Liu Wenyue,Wu Xiaoxia,Zhao Baohong,et al.Application of enhanced recovery after surgery in infants with anal atresia with rectovestibular fistula[J].Journal of Clinical Pediatric Surgery,2022,21(11):1029-1034.[doi:10.3760/cma.j.cn101785-202201040-006]
加速康复外科技术在肛门闭锁并直肠前庭瘘中的应用
- Title:
- Application of enhanced recovery after surgery in infants with anal atresia with rectovestibular fistula
- Keywords:
- Anorectal Malformations; Anus; Imperforate; Rectal Fistula; Minimally Invasive Surgical Procedures
- 摘要:
- 目的 探讨加速康复外科(enhanced recovery after surgery,ERAS)技术应用于小儿肛门闭锁并直肠前庭瘘的有效性及安全性。方法 采用前瞻性研究方法,将2017年1月至2021年10月山西省儿童医院收治的50例肛门闭锁并直肠前庭瘘患儿随机分为ERAS组和非ERAS组,其中ERAS组25例,非ERAS组25例。ERAS组采用手术日清晨清洁灌肠1次,术前2 h口服12.6%碳水化合物液体,术中保温、目标导向性补液,术后不留置尿管及术后镇痛等措施;非ERAS组采用传统围术期处理方案。两组均采用经肛穴肛门成形术,比较两组患儿麻醉开始时血糖、术后24 h血糖、白细胞计数(white blood cell count,WBC)、C反应蛋白(C-reactive protein,CRP)、术后首次肛门排气排便时间、术中输液量、术后静脉输液时间、术后住院时间、住院费用、并发症发生率及出院后30 d内再入院率。结果 两组患儿术前平均年龄、体重、WBC、CRP、血红蛋白、白蛋白、前白蛋白、入院时血糖比较,差异均无统计学意义(P>0.05)。ERAS组和非ERAS组患儿麻醉开始时血糖分别为(4.92±0.50) mmol/L和(4.53±0.42) mmol/L;术后24 h血糖分别为(5.03±0.66) mmol/L和(5.96±1.18) mmol/L,WBC分别为(9.97±3.24)×109/L和(8.28±3.51)×109/L,CRP分别为(3.63±4.00) mg/L和(9.03±15.77) mg/L;术后首次肛门排气排便时间分别为(12.10±6.40) h和(14.00±9.30) h;术中输液量分别为(83.10±32.20) mL和(136.10±68.40) mL;术后静脉输液时间分别为(4.68±1.25) d和(6.60±1.68) d;术后住院时间分别为(7.12±1.56) d和(10.56±3.58) d;住院费用分别为(13 314.34±2 856.86)元和(16 088.69±3 282.34)元;两组并发症发生例数分别为3例(12%)和6例(24%);两组总体满意度分别为88%(22/25)和60%(15/25),均痊愈出院,无一例出院后30 d内再入院患儿。两组患儿术后首次肛门排气排便时间、术后24 h WBC、CRP比较,差异无统计学意义(P>0.05)。非ERAS组麻醉开始时血糖降低,术后24 h血糖水平升高,差异有统计学意义(P<0.05)。ERAS组较非ERAS组术中输液量减少、术后静脉输液时间及住院时间缩短、住院费用减少,差异有统计学意义(P<0.05)。两组并发症发生率差异无统计学意义(P>0.05)。ERAS组总体满意度高于非ERAS组,差异有统计学意义(P<0.05)。结论 加速康复外科技术应用于肛门闭锁并直肠前庭瘘患儿安全、有效,能有效缩短平均住院日和术后住院时间,降低住院费用。
- Abstract:
- Objective To explore the efficacy and safety of enhanced recovery after surgery (ERAS) in children with anal atresia and rectal vestibular fistula.Methods From January 2017 to October 2021, prospective review was conducted for 50 children with anal atresia and rectal vestibular fistula undergoing transanal analoplasty.They were randomized into two groups of ERAS and non-ERAS (n=25 each).ERAS group received enema once in the morning of operation day, oral 12.6% carbohydrate liquid 2 h pre-operation, intraoperative heat preservation, target-oriented rehydration, no indwelling catheter post-operation, postoperative analgesia and other new measures;non-ERAS group had traditional perioperative treatment.Blood glucose at the beginning of anesthesia, blood glucose 24 h post-operation, white blood cell count (WBC), C-reactive protein (CRP), time of initial exhaust and defecation post-operation, amount of intraoperative infusion, time of postoperative intravenous infusion, time of postoperative hospitalization, expenditure of hospitalization, incidence of complications and readmission rate at Day 30 post-discharge were compared between two groups.Results No significant inter-group differences existed in average age, weight, preoperative WBC, CRP, hemoglobin, albumin, prealbumin or blood glucose at admission.Blood glucose at the beginning of anesthesia in ERAS and non-ERAS groups was (4.92±0.50) and (4.53±0.42) mmol/L, blood glucose (5.03±0.66) and (5.96±1.18) mmol/L at 24 h post-operation.WBC at 24h post-operation (9.97±3.24)×109/L and (8.28±3.51)×109/L;CRP at 24 h