王征征，周進(jìn)學(xué)，李慶軍，展翔宇，陳勛，韓風(fēng)

（鄭州大學(xué)附屬腫瘤醫(yī)院 肝膽胰腺外科，河南 鄭州 450008）

胰十二指腸切除術(shù)（pancreaticoduodenectomy，PD）經(jīng)近百年的發(fā)展和改進(jìn)，其圍手術(shù)期病死率已顯著下降，術(shù)后住院時(shí)間長(zhǎng)、并發(fā)癥發(fā)生率高仍困擾臨床一線外科醫(yī)生[1-3]。加速康復(fù)外科（enhanced recovery after surgery，ERAS）理念在多種外科領(lǐng)域的臨床應(yīng)用結(jié)果顯示，ERAS能降低術(shù)后并發(fā)癥發(fā)病率，縮短住院時(shí)間[4-8]。臨床研究[9-11]表明，ERAS應(yīng)用于PD安全可行，能減少住院時(shí)間。本組已成功將ERAS理念應(yīng)用于PD圍手術(shù)期，其臨床效果報(bào)告如下。

1 資料與方法

1.1 一般資料

回顧性分析2015年6月—2016年12月鄭州大學(xué)附屬腫瘤醫(yī)院42例行根治性PD術(shù)患者的臨床資料，其中男19例，女23例；平均年齡（53±11）歲；BMI≥28 2例；糖尿病2例，高血壓3例；所有患者術(shù)前增強(qiáng)CT或MRI檢查提示胰頭占位，腫瘤可根治性切除，術(shù)后病理結(jié)果確診為胰頭癌；所有患者實(shí)施ERAS圍手術(shù)期管理理念，合并糖尿病與高血壓患者，術(shù)前血糖與血壓控制在正?；蛘８咧邓?，記錄患者ERAS具體措施依從情況、術(shù)后出血、膽汁漏、胰瘺、感染等并發(fā)癥、住院時(shí)間及再入院情況等。

1.2 ERAS主要措施

⑴ 術(shù)前：ERAS宣教、術(shù)前減黃、非機(jī)械性腸道準(zhǔn)備、留置胃管、預(yù)防性使用抗生素；⑵ 術(shù)中：全程保溫、目標(biāo)導(dǎo)向性輸液、精準(zhǔn)切除、常規(guī)放置引流管；⑶ 術(shù)后：多模式鎮(zhèn)痛、預(yù)防惡心嘔吐、早期拔除胃管與尿管、早期進(jìn)食、早期下床活動(dòng)、及早拔除腹腔引流管（表1）。

1.3 手術(shù)方法

所有患者取仰臥位，靜脈+吸入全身麻醉，腹部正中切口，以減輕對(duì)腹部肌肉的切割損傷，行不保留幽門的Whipple術(shù)，常規(guī)切除膽囊并徹底清掃淋巴結(jié)，13組及16a2、16b1組淋巴結(jié)常規(guī)清掃，Child+Braun吻合方式重建消化道。胰腸吻合采用3-0 Prolene線雙層連續(xù)縫合，游離左側(cè)胰腺殘端約2 cm，找出主胰管并置入引流管，3-0 Prolene線縫合胰管周圍組織固定引流管，距胰腺斷端1.0 cm處連續(xù)縫合胰腺后壁與空腸近系膜漿肌層，后壁吻合后收緊縫線不打結(jié)；切開(kāi)空腸，3-0 Prolene線連續(xù)縫合胰腺殘端后壁與空腸全層，后壁縫合完成后收線不打結(jié)；將胰管引流管置入空腸，內(nèi)側(cè)縫線繼續(xù)縫合胰腺殘端前壁和空腸全層，完成內(nèi)層吻合；外層縫線連續(xù)縫合胰腺前壁與空腸漿肌層，完成第二層胰腸吻合，縫合完畢后收線打結(jié)。膽腸吻合應(yīng)用可吸收縫線，后壁連續(xù)、前壁間斷縫合，術(shù)后常規(guī)放置2根引流管，分別位于膽腸吻合口與胰腸吻合口下方。

1.4 術(shù)后并發(fā)癥

參照ISGPF及ISGPS界定標(biāo)準(zhǔn)[12-13]。⑴ 胰瘺：PD術(shù)后超過(guò)3 d，腹腔引流液淀粉酶含量超過(guò)正常血清值3倍（術(shù)后第1、3、5天留取引流液送檢）；將胰瘺分為A、B、C 3級(jí)，A級(jí)僅有腹腔引流液淀粉酶升高，無(wú)特殊癥狀且無(wú)需臨床干預(yù)；B級(jí)腹腔引流液淀粉酶升高，伴有臨床癥狀并出現(xiàn)器官損傷征象；C級(jí)出現(xiàn)嚴(yán)重?cái)⊙Y和器官功能障礙，危及患者生命；B或C級(jí)常需臨床干預(yù)。⑵ 死亡：圍手術(shù)期或出院30 d內(nèi)因手術(shù)或術(shù)后并發(fā)癥導(dǎo)致的死亡。⑶ 胃排空延遲：術(shù)后超過(guò)3 d仍攜帶胃管或因惡心嘔吐重新留置胃管。

