Pang Karl H, Groves Ruth, Venugopal Suresh, Noon Aidan P, Catto James W F
Academic Urology Unit, University of Sheffield, Sheffield, UK; Department of Urology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK.
Department of Anaesthetics, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK.
Eur Urol. 2018 Mar;73(3):363-371. doi: 10.1016/j.eururo.2017.07.031. Epub 2017 Aug 8.
Multimodal enhanced recovery after surgery (ERAS) regimens have improved outcomes from colorectal surgery.
We report the application of ERAS to patients undergoing radical cystectomy (RC).
DESIGN, SETTING, AND PARTICIPANTS: Prospective collection of outcomes from consecutive patients undergoing RC at a single institution.
Twenty-six components including prehabilitation exercise, same day admission, carbohydrate fluid loading, targeted intraoperative fluid resuscitation, regional local anaesthesia, cessation of nasogastric tubes, omitting oral bowel preparation, avoiding drain use, early mobilisation, chewing gum use, and audit.
Primary outcomes were length of stay and readmission rate. Secondary outcomes included intraoperative blood loss, transfusion rates, survival, and histopathological findings.
Four hundred and fifty-three consecutive patients underwent RC, including 393 (87%) with ERAS. Length of stay was shorter with ERAS (median [interquartile range]: 8 [6-13] d) than without (18 [13-25], p<0.001). Patients with ERAS had lower blood loss (ERAS: 600 [383-969] ml vs 1050 [900-1575] ml for non-ERAS, p<0.001), lower transfusion rates (ERAS: 8.1% vs 25%, chi-square test, p<0.001), and fewer readmissions (ERAS: 15% vs 25%, chi-square test, p=0.04) than those without. Histopathological parameters (eg, tumour stage, node count, and margin state) and survival outcomes did not differ with ERAS use (all p>0.1). Multivariable analysis revealed ERAS use was (p=0.002) independently associated with length of stay.
The use of ERAS pathways was associated with lower intraoperative blood loss and faster discharge for patients undergoing RC. These changes did not increase readmission rates or alter oncological outcomes.
Recovery after major bladder surgery can be improved by using enhanced recovery pathways. Patients managed by these pathways have shorter length of stays, lower blood loss, and lower transfusion rates. Their adoption should be encouraged.
多模式术后加速康复（ERAS）方案改善了结直肠手术的预后。
我们报告ERAS在接受根治性膀胱切除术（RC）患者中的应用情况。
设计、设置和参与者：前瞻性收集在单一机构接受RC的连续患者的预后数据。
包括术前康复锻炼、当日入院、碳水化合物液体负荷、目标导向的术中液体复苏、区域局部麻醉、停止使用鼻胃管、省略口服肠道准备、避免使用引流管、早期活动、咀嚼口香糖以及审核等26个组成部分。
主要结局为住院时间和再入院率。次要结局包括术中失血量、输血率、生存率和组织病理学结果。
453例连续患者接受了RC，其中393例（87%）采用了ERAS。采用ERAS的患者住院时间较短（中位数[四分位间距]：8[6 - 13]天），而未采用ERAS的患者为18[13 - 25]天，p<0.001。采用ERAS的患者失血量较低（ERAS组：600[383 - 969]毫升，非ERAS组为1050[900 - 1575]毫升，p<0.001），输血率较低（ERAS组：8.1%，非ERAS组为25%，卡方检验，p<0.001），再入院率也低于未采用ERAS的患者（ERAS组：15%，非ERAS组为25%，卡方检验，p = 0.04）。组织病理学参数（如肿瘤分期、淋巴结数量和切缘状态）和生存结局在采用ERAS与否的患者中无差异（所有p>0.1）。多变量分析显示采用ERAS与住院时间独立相关（p = 0.002）。
对于接受RC的患者，采用ERAS路径与术中失血量减少和出院更快相关。这些变化并未增加再入院率或改变肿瘤学结局。
通过采用加速康复路径可改善大型膀胱手术后的恢复情况。采用这些路径管理的患者住院时间更短、失血量更低且输血率更低。应鼓励采用这些路径。
