and analyzed using the MannWhitney test. Count data were analyzed using the chisquare test and Fisher exact probability. Univariate analysis was done by the chisquare test and multivariate analysis was done by the logistic regression model.
Results:(1) Intraoperative status: the cases of smallscale hepatic excision with biliary reconstruction, smallscale hepatic excision without biliary reconstruction, largescale hepatic excision with biliary reconstruction, largescale hepatic excision without biliary reconstruction, pancreaticoduodenectomy, other pancreatic surgery, laparoscpic surgery, operation time, volume of intraoperative blood loss and number of patients receiving blood transfusion were 29, 64, 31,26, 43, 23, 23, (275±122)minutes, (308±254)mL and 42 in the ERAS group, and 27, 67, 34, 20, 47, 22, 20, (281±124)minutes, (356±288)mL and 45 in the traditional group, showing no significant difference between the 2 groups (χ2=1.259, 0.248, t=0.509, 1.788, χ2=0.113, P>0.05). (2) Postoperative efficacy: the numbers of unplaned reoperation and readmission, number of patients with ICU care time>24 hours, duration of postoperative hospital stay of patients with grade Ⅲ-Ⅳ complication were 3, 11, 5, (18±10)days in the ERAS group, and 1, 6, 11, (22±16)days in the traditional group, showing no difference between the 2 groups (t=-1.279, P>0.05). The number of patients with stage Ⅰ-Ⅴ complication, duration of postoperative hospital stay, duration of postoperative hospital stay of patients with grade 0-Ⅱ complication were 111, (11±8)days and (9±6)days in the ERAS group, and 136, (13±10)days and (10±5)days in the traditional group, showing significant differences between the 2 groups (U=20 771.000, t=-2.547,-2.631, P<0.05). (3) Compliance of ERAS: the compliances of ERAS in preventative antivomiting, early removal of gastric tube, early liquid diet intake, early solid food intake, heparin anticoagulant therapy were 48.7%, 77.3%, 76.7%, 72.7%, 36.7% in patients receiving hepatic surgery, and 63.6%, 57.6%, 60.6%, 50.0%, 51.5% in patients receiving pancreatic surgery, showing significant differences between the 2 groups (χ2= 4.126, 8.743, 5.834, 10.455, 4.171, P<0.05). (4) Univariate analysis showed that ASA classification, operation type and Alb were risk factors associated with failure of ERAS program(χ2=13.383, 4.365, 5.953, P<0.05). Extension of hepatic excision in patients receiving hepatic surgery was a risk factor associated with failure of ERAS program in liver surgery (χ2=14.104, P<0.05). (5) Multivariate analysis showed that grade Ⅲ and Ⅳ of ASA and pancreatic surgery were independent risk factors associated with failure of ERAS program (RR=4.621, 2.586, 95% confidence interval: 1.709-12.490, 1.010-6.615, P<0.05).
Conclusions: ERAS program is safe and feasible after middlelarge hepatopancreatobiliary surgery (hepatectomy and-/or pancreatectomy, and can reduce duration of postoperative hospital stay and complications. ERAS program is prone to failure in patients with grade Ⅲ and Ⅳ of ASA or undergoing pancreatic surgery after hepatopancreatobiliary surgery. -
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