post-operation (3.63±4.00) and (9.03±15.77) mg/L;initial postoperative exhaust and defecation time (12.1±6.4) and (14.0±9.3) h;intraoperative infusion volume (83.1±32.2) and (136.1±68.4) mL;postoperative intravenous infusion time (4.68±1.25) and (6.6±1.68) days;postoperative hospital stay (7.12±1.56) and (10.56±3.58) days;hospitalization expense (13 314.34±2 856.86) and (16 088.69±3 282.34) CNY;complications occurred (n=3, 12%) and (n=6, 24%);overall satisfaction was 88% and 60%.Both groups were cured and discharged and there was no re-admission within 30 days post-discharge.No inter-group differences existed in initial exhaust or defecation time, WBC and CRP at 24 h post-operation (P>0.05).In non-ERAS group, blood glucose declined at the beginning of anesthesia while postoperative blood glucose level rose with statistical difference (P<0.05);overall satisfaction of ERAS group was higher than that of non-ERAS group with statistical difference (P<0.05).Conclusion Conceptual application of ERAS is both safe and effective in children with anal atresia with rectovestibular fistula.It can effectively shorten the average time of hospital stay, curtain the length of postoperative hospitalization and lower hospitalization expenditure.A wider popularization is worthy.
参考文献/References:
[1] 中华医学会外科学分会, 中华医学会麻醉学分会.加速康复外科中国专家共识暨路径管理指南(2018)[J].中华麻醉学杂志, 2018, 38(1):8-13.DOI:10.3760/cma.j.issn.0254?1416.2018.01.003. Branch of Surgery, Chinese Medical Association, Branch of Anesthesiology, Chinese Medical Association.Consensus on ERAS and guidelines for pathway management in China (2018)[J].Chin J Anesthesiol, 2018, 38(1):8-13.DOI:10.3760/cma.j.issn.0254?1416.2018.01.003.
[2] Kehlet H.Multimodal approach to control postoperative pathophysiology and rehabilitation[J].Br J Anaesth, 1997, 78(5):606-617.DOI:10.1093/bja/78.5.606.
[3] 吕小逢, 唐杰, 徐小群, 等.加速康复外科在婴儿胆管扩张症围手术期的应用[J].中华小儿外科杂志, 2018, 39(11):851-856.DOI:10.3760/cma.j.issn.0253-3006.2018.11.011. Lyu XF, Tang J, Xu XQ, et al.Application of enhanced recovery after surgery in perioperative management of congenital cholangiectasis in infants[J].Chin J Pediatr Surg, 2018, 39(11):851-856.DOI:10.3760/cma.j.issn.0253-3006.2018.11.011.
[4] 李鑫, 林松, 詹江华, 等.加速康复外科在小儿肠重复畸形围手术期的应用研究[J].中华小儿外科杂志, 2019, 40(9):779-783.DOI:10.3760/cma.j.issn.0253-3006.2019.09.003. Li X, Lin S, Zhan JH, et al.Application of enhanced recovery after surgery for perioperative management of intestinal duplication in children[J].Chin J Pediatr Surg, 2019, 40(9):779-783.DOI:10.3760/cma.j.issn.0253-3006.2019.09.003.
[5] 林松, 苏迎春, 周思海, 等.加速康复外科理念在穿孔性阑尾炎中的应用[J].临床小儿外科杂志, 2019, 18(4):267-271.DOI:10.3969/j.issn.1671-6353.2019.04.004. Lin S, Su YC, Zhou SH, et al.Application of enhanced recovery after surgery for perforated appendicitis[J].J Clin Ped Sur, 2019, 18(4):267-271.DOI:10.3969/j.issn.1671-6353.2019.04.004.
[6] Tang J, Liu X, Ma TS, et al.Application of enhanced recovery after surgery during the perioperative period in infants with Hirschsprung’s disease-a multi-center randomized clinical trial[J].Clin Nutr, 2020, 39(7):2062-2069.DOI:10.1016/j.clnu.2019.10.001.
[7] Gao RY, Yang HY, Li YN, et al.Enhanced recovery after surgery in pediatric gastrointestinal surgery[J].J Int Med Res, 2019, 47(10):4815-4826.DOI:10.1177/0300060519865350.
[8] Bhatnagar S.Anorectal malformations (part 1)[J].J Neonatal Surg, 2015, 4(1):7.
