Huang Shoujiang,Lv Chengjie,Qian Yunzhong,et al.Application of enhanced recovery after surgery for infantile inguinal hernia undergoing ambulatory surgery[J].Journal of Clinical Pediatric Surgery,2019,18(04):261-266.[doi:10.3969/j.issn.1671-6353.2019.04.003]
基于加速康复外科理念的日间手术模式治疗小于1岁腹股沟斜疝的对比研究
- Title:
- Application of enhanced recovery after surgery for infantile inguinal hernia undergoing ambulatory surgery
- Keywords:
- Hernia Inguinal/SU; Enhanced Recovery After Surgery; Intraoperative Period; Stress; Hernia Inguinal
- 分类号:
- R729;R493;R656.2+1
- 摘要:
- 目的 探讨加速康复外科理念指导下日间手术模式治疗小于1岁腹股沟斜疝患儿的价值。方法 收集浙江大学医学院附属儿童医院2015年2月至2018年11月收治的小于1岁的腹股沟斜疝患儿571例作为研究对象。根据是否采用日间手术模式治疗将患儿分为日间组和对照组（常规住院流程治疗），进一步根据是否采用腹腔镜手术分为腔镜日间组（n=41）、腔镜对照组（n=211）、开放日间组（n=192）和开放对照组（n=127）。腔镜日间组和腔镜传统组患儿平均年龄分别为（8.2±2.6）个月和（8.9±2.4）个月，差异无统计学意义（t=-1.536，P=0.126）；双侧腹股沟斜疝比例分别为34.14%（14/41）和40.76%（86/211），差异无统计学意义（χ2=0.627，P=0.428）。开放日间组和开放传统组患儿平均年龄分别为（8.7±2.8）个月和（7.1±3.6）个月，差异有统计学意义（t=-4.126，P<0.001），双侧腹股沟斜疝的比例分别为16.67%（32/192）和21.26%（27/127），差异无统计学意义（χ2=1.070，P=0.301）。比较加速康复外科理念指导的日间手术模式和传统住院手术模式在住院时间、住院费用、术后并发症发生率、非计划再次就诊率、非计划再次入院率和日间手术延迟出院率等方面的差异。结果 日间组在住院时间和住院费用上优于对照组（P<0.05）。日间组当日手术取消率为4.72%（11/233），低于对照组的13.31%（45/338），差异有统计学意义（χ2=11.512，P=0.001）。日间组术前禁清饮时间（132±5）min，短于对照组的（148±13）min，差异有统计学意义（t=19.483，P<0.001）。日间组术后初次进食清饮和奶的时间分别为（49±7）min和（124±12）min，短于对照组的（124±12）min和（305±35）min，差异均有统计学意义（P<0.001）。2018年10月起日间流程患儿术前予右美托咪定滴鼻镇静，进入手术室的哭吵发生率为22.2%（6/27），低于对照组的73.33%（33/45），差异有统计学意义（χ2=17.757，P<0.001）。日间组术后哭吵发生率为30.39%（31/102），低于对照组的61.80%（55/89），差异有统计学意义（χ2=18.939，P<0.001）。在并发症方面，日间组术后发热和呕吐的发生率分别为5.15%和3.00%，低于对照组的10.36%和11.83%，差异有统计学意义（P<0.05）；而非计划就诊率日间组为2.15%，与对照组（2.07%）比较差异无统计学意义（χ2=0.004，P=0.951）。两组患儿均无非计划入院患儿，日间组有3例（1.29%）延迟出院，对照组有1例腹股沟斜疝复发。结论 加速康复外科理念指导下日间手术模式治疗小于1岁腹股沟斜疝安全可行，并优于传统住院手术模式。
- Abstract:
- Objective To evaluate the effect of enhanced recovery after surgery (ERAS) guideline implementation on hospitalization stay,patient outcomes and hospitalization expense in infantile inguinal hernia.Methods A retrospective analysis was conducted for 571 infants with inguinal hernia from February 2015 to November 2018.In this cohort,233 patients underwent ambulatory surgery (AS group) and another 338 patients were treated conventionally (control group).AS and control groups were both comprised of two subgroups (laparoscopy subgroup comprised of patients with laparoscopic hernia repair and open subgroup with open hernia repair).Age at herniorrhaphy showed no significant deference between laparoscopy AS and laparoscopy control subgroups (8.2±2.6 vs 8.9±2.4 months,P=0.126); the age of open AS subgroup at herniorrhaphy was elder than that of open control subgroup (8.7±2.8 vs 7.1±3.6 months,P<0.001).The ratios of bilateral inguinal hernia of laparoscopy AS subgroup (34.14%) vs laparoscopy control subgroup (40.76%) and open AS subgroup (16.67%) vs open control subgroup (21.26%) showed no significant difference (P=0.428 and P=0.301 respectively).The length of stay,hospitalization expense