Application of ERAS clinical pathway in the perioperative period of hepatectomy under MDT cooperation

doi:10.3877/cma.j.issn.2095-3232.2025.05.011

Abstract

Abstract:

Objective

To evaluate the application value of clinical pathway of enhanced recovery after surgery (ERAS) in liver resection under multi-disciplinary team (MDT) cooperation.

Methods

Clinical data of 1 046 patients who underwent liver resection in Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology from January 2018 to December 2019 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 764 patients were male and 282 female, aged from 18 to 84 years, with a median age of 52 years. According to the implementation of clinical pathway of ERAS under MDT cooperation, 416 patients were assigned into the ERAS group and 630 cases into the non-ERAS group. The potential selection bias between two groups was minimized by propensity score matching (PSM). The length of postoperative hospital stay, indwelling time of gastric tube, urinary catheter and drainage tube between two groups were compared by rank-sum test. The incidence of postoperative complications was compared by Chi-square test.

Results

After 1:1 PSM, 253 patients were matched in each group. There was no significant difference in baseline indexes between two groups (all P>0.05). After PSM, the length of postoperative hospital stay in the ERAS group was 9(7,12) d, significantly shorter than 11(8,13) d in the non-ERAS group (Z=-3.610, P<0.001). Postoperative indwelling time of gastric tube, urinary catheter and drainage tube in the ERAS group was 4(2,12) h, 27(21,44) h and 4(3, 6) d, significantly shorter than 21(16,24) h, 41(21,56) h and 5(4,7) d in the non-ERAS group (Z=-14.150,-2.235,-5.202; all P<0.05). The incidence of postoperative complications in the ERAS and non-ERAS groups was 5.9%(15/253) and 8.3%(21/253), with no statistical significance (χ²=1.077, P>0.05).

Conclusions

The application of ERAS clinical pathway in liver resection under MDT cooperation can significantly shorten the length of postoperative hospital stay and accelerate postoperative recovery.

Key words: Hepatectomy, Enhanced recovery after surgery (ERAS), Multi-disciplinary team (MDT), Perioperative management

Awang Danzeng, Chao Wang, Zhenhua Yang, Zhengwei He, Bixiang Zhang, Binhao Zhang, Ting Wang. Application of ERAS clinical pathway in the perioperative period of hepatectomy under MDT cooperation[J]. Chinese Journal of Hepatic Surgery(Electronic Edition), 2025, 14(05): 732-739.

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References 32

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时间	项目	内容	参与学科
术前	全身状况评估	营养状况评估：NRS 2002；心血管系统：ECG、心脏彩超、血压等；呼吸系统：肺康复风险初筛量表、肺功能测定、血气分析等；肾功能：内生肌酐清除率等；糖代谢：空腹及餐后血糖；心理状况评估：SAS量表；深静脉血栓风险评估	外科、内科、营养科、麻醉科
	基础肝病状况评估	肝炎病毒感染、肝硬化程度、门静脉高压、梗阻性黄疸、治疗相关肝损伤、术前对症治疗	外科、内科
	肝脏可切除性评估	Child-Pugh分级，MELD评分，ICGR15	外科
	宣教及准备	术前疾病知识宣教；适应性训练：呼吸训练、有效咳嗽训练等；术前准备知识宣教：包括疼痛、术后康复、ERAS内容；术前禁食水：术前禁食6 h，禁水2 h；无糖尿病患者术前2 h口服碳水化合物350 ml，糖尿病患者服用350 ml温开水；不常规进行机械性灌肠	外科、麻醉科
术中		精细手术操作，采用低中心静脉压技术，预防性使用抗生素，预防术中低体温，目标导向液体治疗，预防性镇痛，视具体情况放置腹腔引流管（非必须）	外科、麻醉科、手术室
术后		预防性镇痛及多模式镇痛，预防恶心呕吐，过度炎症反应和应激反应调控，并发症的预防及治疗，早期拔除鼻胃管及经口进食，营养支持，早期活动，深静脉血栓预防，术后血糖控制，早期拔除尿管及引流管，促进肠道功能恢复，心理睡眠管理	外科、麻醉科、营养科、康复科、内科
出院护理		出院评估：生活能基本自理；疼痛缓解或口服止痛药能良好控制疼痛；能正常进食，不需要静脉补液；通畅排气排便；肝功能 Child-Pugh 分级A级或胆红素恢复正常或接近正常；切口愈合良好无感染（不必等待拆线）；出院指导：心态、活动、饮食、用药等出院随访	外科、康复科

