Savikko Johanna, Vikatmaa Leena, Hiltunen Anna-Maria, Mallat Noora, Tukiainen Eija, Salonen Sari-Mari, Nordin Arno
Department of Transplantation and Liver Surgery, HUS Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00029, Helsinki, Finland.
Department of Anesthesiology and Intensive Care Medicine, HUS Helsinki University Hospital, Helsinki, Finland.
Surg Endosc. 2021 Mar;35(3):1058-1066. doi: 10.1007/s00464-020-07470-2. Epub 2020 Feb 27.
Enhanced recovery protocols (ERP) accelerate recovery and shorten postoperative hospital stay. This increased knowledge of ERPs has also gradually implemented into liver surgery. However, in laparoscopic liver surgery (LLS), the experience of optimized perioperative care protocols is still limited.
We prospectively studied the implementation of multimodal ERP principles to LLS in the first 100 consecutive patients. Opioid-sparing multimodal pain management was applied together with early mobilization already in the postoperative care unit (PACU). Drains and catheters were avoided and per oral intake was initiated promptly. Primary pain control was achieved with iv NSAIDS, low-dose opioid and corticosteroids. Combination of per oral ibuprofen and long-acting tramadol was routinely administered shortly after operation. The multiprofessional adherence to the protocol was also evaluated.
Investigated LLS was performed during Aug 2016-Apr 2019. Operations were done due to malignancy in 83 (83%) of cases, mostly for colorectal liver metastases (n = 52, 52%). Forty-eight (48%) of the operated patients were female. Median age was 65 years (range 17-91). The American Society of Anaesthesiologists Physical Status (ASA) classification median was three. Median postoperative hospital stay was 2 days (range 1-8 days). More than seventy percent of patients were discharged by the second postoperative day and nearly ninety percent by the third postoperative day. Complications after surgery were few. The new ERP elements were adopted in most of the cases.
ERP was introduced safely and effectively after LLS. The adherence to the ERP was good. Routine discharge 1-2 days after LLS is realistic and achievable.
强化康复方案（ERP）可加速康复并缩短术后住院时间。人们对ERP的了解不断增加，其也逐渐应用于肝脏手术。然而，在腹腔镜肝脏手术（LLS）中，优化围手术期护理方案的经验仍然有限。
我们前瞻性地研究了将多模式ERP原则应用于连续100例LLS患者的情况。在术后护理单元（PACU）就开始采用多模式镇痛管理以减少阿片类药物的使用，并尽早进行活动。避免使用引流管和导管，并及时开始经口摄入。通过静脉注射非甾体抗炎药、低剂量阿片类药物和糖皮质激素实现主要的疼痛控制。术后不久常规给予口服布洛芬和长效曲马多的组合。还评估了多专业人员对该方案的依从性。
所研究的LLS手术于2016年8月至2019年4月期间进行。83例（83%）手术是由于恶性肿瘤，主要是结直肠癌肝转移（n = 52，52%）。48例（48%）手术患者为女性。年龄中位数为65岁（范围17 - 91岁）。美国麻醉医师协会身体状况（ASA）分类中位数为3级。术后住院时间中位数为2天（范围1 - 8天）。超过70%的患者在术后第二天出院，近90%的患者在术后第三天出院。术后并发症较少。大多数情况下都采用了新的ERP要素。
LLS术后安全有效地引入了ERP。对ERP的依从性良好。LLS术后1 - 2天常规出院是现实可行的。