表1 PD圍手術(shù)期主要ERAS措施Table 1 Main ERAS protocols used in perioperative management of PD

1.5 出院標(biāo)準(zhǔn)

⑴ 口服鎮(zhèn)痛藥疼痛控制效果佳；⑵ 體溫＜37.5 ℃；⑶ 飲食逐漸恢復(fù)，無(wú)需輸液補(bǔ)給；⑷ 實(shí)驗(yàn)室檢查指標(biāo)基本正常（白細(xì)胞或膽紅素水平逐漸下降）；⑸ 生活自理，能自主活動(dòng)。

2 結(jié) 果

2.1 術(shù)后一般情況

術(shù)后第1天常規(guī)拔除尿管，2例老年男性因前列腺增生再次留置導(dǎo)尿，22例（52.4%）患者下床活動(dòng)，10例（23.8%）達(dá)預(yù)定活動(dòng)標(biāo)準(zhǔn)；術(shù)后第2天常規(guī)拔除胃管，5例發(fā)生胃排空延遲，重新留置胃管，30例（71.4%）能耐受流質(zhì)飲食；術(shù)后第3天35例（83.3%）拔除腹腔引流管；33例（78.6%）術(shù)后第4天固體飲食。

2.2 術(shù)后并發(fā)癥、住院時(shí)間及再入院情況

術(shù)后出現(xiàn)胰瘺3例（其中A級(jí)2例，B級(jí)1例），膽汁漏1例，出血1例，腹腔積液3例，胃排空延遲4例，肺部感染1例，無(wú)死亡病例，出血患者行二次手術(shù)，1例腹腔積液給予B超引導(dǎo)下穿刺引流，術(shù)后總體并發(fā)癥發(fā)生率31.0%，出現(xiàn)并發(fā)癥患者均經(jīng)對(duì)癥治療后順利出院。術(shù)后30 d再入院3例（7.1%），其中胃功能不全1例，腹腔積液并感染1例，膽道感染1例，均經(jīng)對(duì)癥治療后好轉(zhuǎn)，中位住院時(shí)間10（8～35）d。

3 討 論

ERAS以維護(hù)恢復(fù)患者的生理功能，減少痛苦，減少并發(fā)癥，加速患者體質(zhì)康復(fù)為宗旨，基于多學(xué)科協(xié)作，采用一系列具有循證醫(yī)學(xué)基礎(chǔ)的優(yōu)化措施給與患者圍手術(shù)期干預(yù)，以減少手術(shù)創(chuàng)傷應(yīng)激，最終達(dá)到快速康復(fù)目的。ERAS在胃腸外科、泌尿外科及骨科等領(lǐng)域中的應(yīng)用結(jié)果顯示，ERAS能縮短住院時(shí)間、減少并發(fā)癥、降低再入院率、加快術(shù)后康復(fù)進(jìn)程。

胰十二指腸切除術(shù)是治療壺腹部腫瘤的經(jīng)典術(shù)式，其涉及腹腔臟器多、手術(shù)難度大、歷時(shí)長(zhǎng)，是外科最為復(fù)雜的手術(shù)之一。隨著醫(yī)療技術(shù)的提高，PD術(shù)后并發(fā)癥發(fā)生率及病死率較前降低，術(shù)后病死率不足5%，但并發(fā)癥發(fā)生率仍高達(dá)50%，術(shù)后住院時(shí)間長(zhǎng)達(dá)2周[14-15]。

ERAS理念逐漸應(yīng)用于PD中，大量臨床研究[16-19]表明，ERAS在縮短住院時(shí)間的同時(shí)不增加PD術(shù)后并發(fā)癥發(fā)生率及再入院率。筆者將ERAS理念成功應(yīng)用于42例PD患者，初步探討ERAS在我科PD中的臨床應(yīng)用價(jià)值。

本組患者術(shù)前均接受健康宣教，詳細(xì)告知患者ERAS理念、優(yōu)化措施、治療程序、術(shù)后每日康復(fù)目標(biāo)等，以減輕患者焦慮和恐懼，緩解其精神壓力，減少機(jī)體應(yīng)激。術(shù)前機(jī)械性腸道準(zhǔn)備與消化道手術(shù)術(shù)后吻合口瘺或感染無(wú)明顯相關(guān)性，消化道手術(shù)術(shù)前一晚禁食不能降低術(shù)后并發(fā)癥發(fā)生率，反而易引起胰島素抵抗[20-21]，所有患者術(shù)前均不常規(guī)機(jī)械性腸道準(zhǔn)備，要求術(shù)前2 h禁水、6 h禁食固態(tài)食物。術(shù)前30 min常規(guī)應(yīng)用頭孢西丁預(yù)防感染，術(shù)后24 h內(nèi)停用，以預(yù)防和降低術(shù)后感染的發(fā)生[22]。