and patient outcomes were compared between groups.Results The hospitalization stay of laparoscopy AS subgroup was shorter than that of laparoscopy control subgroup (1 vs 4.6±1.5 days,P<0.001) and open AS subgroup versus open control subgroup (1 vs 4.5±1.7 days,P<0.001).Hospitalization expense of laparoscopy AS subgroup was lower than that of laparoscopy control subgroup (8 439±2 492 vs 10 645±2 014 yuan,P<0.001) and open AS subgroup versus open control subgroup (4 654±1 418 vs 6437±1 716 yuan,P<0.001).The cancellations on day of surgery was lower in AS group than that in control group (4.72% vs 13.31%,P=0.001).The duration of preoperative water fasting was shorter in AS group than that in control group (132±5 vs 148±13 min,P<0.001).The duration of postoperative water/milk intake was also shorter in AS group than that in control group (49±7 vs 142±10 min,124±12 vs 305±35 min respectively,both P<0.001).The incidence of postoperative fever of AS group was lower than that of control group (5.15% vs 10.36%,P=0.026).The incidence of postoperative omit of AS group was lower than that of control group (3.00% vs 11.83%,P<0.001).The incidence of non-programmed consultation showed no significant deference between AS and control groups (2.15% vs 2.07%,P=0.951).No hospital readmission was found for either group.There was only 1 recurrent case in control group while no recurrence in AS group.Conclusion ERAS guideline implementation during ambulatory surgery is both safe and preferred for infantile inguinal hernia.
参考文献/References:
1 Wang JH,Zhang W,Tou JF,et al.Incidence of pediatric metachronous contralateral inguinal hernia in children aged>/=1 year[J].World J Pediatr,2012,8(3):256-259.DOI:10.1007/s12519-012-0367-z.
2 尹强,周小渔,张甜,等.小儿腹股沟斜疝日间手术分析2532例[J].中华腔镜外科杂志(电子版),2013,6(4):298-299.DOI:10.3877/cma.j.issn.1674-6899.2013.04.016. Yin Q,Zhou XY,Zhang T,et al.Analysis of [2532] cases of indirect inguinal hernia in children by day operation[J].Chin J Laparoscopic Surg (Electronic Edition),2013,6(4):298-299.DOI:10.3877/cma.j.issn.1674-6899.2013.04.016.
3 马洪升,蒋丽莎,刘洋,等.快速康复外科理念在日间手术中的实践[J].中国普外基础与临床杂志,2015,22(11):1384-1385.DOI:10.7507/1007-9424.20150364. Ma HS,Jiang LS,Liu Y,et al.The practice of the concept of fast track surgery in daytime surgery[J].Chin J Bases Clin General Surg,2015,22(11):1384-1385.DOI:10.7507/1007-4848.20160024.
4 马洪升,程南生,朱涛,等.华西医院日间手术快速康复(ERAS)规范[J].中国胸心血管外科临床杂志,2016,23(2):104-106.DOI:10.7507/1007-4848.20160024. Ma HS,Cheng NS,Zhu T,et al.Standard of enhanced recovery after surgery for day surgery in West China Hospital[J].Chin J Clin Thorac Cardiovasc Surg,2016,23(2):104-106.DOI:10.7507/1007-4848.20160024.
5 Jawaha K,Scarisbrick AA.Parental perceptions in pediatric cardiac fast-track surgery[J].AORN J,2009,89(4):725-731.DOI:10.1016/j.aorn.2008.11.029.
6 Vrecenak JD,Mattei P.Fast-track management is safe and effective after bowel resection in children with Crohn’s disease[J].J Pediatr Surg,2014,49(1):99-102.DOI:10.1016/j.jpedsurg.2013.09.038.
