Division of Urologic Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7235, USA.
J Am Coll Surg. 2010 Jan;210(1):93-9. doi: 10.1016/j.jamcollsurg.2009.09.026. Epub 2009 Oct 28.
This article outlines our current perioperative management of patients undergoing cystectomy and urinary diversion using advancements in perioperative care to allow for early institution of an oral diet and early hospital discharge.
Three hundred sixty-two consecutive patients underwent radical cystectomy and urinary diversion with curative intent (2001 through 2008). Each underwent a perioperative care plan ("fast track" program). Throughout our experience, evidence-based modifications to this program were instituted. We analyzed the impact of these modifications and report the outcomes with the most recent 100 patients in whom no additional modification has been used.
Mean age of patients is 66.3 years, with 44% of the patients older than age 70 years and 12% older than age 80 years. We found no detrimental effects to immediate removal of the orogastric tube at the end of the procedure, but found a beneficial effect of empiric metoclopramide use, with lower rates of nausea and vomiting. Perioperative antibiotic coverage has been reduced to 24 hours as per American Urological Association guidelines. Gum-chewing has also been shown to be of benefit with regard to a more rapid recovery of bowel function. Use of nonnarcotic analgesics (eg, ketrolac) has also been central in the pathway. Finally, early institution of an oral diet has been an original and central component to our fast track program.
Successful application of a fast track program has been applied to our patients undergoing radical cystectomy and urinary diversion, with the potential to use evidence-based modifications to reduce morbidity and improve recovery.
本文概述了我们目前对接受根治性膀胱切除术和尿流改道术患者的围手术期管理，通过围手术期护理的进步，使患者能够更早地开始口服饮食并提前出院。
362 例连续患者接受根治性膀胱切除术和尿流改道术（2001 年至 2008 年）。所有患者均接受围手术期护理计划（“快速通道”计划）。在我们的经验中，对该计划进行了基于证据的修改。我们分析了这些修改的影响，并报告了最近 100 例患者的结果，这些患者没有使用其他额外的修改。
患者的平均年龄为 66.3 岁，其中 44%的患者年龄大于 70 岁，12%的患者年龄大于 80 岁。我们发现，在手术结束时立即取出经口胃管不会产生不利影响，但经验性使用胃复安有益，恶心和呕吐的发生率较低。根据美国泌尿外科学会的指南，围手术期抗生素覆盖时间已减少至 24 小时。咀嚼口香糖也被证明有助于更快地恢复肠道功能。使用非麻醉性镇痛药（如酮咯酸）在该途径中也很重要。最后，早期开始口服饮食是我们快速通道计划的一个原始和核心组成部分。
成功应用快速通道计划已应用于接受根治性膀胱切除术和尿流改道术的患者，可使用基于证据的修改来降低发病率并促进康复。
