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中华胸部外科电子杂志 ›› 2017, Vol. 04 ›› Issue (03) : 140 -148. doi: 10.3877/cma.j.issn.2095-8773.2017.03.03

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食管癌加速康复外科治疗的进展及展望
李印1,(), 孙海波1   
  1. 1. 450008 郑州大学附属肿瘤医院胸外科
  • 收稿日期:2017-04-10 出版日期:2017-08-28
  • 通信作者: 李印

Progress and prospect of enhanced recovery after surgery for esophageal cancer

Yin Li1,(), Haibo Sun1   

  1. 1. Department of Thoracic Surgery, Henan Cancer Hospital, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou 450008, China
  • Received:2017-04-10 Published:2017-08-28
  • Corresponding author: Yin Li
  • About author:
    Corresponding author: Li Yin, Email:
引用本文:

李印, 孙海波. 食管癌加速康复外科治疗的进展及展望[J/OL]. 中华胸部外科电子杂志, 2017, 04(03): 140-148.

Yin Li, Haibo Sun. Progress and prospect of enhanced recovery after surgery for esophageal cancer[J/OL]. Chinese Journal of Thoracic Surgery(Electronic Edition), 2017, 04(03): 140-148.

加速康复外科(ERAS)是以病人为中心,以外科为主导,结合麻醉、护理、营养、心理等多学科团队,旨在减轻围手术期创伤应激反应,维护患者生理功能的一系列措施,从而达到促进患者康复的目的。ERAS的理念和模式最先是应用于结直肠外科领域,随后广泛应用于其他外科领域。由于食管癌外科手术的复杂性和较高的并发症发生率,极大限制了ERAS在食管癌中的应用和推广。究其根本,制约ERAS在食管癌外科领域推广的是术后并发症,尤其是外科技术并发症(如胸胃相关并发症)未得到有效控制。近年来,随着胸腹腔镜微创技术的日益成熟、组织器官保护理念的重视、管状胃技术的提高、吻合技术的突破和一些突破传统认识新理念的提出和应用,ERAS在食管癌外科领域取得了突破性进展。"昨天手术,今天吃饭,5~7天出院",以"免管免禁"微创外科技术为特色的食管癌ERAS模式在个别中心已成为成熟的治疗模式。未来的关键在于对这一治疗模式不断完善并进行系统培训和推广,以期在更多医疗中心推广应用,促进多中心临床研究,以不断充实和完善,从而形成普遍的专家共识。

Enhanced recovery after surgery (ERAS) is a patient-centered, surgeon-led combined with anesthesia, nursing, nutrition, psychological and other multi-disciplinary team, aimed to reduce the perioperative wound stress response, to maintain the physiological function of patients, and to achieve the purpose of promoting patient rehabilitation. ERAS theory was first used in colorectal surgery, then widely used in other surgical fields. However, ERAS program was not used commonly in esophagectomy due to its surgical complexity and high postoperative complications. Basically, the main reason is that postoperative complications like gastric tube-associated complications limit the application of ERAS in the field of esophagectomy. In recent years, with the progression of minimally invasive esophagectomy, attention to tissue and organ protection concept, improvement of gastric tube technique, breakthrough of anastomotic technique and new theories, ERAS has made great progresses in the field of esophagectomy. "Received surgery yesterday, eat normally today, and discharged in5-7 days" , ERAS program based on "no tube no abstaining" has been applied in some medical centers and is becoming more and more mature. In the future we will rely on the improvement, systemic training and promotion of this system. We expect more medical centers will apply ERAS program and multi-center clinical trials will be initiated.