[9] Hulst JM, Zwart H, Hop WC, et al.Dutch national survey to test the STRONGkids nutritional risk screening tool in hospitalized children[J].Clin Nutr, 2010, 29(1):106-111.DOI:10.1016/j.clnu.2009.07.006.
[10] 中国加速康复外科专家组.中国加速康复外科围术期管理专家共识(2016版)[J].中华消化外科杂志, 2016, 15(6):527-533.DOI:10.3760/cma.j.issn.1673-9752.2016.06.001. China Accelerated Rehabilitation Surgery Expert Group.Chinese expert consensus on enhanced recovery after surgery in perioperative management (2016 Edition)[J].Chin J Dig Surg, 2016, 15(6):527-533.DOI:10.3760/cma.j.issn.1673-9752.2016.06.001.
[11] Short HL, Taylor N, Thakore M, et al.A survey of pediatric surgeons’ practices with enhanced recovery after children’s surgery[J].J Pediatr Surg, 2018, 53(3):418-430.DOI:10.1016/j.jpedsurg.2017.06.007.
[12] Torgersen Z, Balters M.Perioperative nutrition[J].Surg Clin North Am, 2015, 95(2):255-267.DOI:10.1016/j.suc.2014.10.003.
[13] Pogatschnik C, Steiger E.Review of preoperative carbohydrate loading[J].Nutr Clin Pract, 2015, 30(5):660-664.DOI:10.1177/0884533615594013.
[14] Nygren J.The metabolic effects of fasting and surgery[J].Best Pract Res Clin Anaesthesiol, 2006, 20(3):429-438.DOI:10.1016/j.bpa.2006.02.004.
[15] Smith I, Kranke P, Murat I, et al.Perioperative fasting in adults and children:guidelines from the European Society of Anaesthesiology[J].Eur J Anaesthesiol, 2011, 28(8):556-569.DOI:10.1097/EJA.0b013e3283495ba1.
[16] Mattioli G, Palomba L, Avanzini S, et al.Fast-track surgery of the colon in children[J].J Laparoendosc Adv Surg Tech A, 2009, 19(Suppl 1):S7-S9.DOI:10.1089/lap.2008.0121.supp.
[17] Vinay HG, Raza M, Siddesh G.Elective bowel surgery with or without prophylactic nasogastric decompression:a prospective, randomized trial[J].J Surg Tech Case Rep, 2015, 7(2):37-41.DOI:10.4103/2006-8808.185654.
[18] Zwart K, Van Ginkel DJ, Hulsker CCC, et al.Does mechanical bowel preparation reduce the risk of developing infectious complications in pediatric colorectal surgery? A systematic review and Meta-analysis[J].J Pediatr, 2018, 203:288-293.e1.DOI:10.1016/j.jpeds.2018.07.057.
[19] Rollins KE, Javanmard-Emamghissi H, Lobo DN.Impact of mechanical bowel preparation in elective colorectal surgery:a Meta-analysis[J].World J Gastroenterol, 2018, 24(4):519-536.DOI:10.3748/wjg.v24.i4.519.
[20] Hooper VD, Chard R, Clifford T, et al.ASPAN’s evidence-based clinical practice guideline for the promotion of perioperative normothermia:second edition[J].J Perianesth Nurs, 2010, 25(6):346-365.DOI:10.1016/j.jopan.2010.10.006.
[21] Sessler DI.Perioperative thermoregulation and heat balance[J].Ann N Y Acad Sci, 1997, 813:757-777.DOI:10.1111/j.1749-6632.1997.tb51779.x.
[22] Zhu ACC, Agarwala A, Bao XD.Perioperative fluid management in the enhanced recovery after surgery (ERAS) pathway[J].Clin Colon Rectal Surg, 2019, 32(2):114-120.DOI:10.1055/s-0038-1676476.
[23] Voldby AW, Brandstrup B.Fluid therapy in the perioperative setting-a clinical review[J].J Intensive Care, 2016, 4:27.DOI:10.1186/s40560-016-0154-3.
相似文献/References:
[1]孙文丽,周薇莉,周玉玲,等.一期Pena肛门成形治疗婴儿中间位无肛7例[J].临床小儿外科杂志,2008,7(03):31.
[2]李水学 阿不都赛米 和军 周玲 沈勇虎 阿孜古丽. 新疆维吾尔族儿童肛门闭锁合并巨结肠症12例[J].临床小儿外科杂志,2011,10(05):396.
[J].Journal of Clinical Pediatric Surgery,2011,10(11):396.
[3]陈子民 叶明 王斌. 一期与分期腹骶会阴肛门成形术治疗高位肛门直肠畸形的疗效比较[J].临床小儿外科杂志,2014,13(05):404.
