Zhang Xiaoying, Dong Xuewei, Luo Huili, Song Yanli, Chen Shengmin
Department of Pediatrics, Qianxi County People's Hospital, Shijiazhuang, Hebei China.
Department of Spinal surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China.
Geriatr Orthop Surg Rehabil. 2024 Aug 15;15:21514593241273117. doi: 10.1177/21514593241273117. eCollection 2024.
Patients with frailty are more prone to have perioperative adverse events, and enhanced recovery after surgery (ERAS) has been widely adopted to improve perioperative outcomes. The purpose of this study was to assess the impact of improved compliance with ERAS on perioperative outcomes in frail patients.
Geriatric patients (over 65 years) who underwent multi-level lumbar fusion surgery between June 2017 and June 2022 were included. The patients were divided into two groups according to their degree of compliance with the ERAS. Stepwise nearest-neighbor propensity score matching 1:1 cohorts for age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classfication and Charlson Comorbidity Index (CCI) was performed between groups, namely frail-compliant (FC), frail-noncompliant (FN). Further length of stay (LOS), complications and clinical efficacy were compared between groups.
There were 83 pairs of well-balanced patients with comparable clinical baseline data. It was worth noting that patients in FC group has significant lower overall complications (20.5% in the FC group vs 39.8% in the FN group, = 0.007), major complications (7.2% in the FC group vs 19.3% in the FN group, = 0.022) and shorter LOS (11.18 ± 5.32 in the FC group vs 14.45 ± 4.68 in the FN group, < 0.001) than patients in FN group. In addition, the initial occurrence of ambulation (2.14 ± 1.21 in FC group vs 3.18 ± 1.73 in FN group, = 0.012) and bowel movement (3.68 ± 1.24 in FC group vs 4.17 ± 1.32 in FN group, = 0.031) were earlier for patients in FC group than patients in FN group. With regard to clinical efficacy, there were no significant difference between FC and FN group in terms of patients who meet minimal clinical important difference (MCID) for Oswestry Disability Index (ODI) at postoperative day (POD) 30, Visual Analog Scale (VAS) for back at POD 30-90 and VAS for legs at POD 30, 90, and 180 follow-up intervals. However, there were significant more patients meeting MCID for ODI at POD 90 and180, and VAS for back at POD 180 between FC and FN group.
In this retrospective cohort study, we found that frail patients with higher ERAS adherence group had a lower incidence of overall complication, mjor complications, and a shorter LOS than their lower ERAS adherence counterparts. In addition, frail patients with higher ERAS adherence had earlier ambulatioin and bowel movement. More importantly, we found there were significant more patients meeting MCID for ODI at POD 90 and180, and VAS for back at POD 180 in higher ERAS adherence than their lower counterparts.
虚弱患者围手术期更易发生不良事件，而加速康复外科（ERAS）已被广泛采用以改善围手术期结局。本研究旨在评估改善ERAS依从性对虚弱患者围手术期结局的影响。
纳入2017年6月至2022年6月期间接受多节段腰椎融合手术的老年患者（65岁以上）。根据患者对ERAS的依从程度将其分为两组。在两组之间进行年龄、性别、体重指数（BMI）、美国麻醉医师协会（ASA）分级和Charlson合并症指数（CCI）的逐步最近邻倾向评分匹配1:1队列，即虚弱-依从组（FC）、虚弱-不依从组（FN）。进一步比较两组之间的住院时间（LOS）、并发症和临床疗效。
共有83对临床基线数据可比的平衡良好的患者。值得注意的是，FC组患者的总体并发症（FC组为20.5%，FN组为39.8%，P = 0.007）、主要并发症（FC组为7.2%，FN组为19.3%，P = 0.022）显著低于FN组，且住院时间更短（FC组为11.18±5.32天，FN组为14.45±4.68天，P < 0.001）。此外，FC组患者的首次下床活动时间（FC组为2.14±1.21天，FN组为3.18±1.73天，P = 0.012）和首次排便时间（FC组为3.68±1.24天，FN组为4.17±1.32天，P = 0.031）均早于FN组。在临床疗效方面，术后30天Oswestry功能障碍指数（ODI）、术后30 - 90天背部视觉模拟评分（VAS）以及术后30天、90天和180天腿部VAS达到最小临床重要差异（MCID）的患者，FC组和FN组之间无显著差异。然而，在术后90天和180天ODI达到MCID以及术后180天背部VAS达到MCID的患者中，FC组显著多于FN组。
在这项回顾性队列研究中，我们发现ERAS依从性较高的虚弱患者与依从性较低的患者相比，总体并发症、主要并发症发生率更低，住院时间更短。此外，ERAS依从性较高的虚弱患者下床活动和排便更早。更重要的是，我们发现ERAS依从性较高的患者在术后90天和180天ODI达到MCID以及术后180天背部VAS达到MCID的人数显著多于依从性较低的患者。