本組患者術(shù)中全程保溫，采用加溫補(bǔ)液、溫水沖洗腹腔、調(diào)控室溫等保溫措施，以預(yù)防手術(shù)患者發(fā)生低體溫而影響其凝血功能，減少術(shù)中出血量，從而降低手術(shù)并發(fā)癥發(fā)生率，促進(jìn)患者術(shù)后早期康復(fù)。術(shù)中限制性補(bǔ)液，根據(jù)患者心率、血壓、尿量、出血量及中心靜脈壓綜合評(píng)估制定輸液計(jì)劃，以減少組織細(xì)胞及細(xì)胞間質(zhì)鈉水儲(chǔ)留，預(yù)防腸水腫和腸麻痹，降低吻合口瘺發(fā)生率，減輕心臟負(fù)荷，減少術(shù)后并發(fā)癥[23-24]。腹腔引流管對(duì)胰腺手術(shù)術(shù)后并發(fā)癥發(fā)生率及病死率雖無(wú)影響，但胰瘺是PD術(shù)后最嚴(yán)重的并發(fā)癥，也是PD術(shù)后病死最主要原因，PD術(shù)后胰瘺發(fā)生率高達(dá)15%，術(shù)中常規(guī)放置腹腔引流管，以便術(shù)后檢測(cè)引流液中胰淀粉酶含量，對(duì)胰瘺發(fā)生風(fēng)險(xiǎn)進(jìn)行評(píng)估。

術(shù)后充分鎮(zhèn)痛可減輕患者不適，減少疼痛引起的機(jī)體應(yīng)激，利于患者早期下床活動(dòng)；本組患者術(shù)后采用PCI聯(lián)合靜脈輸液鎮(zhèn)痛，對(duì)于可進(jìn)食患者及早口服NSAIDS鎮(zhèn)痛，術(shù)后疼痛控制佳。胃管不能防止吻合口瘺，反而引起咽部不適甚至嘔吐、誤吸，增加肺部感染機(jī)會(huì)，不利患者早期進(jìn)食，術(shù)后早期拔除胃管，能夠減少肺炎、肺不張等并發(fā)癥的發(fā)生[25]。術(shù)后早期進(jìn)流食有利于腸黏膜屏障功能恢復(fù)，減少細(xì)菌移位，避免內(nèi)源性感染，有利于機(jī)體維持水、電解質(zhì)和酸堿平衡，緩解術(shù)后惡心、嘔吐及腸麻痹，PD術(shù)后早期進(jìn)食安全可行，不增加術(shù)后胃排空延遲和吻合口瘺發(fā)生率[26-27]。本組所有患者術(shù)后第1天即開(kāi)始飲水，術(shù)后第2天拔除胃管，對(duì)于可耐受患者第2天開(kāi)始流質(zhì)飲食。早期拔除尿管，以減少尿道刺激，降低尿路感染發(fā)生風(fēng)險(xiǎn)，增加患者舒適性，利于術(shù)后早期鍛煉與恢復(fù)。腹腔引流管的長(zhǎng)期留置可引起腹腔逆行感染，增加術(shù)后腸粘連等并發(fā)癥的風(fēng)險(xiǎn)，使患者活動(dòng)受限，延遲進(jìn)食時(shí)間，腹腔引流管還會(huì)使體內(nèi)蛋白質(zhì)隨腹腔滲液及腹水的流出大量喪失，導(dǎo)致低蛋白血癥，指南亦指出，PD術(shù)后3 d，引流液中胰淀粉酶含量＜5 000 U/L拔除腹腔引流管安全可取[28-29]；本組患者術(shù)后第3、5天查引流液淀粉酶含量，引流液淀粉酶含量達(dá)拔管要求時(shí)當(dāng)日拔除引流管。本組患者術(shù)后第1天即開(kāi)始下床活動(dòng)，有效防止下肢深靜脈血栓形成，避免腸粘連，增加肌肉強(qiáng)度及組織氧供，促進(jìn)胃腸功能恢復(fù)，增強(qiáng)機(jī)體抵抗力，改善全身血循環(huán)，促進(jìn)切口愈合[18,30]。

結(jié)果顯示，術(shù)后13例患者出現(xiàn)并發(fā)癥，出血患者行二次手術(shù)康復(fù)出院，1例腹腔積液給予B超引導(dǎo)下穿刺引流，無(wú)死亡病例，總體并發(fā)癥發(fā)生率31.0%，與大多臨床報(bào)道相近，術(shù)后中位住院時(shí)間10 d，較傳統(tǒng)住院時(shí)間明顯縮短[9,21,31]。ERAS理念應(yīng)用于胰十二指腸切除術(shù)安全可行，縮短住院時(shí)間的同時(shí)不增加PD術(shù)后總體并發(fā)癥發(fā)生率。

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