王征征,周進學,李慶軍,展翔宇,陳勛,韓風
(鄭州大學附屬腫瘤醫(yī)院 肝膽胰腺外科,河南 鄭州 450008)
胰十二指腸切除術(pancreaticoduodenectomy,PD)經(jīng)近百年的發(fā)展和改進,其圍手術期病死率已顯著下降,術后住院時間長、并發(fā)癥發(fā)生率高仍困擾臨床一線外科醫(yī)生[1-3]。加速康復外科(enhanced recovery after surgery,ERAS)理念在多種外科領域的臨床應用結果顯示,ERAS能降低術后并發(fā)癥發(fā)病率,縮短住院時間[4-8]。臨床研究[9-11]表明,ERAS應用于PD安全可行,能減少住院時間。本組已成功將ERAS理念應用于PD圍手術期,其臨床效果報告如下。
回顧性分析2015年6月—2016年12月鄭州大學附屬腫瘤醫(yī)院42例行根治性PD術患者的臨床資料,其中男19例,女23例;平均年齡(53±11)歲;BMI≥28 2例;糖尿病2例,高血壓3例;所有患者術前增強CT或MRI檢查提示胰頭占位,腫瘤可根治性切除,術后病理結果確診為胰頭癌;所有患者實施ERAS圍手術期管理理念,合并糖尿病與高血壓患者,術前血糖與血壓控制在正?;蛘8咧邓?,記錄患者ERAS具體措施依從情況、術后出血、膽汁漏、胰瘺、感染等并發(fā)癥、住院時間及再入院情況等。
⑴ 術前:ERAS宣教、術前減黃、非機械性腸道準備、留置胃管、預防性使用抗生素;⑵ 術中:全程保溫、目標導向性輸液、精準切除、常規(guī)放置引流管;⑶ 術后:多模式鎮(zhèn)痛、預防惡心嘔吐、早期拔除胃管與尿管、早期進食、早期下床活動、及早拔除腹腔引流管(表1)。
所有患者取仰臥位,靜脈+吸入全身麻醉,腹部正中切口,以減輕對腹部肌肉的切割損傷,行不保留幽門的Whipple術,常規(guī)切除膽囊并徹底清掃淋巴結,13組及16a2、16b1組淋巴結常規(guī)清掃,Child+Braun吻合方式重建消化道。胰腸吻合采用3-0 Prolene線雙層連續(xù)縫合,游離左側胰腺殘端約2 cm,找出主胰管并置入引流管,3-0 Prolene線縫合胰管周圍組織固定引流管,距胰腺斷端1.0 cm處連續(xù)縫合胰腺后壁與空腸近系膜漿肌層,后壁吻合后收緊縫線不打結;切開空腸,3-0 Prolene線連續(xù)縫合胰腺殘端后壁與空腸全層,后壁縫合完成后收線不打結;將胰管引流管置入空腸,內側縫線繼續(xù)縫合胰腺殘端前壁和空腸全層,完成內層吻合;外層縫線連續(xù)縫合胰腺前壁與空腸漿肌層,完成第二層胰腸吻合,縫合完畢后收線打結。膽腸吻合應用可吸收縫線,后壁連續(xù)、前壁間斷縫合,術后常規(guī)放置2根引流管,分別位于膽腸吻合口與胰腸吻合口下方。
參照ISGPF及ISGPS界定標準[12-13]。⑴ 胰瘺:PD術后超過3 d,腹腔引流液淀粉酶含量超過正常血清值3倍(術后第1、3、5天留取引流液送檢);將胰瘺分為A、B、C 3級,A級僅有腹腔引流液淀粉酶升高,無特殊癥狀且無需臨床干預;B級腹腔引流液淀粉酶升高,伴有臨床癥狀并出現(xiàn)器官損傷征象;C級出現(xiàn)嚴重敗血癥和器官功能障礙,危及患者生命;B或C級常需臨床干預。⑵ 死亡:圍手術期或出院30 d內因手術或術后并發(fā)癥導致的死亡。⑶ 胃排空延遲:術后超過3 d仍攜帶胃管或因惡心嘔吐重新留置胃管。
表1 PD圍手術期主要ERAS措施Table 1 Main ERAS protocols used in perioperative management of PD
⑴ 口服鎮(zhèn)痛藥疼痛控制效果佳;⑵ 體溫<37.5 ℃;⑶ 飲食逐漸恢復,無需輸液補給;⑷ 實驗室檢查指標基本正常(白細胞或膽紅素水平逐漸下降);⑸ 生活自理,能自主活動。
術后第1天常規(guī)拔除尿管,2例老年男性因前列腺增生再次留置導尿,22例(52.4%)患者下床活動,10例(23.8%)達預定活動標準;術后第2天常規(guī)拔除胃管,5例發(fā)生胃排空延遲,重新留置胃管,30例(71.4%)能耐受流質飲食;術后第3天35例(83.3%)拔除腹腔引流管;33例(78.6%)術后第4天固體飲食。
術后出現(xiàn)胰瘺3例(其中A級2例,B級1例),膽汁漏1例,出血1例,腹腔積液3例,胃排空延遲4例,肺部感染1例,無死亡病例,出血患者行二次手術,1例腹腔積液給予B超引導下穿刺引流,術后總體并發(fā)癥發(fā)生率31.0%,出現(xiàn)并發(fā)癥患者均經(jīng)對癥治療后順利出院。術后30 d再入院3例(7.1%),其中胃功能不全1例,腹腔積液并感染1例,膽道感染1例,均經(jīng)對癥治療后好轉,中位住院時間10(8~35)d。