表1 食管癌患者ERAS与传统治疗术前准备的比较
表2 食管患者癌ERAS与传统治疗术中措施比较
表3 食管癌患者ERAS与传统治疗术后路径比较
术后时间 ERAS路径 传统路径 术后时间 ERAS路径 传统路径
第1天 肠内营养500 ml(20 ml/h) 静脉营养 第6天 增加流食量 拔除胃管
早期下床活动(>2 h) 卧床 减少肠内营养(500~1 000 ml) 肠内营养1 500 ml(60~80 ml/h)
功能锻炼 胃肠减压 防误吸指导 拔除胸管
拔除尿管 需要时止痛 功能锻炼 走廊内走动4~5次
床头抬高30° ? ? 坐椅子3次,30~60 min/次
? ? ? 深呼吸锻炼
充分止痛 ? ? ?
第2天 肠内营养1 000 ml(40 ml/h) 肠内营养500 ml(20 ml/h) 第7天 拔除空肠造瘘管 上消化道造影
增加下床活动(>4 h) 拔除尿管 全量流食 排除瘘后进流食
功能锻炼 坐椅子2次,30 min/次 进软食指导 肠内营养1 500 ml(60~80 ml/h)
床头抬高30° 胃肠减压 防误吸指导
? ? 出院 增加下床时间(>4 h)
? ? ? 深呼吸锻炼
第3天 肠内营养1 500 ml (60~80  ml/h) 肠内营养1 000 ml(40 ml/h) 第8天 出院 深呼吸锻炼
坐椅子3次,30~60 min/次 ? 增加流食量
拔除胸管 协助下室内走动2次 ? 减少肠内营养(500~1 000 ml)
拔除硬膜外置管 深呼吸锻炼 ? 增加下床时间(>6 h)
增加下床活动(>6 h) 胃肠减压 ? 深呼吸锻炼
功能锻炼 ? ? ?
床头抬高30° ? ? ? ?
第4天 上消化道造影 肠内营养1 000 ml(40 ml/h) 第9天 ? 拔除营养管
排除瘘后进食 坐椅子3次,30~60 min/次 ? 全量流食
肠内营养1 500 ml(60~80  ml/h) 协助下室内走动3次 ? 增加下床时间(>6 h)
深呼吸锻炼 ? ?
功能锻炼 胃肠减压 ? ?
防误吸指导 ? ? ?
咀嚼及吞咽指导 ? ? ? ?
第5天 肠内营养1 500 ml(60~80  ml/h) 肠内营养1 500 ml(60~80  ml/h) 第10~ 11天 ? 深呼吸锻炼
软食+流食
鼓励患者进流食 走廊内走动4~5次 ? ?
防误吸指导 坐椅子3次,30~60 min/次 ? 增加下床时间(>6 h)
功能锻炼 深呼吸锻炼 ? 观察有无延迟性瘘
? ? ? 第12天 ? 出院
表4 食管癌ERAS的相关研究
表5 "免管免禁"食管癌患者ERAS临床路径
时间 ERAS临床路径 时间 ERAS临床路径
术前 营养筛查(根据营养师建议行营养干预) 术后第2天 指导患者下床活动,1天至少6次有效止痛(NSAID及切口罗哌卡因浸润)
术前指导(肺功能锻炼)
术前教育(指导患者如何配合完成路径) 营养师指导下进食(增加进食量)
? 指导患者如何预防误吸
术前1天 应用缓泻剂避免灌肠 术后第3天 增加下床次数
术中 应用胸腹腔镜微创手术方式 营养师指导下进食(增加进食量)
控制液体入量(6ml·kg-1·h-1) 继续指导患者如何预防误吸
行切口浸润麻醉(罗哌卡因) 有效止痛(NSAIDs及切口罗哌卡因浸润)
胃保护 抽血检查
采用可靠的李氏吻合方法[45] 术后第4天 营养师指导下进食(增加进食量)
不放置胃管及营养管 停止静脉营养支持
仅留置1根纵隔管 指导患者增加功能锻炼
术后当天 拔气管插管回普通病房 继续指导患者如何预防误吸
术后第1天 拔除尿管 有效止痛(NSAIDs)
指导患者咳嗽、呼吸功能锻炼 胸部+上腹部CT检查
营养师指导下进食("50次咀嚼法") 术后第5天 拔除纵隔管;
保持日常进食口味和种类 营养师指导下进食(增加进食量)
床头抬高30°、进食后活动,谨防误吸 指导患者增加功能锻炼
有效止痛(NSAID及切口罗哌卡因浸润) 继续指导患者如何预防误吸
帮助患者下床活动,1天至少4次 术后第6天 指导患者出院后进食
抽血检查 指导患者如何防止误吸
? ? 出院 ?
1
Torre LA, Bray F, Siegel RL, et al. Global cancer statistics, 2012[J]. CA Cancer J Clin, 2015, 65(2): 87-108.
2
Chen W, Zheng R, Baade PD, et al. Cancer statistics in China, 2015[J]. CA Cancer J Clin, 2016, 66(2): 115-132.
3
Wouters MW, Wijnhoven BP, Karim-Kos HE, et al. High-volume versus low-volume for esophageal resections for cancer: the essential role of case-mix adjustments based on clinical data[J]. Ann Surg Oncol, 2008, 15(1): 80-87.
4
Biere SS, van Berge Henegouwen MI, Maas KW, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial[J]. Lancet, 2012, 379(9829): 1887-1892.
5
Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: review of over 1000 patients[J]. Ann Surg, 2012, 256(1): 95-103.
6
Luketich JD, Pennathur A, Franchetti Y, et al. Minimally invasive esophagectomy: results of a prospective phase Ⅱ multicenter trial-the eastern cooperative oncology group (E2202) study[J]. Ann Surg, 2015, 261(4): 702-707.
7
Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome[J]. Am J Surg, 2002; 183(6): 630-641.
8
Wilmore DW, Kehlet H. Management of patients in fast track surgery[J]. BMJ, 2001, 322(7284): 473-476.
9
李印. 快速康复外科在食管癌治疗中的应用[J]. 中华胃肠外科杂志,2014, 17(9): 865-868.
10