[4]周薇莉 孙立宝 赵晓波. 后人字切口手术治疗中低位肛门闭锁合并会阴瘘[J].临床小儿外科杂志,2014,13(06):546.
[5]莫优炼,胡小华,杨六成,等.后矢状入路经骶会阴肛门成形术治疗不同年龄段先天性中高位肛门闭锁的疗效比较[J].临床小儿外科杂志,2018,17(08):600.
Mo Youlian,Hu Xiaohua,Yang Liucheng,et al.Clinical efficacies of posterior sagittal sacroperineal anoplasty (Pena surgery) on children of different ages with intermediate and highorder position congenital anal atresia.[J].Journal of Clinical Pediatric Surgery,2018,17(11):600.
[6]孙小兵,李健,代晋宇.. 前矢状入路肛门成形术治疗肛门闭锁直肠前庭瘘的疗效评价[J].临床小儿外科杂志,2018,17(10):763.
Sun Xiaobing,Li Jian,Dai Jinyu..Evaluation of anterior sagittal anoplasty for anorectal malformation with rectovestibular fistula.[J].Journal of Clinical Pediatric Surgery,2018,17(11):763.
[7]王维林.重视复杂肛门直肠畸形的综合治疗[J].临床小儿外科杂志,2020,19(10):861.[doi:10.3969/j.issn.1671-6353.2020.10.001]
Wang Weilin.Attaching a higher importance to a comprehensive management of children with complicated anorectal malformatons[J].Journal of Clinical Pediatric Surgery,2020,19(11):861.[doi:10.3969/j.issn.1671-6353.2020.10.001]
[8]黄焱磊,沈淳,郑珊,等.改良Pe?a术一期根治肛门闭锁伴直肠前庭瘘的疗效分析[J].临床小儿外科杂志,2020,19(10):897.[doi:10.3969/j.issn.1671-6353.2020.10.007]
Huang Yanlei,Shen Chun,Zheng Shan,et al.A follow-up study on postoperative function after modified semi-posterior sagittal one-stage anorectoplasty for imperforate anus with rectovesibula fistula[J].Journal of Clinical Pediatric Surgery,2020,19(11):897.[doi:10.3969/j.issn.1671-6353.2020.10.007]
[9]王国辉,鲁金鹏,刘锋,等.改良小切口前矢状入路手术治疗肛门闭锁合并直肠前庭瘘的疗效分析[J].临床小儿外科杂志,2021,20(12):1163.[doi:10.12260/lcxewkzz.2021.12.012]
Wang Guohui,Lu Jinpeng,Liu Feng,et al.Efficacy analysis of modified limited anterior sagittal anorectoplasty for anal atresia with rectovestibular fistula[J].Journal of Clinical Pediatric Surgery,2021,20(11):1163.[doi:10.12260/lcxewkzz.2021.12.012]
[10]汤绍涛,张梦欣,池水清.肛门直肠畸形外科治疗前沿:机器人手术现状及未来趋势[J].临床小儿外科杂志,2022,21(11):1001.[doi:10.3760/cma.j.cn101785-202210006-001]
Tang Shaotao,Zhang Mengxin,Chi Shuiqing.Frontiers in surgical treatment of anorectal malformations: current status and future trend of robotic-assisted surgery[J].Journal of Clinical Pediatric Surgery,2022,21(11):1001.[doi:10.3760/cma.j.cn101785-202210006-001]
[11]苏璠,杨合英,岳铭,等.先天性肛门闭锁伴直肠前庭瘘经肛穴肛门成形术与矢状入路肛门成形术后近期及远期并发症的Meta分析[J].临床小儿外科杂志,2022,21(10):958.[doi:10.3760/cma.j.cn101785-202110006-011]
Su Fan,Yang Heying,Yue Ming,et al.Clinical efficacies of congenital anorectal malformation with rectovestibular fistula in girls: a Meta-analysis[J].Journal of Clinical Pediatric Surgery,2022,21(11):958.[doi:10.3760/cma.j.cn101785-202110006-011]
[12]陈思颖,邬文杰,沈志云,等.新生儿期一期肛门成形术治疗中位肛门直肠畸形疗效评价[J].临床小儿外科杂志,2022,21(12):1168.[doi:10.3760/cma.j.cn101785-202111033-013]
Chen Siying,Wu Wenjie,Shen Zhiyun,et al.Functional evaluations of neonates with intermediate anorectal malformations after primary anoplasty[J].Journal of Clinical Pediatric Surgery,2022,21(11):1168.[doi:10.3760/cma.j.cn101785-202111033-013]
备注/Memo
收稿日期:2022-01-18。
基金项目:山西省儿童医院院内课题项目(202055)
通讯作者:任红霞,Email:renhongxia100@sina.com