Application of enhanced recovery after surgery in laparoscopic partial nephrectomy
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摘要:目的 探讨加速康复外科（ERAS）理念应用于腹腔镜肾部分切除术患者围术期管理的安全性和有效性。方法 将105例腹腔镜肾部分切除术患者分为ERAS组（n=55）和对照组（n=50）。对照组采用常规传统围术期方案，ERAS组采用ERAS方案。比较2组患者术后恢复情况、应激指标、并发症发生情况以及术后1个月随访的非预期再住院情况。结果 ERAS组术后首次饮水时间、首次通气时间、首次下床活动时间、引流管留置时间、尿管留置时间及术后住院时间均短于对照组，差异有统计学意义（P < 0.05）。ERAS组术后24 h疼痛评分低于对照组，差异有统计学意义（P < 0.05）。ERAS组术后第3天血清白细胞计数（WBC）以及术后第3、5天C反应蛋白（CRP）水平低于对照组，差异有统计学意义（P < 0.05）。2组患者术后并发症发生率比较，差异无统计学意义（P>0.05）。结论 ERAS用于腹腔镜肾部分切除术患者围术期管理安全性较好，同时可减轻术后应激反应，促进早期康复。Abstract:Objective To explore the safety and effectiveness of the concept of enhanced recovery after surgery (ERAS) applied to the perioperative management of patients undergoing laparoscopic partial nephrectomy.Methods A total of 105 patients with laparoscopic partial nephrectomy were divided into ERAS group (n=55) and control group (n=50). The conventional perioperative protocol was used in the control group, and the ERAS protocol was used in the ERAS group. The postoperative recovery, stress indexes and incidence of complications were compared between the two groups, and the unexpected readmission rate at one month after surgery was compared during follow-up.Results After operation, the first time of drinking water, first time of ventilation, first time of getting out of bed, indwelling time of drainage tube, indwelling time of urinary tube and postoperative hospitalization time in the ERAS group were significantly shorter than those in control group (P < 0.05). The 24 hours postoperative pain score of the ERAS group was significantly lower than that of the control group (P < 0.05). Serum white blood cell count (WBC) at the 3rd day after surgery and C-reactive protein (CRP) levels at the 3rd and 5th day after surgery of the ERAS group were significantly lower than those of the control group (P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P>0.05).Conclusion ERAS is safe for perioperative management of patients undergoing laparoscopic partial nephrectomy. At the same time, it can relieve postoperative stress reaction and promote early postoperative recovery.
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表 1 ERAS组与对照组围术期管理措施的主要区别
管理措施 ERAS组(n=55) 对照组(n=50) 术前宣教 充分告知患者及家属ERAS方案的目的和主要项目 传统健康教育 饮食 术前禁食6 h, 禁水2 h, 术前2~3 h口服500 mL
葡萄糖氯化钠溶液术前禁食12 h, 禁水10 h 肠道准备 不行肠道准备 行肠道准备，术前1 d服用
复方聚乙二醇电解质散术前预防性镇痛 术前8 h, 口服布洛芬1片 无 麻醉 全身麻醉联合硬膜外麻醉 单纯全身麻醉 生物胶 用于肾脏创面 常规不用 体温 监测患者鼻腔体温，采用输液保温器、
机器保温毯控制体温在36.5~37.5 ℃常规保温措施 补液 目标导向性补液，控制补液，防止补液过多 无特殊要求 切口 切口皮下注射0.75%罗哌卡因20 mL 无特殊处理 术后镇痛 术后6 h口服布洛芬1片，必要时加用氟比洛芬酯注射液，
减少使用阿片类药物常规止痛 术后恶心、呕吐 预防性应用止吐药 常规对症处理 术后预防血栓 肢体气压治疗 无 术后肺功能 术后雾化吸入 常规对症处理 术后下床活动 一般术后第1天床上活动，第2天床边站立，
第3天下床活动术后5 d左右 饮食 鼓励患者术后2~4 h少量饮水，若无恶心不适，可少量进食流质，
根据患者胃肠耐受量增加进食次数和进食量待肠道通气后进水、进食 尿管 一般术后第1天予以拔除 常规术后第3天予以拔除 引流管 每日引流液较少时予以拔除 无明显引流液时予以拔除 
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表 2 2组患者术前、术中一般资料比较(x±s)
一般资料 ERAS组(n=55) 对照组(n=50) t/χ2 P 年龄/岁 53.55±12.44 55.92±13.15 0.949 0.345 性别 男 35 31 0.030 0.862 女 20 19 体质量指数/(kg/m2) 20.51±1.67 21.02±1.55 1.617 0.109 肿瘤侧别/例 左 32 28 0.051 0.821 右 23 22 肿瘤直径/cm 2.98±1.55 3.15±1.63 0.548 0.585 肿瘤分期/例 T1a 43 39 0.001 0.982 T1b 12 11 术前白细胞计数/(×109/L) 5.56±0.76 5.34±0.86 1.392 0.167 术前C反应蛋白/(mg/L) 13.45±23.51 11.56±23.96 0.408 0.684 术前红细胞沉降率/(mm/h) 21.50±30.56 25.80±31.33 0.712 0.478 手术入路/例 经腹 15 14 0.007 0.934 经腰 40 36 术中出血量/mL 36.67±12.25 38.89±26.31 0.562 0.575 术中补液量/mL 410.28±151.58 461.57±183.66 1.566 0.120 手术时间/min 99.67±37.38 110.78±44.08 1.413 0.161
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表 3 2组患者术后临床指标比较(x±s)
术后恢复指标 ERAS组(n=55) 对照组(n=50) 首次饮水时间/h 2.56±0.65* 29.85±8.31 首次通气时间/h 24.62±2.58* 30.84±3.55 术后首次下床时间/d 3.56±1.15* 4.13±1.02 引流管留置时间/d 2.67±0.93* 4.68±1.15 尿管留置时间/d 1.62±0.84* 3.55±1.12 手术并发症/例 麻醉误吸 0 0 严重出血 3 2 褥疮 0 0 肺部感染 2 3 尿潴留 2 3 术后住院时间/d 5.15±0.87* 6.04±1.28 术后满意度评分/分 8.65±1.55 8.06±1.53 术后1个月再入院/例 0 0 与对照组比较, *P < 0.05
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表 4 2组患者术后疼痛评分及应激指标比较
指标 ERAS组(n=55) 对照组(n=50) 术后24 h疼痛评分/分 2.36±1.93* 3.53±2.23 术后WBC/(×109/L) 术后1 d 9.31±2.68 9.43±2.87 术后3 d 7.46±2.13* 8.55±2.56 术后5 d 5.23±1.28 5.54±1.56 术后CRP/(mg/L) 术后1 d 31.67±24.87 34.20±26.85 术后3 d 84.56±54.76* 110.65±68.51 术后5 d 20.23±16.58* 28.54±17.55 术后ESR/(mm/h) 术后1 d 17.78±18.54 17.35±19.23 术后3 d 46.60±18.03 50.45±17.82 术后5 d 45.55±20.26 44.68±21.58 WBC: 白细胞计数; CRP: C反应蛋白; ESR: 红细胞沉降率。
与对照组比较, *P < 0.05。
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