Basse L, Hjort Jakobsen D, Billesbolle P, et al. A clinical pathway to accelerate recovery after colonic resection[J]. Ann Surg, 2000, 232(1): 51-57.
11
Basse L, Jacobsen DH, Billesbolle P, et al. Colostomy closure after Hartmann's procedure with fast-track rehabilitation[J]. Dis Colon Rectum, 2002, 45(12): 1661-1664.
12
Basse L, Jakobsen DH, Bardram L, et al. Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study[J]. Ann Surg, 2005, 241(3): 416-423.
13
Carter J, Szabo R, Sim WW, et al. Fast track surgery: a clinical audit[J]. Aust N Z J Obstet Gynaecol, 2010, 50(2): 159-163.
14
Wille-Jorgensen P, Guenaga KF, Matos D, et al. Pre-operative mechanical bowel cleansing or not? an updated meta-analysis[J]. Colorectal Dis, 2005, 7(4): 304-310.
15
Slim K, Vicaut E, Panis Y, et al. Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation[J]. Br J Surg, 2004, 91(9): 1125-1130.
16
Basse L, Thorbol JE, Lossl K, et al. Colonic surgery with accelerated rehabilitation or conventional care[J]. Dis Colon Rectum, 2004, 47(3): 271-277; discussion 7-8.
17
Foss NB, Kristensen MT, Kristensen BB, et al. Effect of postoperative epidural analgesia on rehabilitation and pain after hip fracture surgery: a randomized, double-blind, placebo-controlled trial[J]. Anesthesiology, 2005, 102(6): 1197-204.
18
Brandstrup B. Fluid therapy for the surgical patient[J]. Best Pract Res Clin Anaesthesiol, 2006, 20(2): 265-283.
19
Sessler DI. Mild perioperative hypothermia[J]. N Engl J Med, 1997, 336(24): 1730-1737.
20
Jin F, Chung F. Multimodal analgesia for postoperative pain control[J]. J Clin Anesth, 2001, 13(7): 524-539.
21
Gan TJ, Meyer T, Apfel CC, et al. Consensus guidelines for managing postoperative nausea and vomiting[J]. Anesth Analg, 2003, 97(1): 62-71.
22
Page CP, Ryan JA, Jr Haff RC. Continual catheter administration of an elemental diet[J]. Surg Gynecol Obstet, 1976, 142(2): 184-188.
23
王总飞,张瑞祥,刘先本,等. 不常规经鼻胃肠减压在食管癌腔镜手术中应用的可行性研究[J]. 中国胸心血管外科临床杂志,2014, 21(4): 494-497.
24
Cao S, Zhao G, Cui J, et al. Fast-track rehabilitation program and conventional care after esophagectomy: a retrospective controlled cohort study[J]. Support Care Cancer, 2013, 21(3): 707-714. .
25
Zehr KJ, Dawson PB, Yang SC, et al. Standardized clinical care pathways for major thoracic cases reduce hospital costs[J]. Ann Thorac Surg, 1998, 66(3): 914-919.
26
Low DE, Kunz S, Schembre D, et al. Esophagectomy--it's not just about mortality anymore: standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer[J]. J Gastrointest Surg, 2007, 11(11): 1395-1402; discussion 402.
27
Ford SJ, Adams D, Dudnikov S, et al. The implementation and effectiveness of an enhanced recovery programme after oesophago-gastrectomy: a prospective cohort study[J]. Int J Surg, 2014, 12(4): 320-324.
28
Lee L, Li C, Robert N, et al. Economic impact of an enhanced recovery pathway for oesophagectomy[J]. Br J Surg, 2013, 100(10): 1326-1334.
29