7 Itou K,Fukuyama T,Sasabuchi Y,et al.Safety and efficacy of oral rehydration therapy until 2 h before surgery:a multicenter randomized controlled trial[J].J Anesth,2012,26(1):20-27.DOI:10.1007/s00540-011-1261-x.
8 Rawlinson A,Kitchingham N,Hart C,et al.Mechanisms of reducing postoperative pain,nausea and vomiting:a systematic review of current techniques[J].Evid Based Med,2012,17(5):75-80.DOI:10.1136/ebmed-2011-100265.
9 De Mattia AL,Barbosa MH,de Freitas Filho JP,et al.Warmed intravenous infusion for controlling intraoperative hypothermia[J].Rev Lat Am Enfermagem,2013,21(3):803-810.DOI:10.1590/S0104-11692013000300021.
10 江志伟,李宁,黎介寿.快速康复外科的概念及临床意义[J].中国实用外科杂志,2007,27(2):131-133.DOI:10.3321/j.issn:1005-2208.2007.02.013. Jiang ZW,Li N,Li JS.Concept and clinical significance of fast track surgery[J].Chin J Practical Surg,2007,27(2):131-133.DOI:10.3321/j.issn:1005-2208.2007.02.013.
11 刘子嘉,黄宇光.临床麻醉在快速康复外科方面新进展[J].中国医学科学院学报,2015,37(06):750-754.DOI:10.3881/j.issn.1000-503X.2015.06.021. Liu ZJ,Huang YG.Anesthesia update in enhanced recovery after surgery[J].Acta Acad Med Sin,2015,37(6):750-754.DOI:10.3881/j.issn.1000-503X.2015.06.021.
12 Reismann M,von Kampen M,Laupichler B,et al.Fast track surgery in infants and children[J].J Pediatr Surg,2007,42(1):234-238.DOI:10.1016/j.jpedsurg.2006.09.022.
13 潘茜恒,汪玉雯,陈永权.多模式围术期处理在小儿加速康复外科中的应用[J].临床麻醉学杂志,2018,34(8):773-776.DOI:10.12089/jca.2018.08.010. Pan XH,Wang YW,Chen YQ.Application of multimodal perioperative treatment of enhanced recovery after surgery in pediatric surgery[J].J Clin Anesthesiol,2018,34(8):773-776.DOI:10.12089/jca.2018.08.010.
14 Reismann M,Arar M,Hofmann A,et al.Feasibility of fast-track elements in pediatric surgery[J].Eur J Pediatr Surg,2012,22(1):40-44.DOI:10.1055/s-0031-1284422.
15 Baumann LM,Williams K,Ghomrawi H,et al.Current practice patterns for postoperative activity restrictions in children[J].J Pediatr Surg,2018,pii:S0022-3468(18)30402-0.DOI:10.1016/j.jpedsurg.2018.06.025.
16 何威,李国新.加速康复外科的临床应用进展[J].国际外科学杂志,2008,35(6):416-419.DOI:10.3760/cma.j.issn.1673-4203.2008.06.021. He W,Li GX.CliIlical progress on the fast-track surgery[J].International Journal of Surgery,2008,35(6):416-419.DOI:10.3760/cma.j.issn.1673-4203.2008.06.021.
相似文献/References:
[1]王勇,汤绍涛,毛永忠,等.腔镜下手术治疗小儿膈肌疾病31例[J].临床小儿外科杂志,2010,9(06):441.
[2]欧阳帆,张治明,曾宾,等.七氟醚复合髂腹股沟-髂腹下神经阻滞用于小儿腹股沟手术[J].临床小儿外科杂志,2010,9(06):466.
[3]寿铁军李勇马能强龚晟.腹腔镜手术治疗小儿腹股沟斜疝1582例[J].临床小儿外科杂志,2011,10(01):0.
[4]朱琳琳吕志葆陈 功肖现民.腹腔镜下U型缝合膈肌缺损治疗儿童先天性胸骨后疝[J].临床小儿外科杂志,2010,9(03):0.
ZHU Lin-lin,LV Zhi-bao,CHEN Gong,et al.Laparoscopic-assisted full-thickness anterior abdominal wall repair of Morgagni hernia in children.[J].Journal of Clinical Pediatric Surgery,2010,9(04):0.
[5].小儿先天性腰疝治疗分析[J].临床小儿外科杂志,2010,9(04):0.