ERAS以維護恢復患者的生理功能,減少痛苦,減少并發(fā)癥,加速患者體質康復為宗旨,基于多學科協(xié)作,采用一系列具有循證醫(yī)學基礎的優(yōu)化措施給與患者圍手術期干預,以減少手術創(chuàng)傷應激,最終達到快速康復目的。ERAS在胃腸外科、泌尿外科及骨科等領域中的應用結果顯示,ERAS能縮短住院時間、減少并發(fā)癥、降低再入院率、加快術后康復進程。
胰十二指腸切除術是治療壺腹部腫瘤的經(jīng)典術式,其涉及腹腔臟器多、手術難度大、歷時長,是外科最為復雜的手術之一。隨著醫(yī)療技術的提高,PD術后并發(fā)癥發(fā)生率及病死率較前降低,術后病死率不足5%,但并發(fā)癥發(fā)生率仍高達50%,術后住院時間長達2周[14-15]。
ERAS理念逐漸應用于PD中,大量臨床研究[16-19]表明,ERAS在縮短住院時間的同時不增加PD術后并發(fā)癥發(fā)生率及再入院率。筆者將ERAS理念成功應用于42例PD患者,初步探討ERAS在我科PD中的臨床應用價值。
本組患者術前均接受健康宣教,詳細告知患者ERAS理念、優(yōu)化措施、治療程序、術后每日康復目標等,以減輕患者焦慮和恐懼,緩解其精神壓力,減少機體應激。術前機械性腸道準備與消化道手術術后吻合口瘺或感染無明顯相關性,消化道手術術前一晚禁食不能降低術后并發(fā)癥發(fā)生率,反而易引起胰島素抵抗[20-21],所有患者術前均不常規(guī)機械性腸道準備,要求術前2 h禁水、6 h禁食固態(tài)食物。術前30 min常規(guī)應用頭孢西丁預防感染,術后24 h內停用,以預防和降低術后感染的發(fā)生[22]。
本組患者術中全程保溫,采用加溫補液、溫水沖洗腹腔、調控室溫等保溫措施,以預防手術患者發(fā)生低體溫而影響其凝血功能,減少術中出血量,從而降低手術并發(fā)癥發(fā)生率,促進患者術后早期康復。術中限制性補液,根據(jù)患者心率、血壓、尿量、出血量及中心靜脈壓綜合評估制定輸液計劃,以減少組織細胞及細胞間質鈉水儲留,預防腸水腫和腸麻痹,降低吻合口瘺發(fā)生率,減輕心臟負荷,減少術后并發(fā)癥[23-24]。腹腔引流管對胰腺手術術后并發(fā)癥發(fā)生率及病死率雖無影響,但胰瘺是PD術后最嚴重的并發(fā)癥,也是PD術后病死最主要原因,PD術后胰瘺發(fā)生率高達15%,術中常規(guī)放置腹腔引流管,以便術后檢測引流液中胰淀粉酶含量,對胰瘺發(fā)生風險進行評估。
術后充分鎮(zhèn)痛可減輕患者不適,減少疼痛引起的機體應激,利于患者早期下床活動;本組患者術后采用PCI聯(lián)合靜脈輸液鎮(zhèn)痛,對于可進食患者及早口服NSAIDS鎮(zhèn)痛,術后疼痛控制佳。胃管不能防止吻合口瘺,反而引起咽部不適甚至嘔吐、誤吸,增加肺部感染機會,不利患者早期進食,術后早期拔除胃管,能夠減少肺炎、肺不張等并發(fā)癥的發(fā)生[25]。術后早期進流食有利于腸黏膜屏障功能恢復,減少細菌移位,避免內源性感染,有利于機體維持水、電解質和酸堿平衡,緩解術后惡心、嘔吐及腸麻痹,PD術后早期進食安全可行,不增加術后胃排空延遲和吻合口瘺發(fā)生率[26-27]。本組所有患者術后第1天即開始飲水,術后第2天拔除胃管,對于可耐受患者第2天開始流質飲食。早期拔除尿管,以減少尿道刺激,降低尿路感染發(fā)生風險,增加患者舒適性,利于術后早期鍛煉與恢復。腹腔引流管的長期留置可引起腹腔逆行感染,增加術后腸粘連等并發(fā)癥的風險,使患者活動受限,延遲進食時間,腹腔引流管還會使體內蛋白質隨腹腔滲液及腹水的流出大量喪失,導致低蛋白血癥,指南亦指出,PD術后3 d,引流液中胰淀粉酶含量<5 000 U/L拔除腹腔引流管安全可取[28-29];本組患者術后第3、5天查引流液淀粉酶含量,引流液淀粉酶含量達拔管要求時當日拔除引流管。本組患者術后第1天即開始下床活動,有效防止下肢深靜脈血栓形成,避免腸粘連,增加肌肉強度及組織氧供,促進胃腸功能恢復,增強機體抵抗力,改善全身血循環(huán),促進切口愈合[18,30]。
結果顯示,術后13例患者出現(xiàn)并發(fā)癥,出血患者行二次手術康復出院,1例腹腔積液給予B超引導下穿刺引流,無死亡病例,總體并發(fā)癥發(fā)生率31.0%,與大多臨床報道相近,術后中位住院時間10 d,較傳統(tǒng)住院時間明顯縮短[9,21,31]。ERAS理念應用于胰十二指腸切除術安全可行,縮短住院時間的同時不增加PD術后總體并發(fā)癥發(fā)生率。
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