Munitiz V, Martinez-de-Haro LF, Ortiz A, et al. Effectiveness of a written clinical pathway for enhanced recovery after transthoracic (Ivor Lewis) oesophagectomy[J]. Br J Surg, 2010, 97(5): 714-718.
30
Cerfolio RJ, Bryant AS, Bass CS, et al. Fast tracking after Ivor Lewis esophagogastrectomy[J]. Chest, 2004, 126(4): 1187-1194.
31
Shewale JB, Correa AM, Baker CM, et al. Impact of a fast-track esophagectomy protocol on esophageal cancer patient outcomes and hospital charges[J]. Ann Surg, 2015, 261(6): 1114-1123.
32
Chen L, Sun L, Lang Y, et al. Fast-track surgery improves postoperative clinical recovery and cellular and humoral immunity after esophagectomy for esophageal cancer[J]. BMC Cancer, 2016, 16: 449.
33
Sun HB, Liu XB, Zhang RX, et al. Early oral feeding following thoracolaparoscopic oesophagectomy for oesophageal cancer[J]. Eur J Cardiothorac Surg, 2015, 47(2): 227-233.
34
Findlay JM, Tustian E, Millo J, et al. The effect of formalizing enhanced recovery after esophagectomy with a protocol[J]. Dis Esophagus, 2015, 28(6): 567-573.
35
Tang J, Humes DJ, Gemmil E, et al. Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages[J]. Ann R Coll Surg Engl, 2013, 95(5): 323-328.
36
Blom RL, van Heijl M, Bemelman WA, et al. Initial experiences of an enhanced recovery protocol in esophageal surgery. World JSurg, 2013, 37(10): 2372-2378.
37
Preston SR, Markar SR, Baker CR, et al. Impact of a multidisciplinary standardized clinical pathway on perioperative outcomes in patients with oesophageal cancer[J]. Br JSurg, 2013, 100(1): 105-112.
38
Koukouras D, Mastronikolis NS, Tzoracoleftherakis E, et al. The role of nasogastric tube after elective abdominal surgery[J]. Clin Ter, 2001, 152(4): 241-244.
39
Han-Geurts IJ, Jeekel J, Tilanus HW, et al. Randomized clinical trial of patient-controlled versus fixed regimen feeding after elective abdominal surgery[J]. Br J Surg, 2001, 88(12): 1578-1582.
40
O'Keefe SJ. A guide to enteral access procedures and enteral nutrition[J]. Nat Rev Gastroenterol Hepatol, 2009, 6(4): 207-215.
41
Barlow R, Price P, Reid TD, et al. Prospective multicentre randomised controlled trial of early enteral nutrition for patients undergoing major upper gastrointestinal surgical resection[J]. Clin Nutr, 2011, 30(5): 560-566.
42
Heintze U, Birkhed D, Bjorn H. Secretion rate and buffer effect of resting and stimulated whole saliva as a function of age and sex[J]. Swed Dent J, 1983, 7(6): 227-238.
43
闫明,李印,秦建军,等. 食管癌术前及术后早期胸胃排空功能的对比观察[J]. 中国肿瘤临床,2011,38(8): 452-454.
44
Weijs TJ, Berkelmans GH, Nieuwenhuijzen GA, et al. Immediate postoperative oral nutrition following esophagectomy: amulticenter clinical trial[J]. Ann Thorac Surg, 2016, 102(4): 1141-1148.
45
Sun HB, Li Y, Liu XB, et al. Embedded three-layer esophagogastric anastomosis reduces morbidity and improves short-term outcomes after esophagectomy for cancer[J]. Ann Thorac Surg, 2016, 101(3): 1131-1138.
46
中国医师协会胸外科分会快速康复专家委员会. 食管癌加速康复外科技术应用专家共识(2016版)[J]. 中华胸心血管外科杂志,2016, 32(12): 717-722.
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