GUO Zheng-tuan,XU Quan,LI Peng,et al.Diagnosis and management of congenital lumbar hernias in children.[J].Journal of Clinical Pediatric Surgery,2010,9(04):0.
[6]唐志贤,余家康,王凤华,等.地塞米松对先天性膈疝胎鼠肺发育的影响[J].临床小儿外科杂志,2008,7(01):8.
[7]浦征宇,潘永康,段光琦,等.小儿腹股沟嵌顿性斜疝合并阑尾炎的临床分析[J].临床小儿外科杂志,2008,7(01):37.
[8]马洪,李旭良,方勇,等.经腹股沟皮纹横切口治疗小儿隐睾[J].临床小儿外科杂志,2008,7(04):0.
[9]葛午平,俞钢,朱小春,等.新生儿小型脐膨出的产前诊断与手法复位治疗[J].临床小儿外科杂志,2008,7(04):0.
[10]刘翔,郑训淮,戚士芹,等.用硅胶袋修复巨型脐膨出与腹裂13例报告[J].临床小儿外科杂志,2007,6(03):11.
[11]杜宝峰,易军,刘继炎,等.腹腔镜治疗复发性斜疝58例[J].临床小儿外科杂志,2008,7(04):0.
[12]王剑锋,刘国庆,唐华建,等.腹腔镜下网片修补小儿巨大腹股沟斜疝的初步报告[J].临床小儿外科杂志,2007,6(01):31.
[13]唐剑平,何东北,唐向东,等.腹腔镜下小儿腹股沟斜疝高位结扎术45例[J].临床小儿外科杂志,2007,6(01):24.
[14]归奕飞,韦勇杰,王奇,等.一孔法腹腔镜手术治疗小儿嵌顿性腹股沟斜疝[J].临床小儿外科杂志,2007,6(02):8.
[15]薛彦生,曹立平,佟亮,等.小切口治疗小儿腹股沟斜疝518例[J].临床小儿外科杂志,2007,6(04):32.
[16]苏海龙,隋武,王云惠,等.微型腹腔镜套线法治疗小儿斜疝及鞘膜积液(附747例报告)[J].临床小儿外科杂志,2007,6(04):33.
[17]张刚 刘丹丹.婴幼儿Ａｍｙａｎｄ疝的临床分析[J].临床小儿外科杂志,2013,12(01):55.
[18]赵正,席红卫.不同手术方式治疗小儿腹股沟嵌顿斜疝的疗效对比研究[J].临床小儿外科杂志,2019,18(04):299.[doi:10.3969/j.issn.1671-6353.2019.04.010]
Zhao Zheng,Xi Hongwei.Efficacies of different surgical approaches for pediatric incarcerated inguinal hernia[J].Journal of Clinical Pediatric Surgery,2019,18(04):299.[doi:10.3969/j.issn.1671-6353.2019.04.010]
[19]莫智峰,何汉忠,张焯荣,等.腹腔镜下个体化处置疝囊治疗小儿腹股沟斜疝的应用体会[J].临床小儿外科杂志,2020,19(12):1130.[doi:10.3969/j.issn.1671-6353.2020.12.013]
Mo Zhifeng,He Hanzhong,Zhang Zhuorong,et al.Application of individualized laparoscopy for oblique inguinal hernia based upon the classification of internal ring in children[J].Journal of Clinical Pediatric Surgery,2020,19(04):1130.[doi:10.3969/j.issn.1671-6353.2020.12.013]
[20]唐玲,肖婷,杜真,等.右旋氯胺酮用于小儿腹腔镜疝囊高位结扎术麻醉的有效性与安全性评价[J].临床小儿外科杂志,2022,21(08):758.[doi:10.3760/cma.j.cn101785-202110038-010]
Tang Ling,Xiao Ting,Du Zhen,et al.Effectiveness and safety evaluations of s-ketamine during laparoscopic high ligation of hernia sac in children[J].Journal of Clinical Pediatric Surgery,2022,21(04):758.[doi:10.3760/cma.j.cn101785-202110038-010]
备注/Memo
收稿日期:2018-10-10。
基金项目:浙江省医药卫生科技计划项目（编号：2013KYB151）
通讯作者:钭金法,Email:toujinfa@zju.edu.cn