时间	项目	内容	参与学科
术前	全身状况评估	营养状况评估：NRS 2002；心血管系统：ECG、心脏彩超、血压等；呼吸系统：肺康复风险初筛量表、肺功能测定、血气分析等；肾功能：内生肌酐清除率等；糖代谢：空腹及餐后血糖；心理状况评估：SAS量表；深静脉血栓风险评估	外科、内科、营养科、麻醉科
	基础肝病状况评估	肝炎病毒感染、肝硬化程度、门静脉高压、梗阻性黄疸、治疗相关肝损伤、术前对症治疗	外科、内科
	肝脏可切除性评估	Child-Pugh分级，MELD评分，ICGR15	外科
	宣教及准备	术前疾病知识宣教；适应性训练：呼吸训练、有效咳嗽训练等；术前准备知识宣教：包括疼痛、术后康复、ERAS内容；术前禁食水：术前禁食6 h，禁水2 h；无糖尿病患者术前2 h口服碳水化合物350 ml，糖尿病患者服用350 ml温开水；不常规进行机械性灌肠	外科、麻醉科
术中		精细手术操作，采用低中心静脉压技术，预防性使用抗生素，预防术中低体温，目标导向液体治疗，预防性镇痛，视具体情况放置腹腔引流管（非必须）	外科、麻醉科、手术室
术后		预防性镇痛及多模式镇痛，预防恶心呕吐，过度炎症反应和应激反应调控，并发症的预防及治疗，早期拔除鼻胃管及经口进食，营养支持，早期活动，深静脉血栓预防，术后血糖控制，早期拔除尿管及引流管，促进肠道功能恢复，心理睡眠管理	外科、麻醉科、营养科、康复科、内科
出院护理		出院评估：生活能基本自理；疼痛缓解或口服止痛药能良好控制疼痛；能正常进食，不需要静脉补液；通畅排气排便；肝功能 Child-Pugh 分级A级或胆红素恢复正常或接近正常；切口愈合良好无感染（不必等待拆线）；出院指导：心态、活动、饮食、用药等出院随访	外科、康复科

指标	PSM前				PSM后
指标	ERAS组	非ERAS组	统计值	P值	ERAS组	非ERAS组	统计值	P值
男性(例)	305	459	χ²=0.027	0.870	185	186	χ²=0.010	0.920
年龄[岁, M(Q₁, Q₃)]	51(44, 58)	53(46, 61)	Z=-2.834	0.005	51(44, 57)	53(45, 61)	Z=-1.600	0.110
吸烟史(例)	128	193	χ²=0.002	0.963	76	72	χ²=0.153	0.696
饮酒史(例)	96	98	χ²=9.382	0.002	53	55	χ²=0.047	0.828
HBV感染(例)	197	312	χ²=0.471	0.492	121	122	χ²=0.008	0.929
HCV感染(例)	2	7	χ²=1.167	0.280	1	1	χ²=0.000	1.000
高血压(例)	57	13	χ²=54.351	<0.001	15	12	χ²=0.352	0.553
糖尿病(例)	29	16	χ²=11.951	0.001	13	9	χ²=0.760	0.383
腹部手术史(例)	82	44	χ²=38.308	<0.001	29	34	χ²=0.453	0.501
BMI[kg/m², M(Q₁, Q₃)]	23(21, 25)	23(21, 25)	Z=-2.144	0.032	23(21, 25)	23(21, 25)	Z=-0.028	0.978
ASA分级1~2级(例)	315	393	χ²=20.386	<0.001	186	184	χ²=0.040	0.841
恶性肿瘤(例)	316	492	χ²=0.649	0.420	192	199	χ²=0.551	0.458
肝硬化(例)	138	286	χ²=16.919	<0.001	86	86	χ²=0.030	0.985

指标	PSM前				PSM后
指标	ERAS组	非ERAS组	统计值	P值	ERAS组	非ERAS组	统计值	P值
男性(例)	305	459	χ²=0.027	0.870	185	186	χ²=0.010	0.920
年龄[岁, M(Q₁, Q₃)]	51(44, 58)	53(46, 61)	Z=-2.834	0.005	51(44, 57)	53(45, 61)	Z=-1.600	0.110
吸烟史(例)	128	193	χ²=0.002	0.963	76	72	χ²=0.153	0.696
饮酒史(例)	96	98	χ²=9.382	0.002	53	55	χ²=0.047	0.828
HBV感染(例)	197	312	χ²=0.471	0.492	121	122	χ²=0.008	0.929
HCV感染(例)	2	7	χ²=1.167	0.280	1	1	χ²=0.000	1.000
高血压(例)	57	13	χ²=54.351	<0.001	15	12	χ²=0.352	0.553
糖尿病(例)	29	16	χ²=11.951	0.001	13	9	χ²=0.760	0.383
腹部手术史(例)	82	44	χ²=38.308	<0.001	29	34	χ²=0.453	0.501
BMI[kg/m², M(Q₁, Q₃)]	23(21, 25)	23(21, 25)	Z=-2.144	0.032	23(21, 25)	23(21, 25)	Z=-0.028	0.978
ASA分级1~2级(例)	315	393	χ²=20.386	<0.001	186	184	χ²=0.040	0.841
恶性肿瘤(例)	316	492	χ²=0.649	0.420	192	199	χ²=0.551	0.458
肝硬化(例)	138	286	χ²=16.919	<0.001	86	86	χ²=0.030	0.985

指标	ERAS组	非ERAS组	Z值	P值
RBC(×10¹²/L)	4(4, 5)	4(4, 5)	-0.862	0.388
Hb(g/L)	137(124, 149)	138(126, 152)	-0.952	0.341
Plt(×10⁹/L)	173(131, 231)	182(135, 229)	-0.557	0.578
ALT(U/L)	24(15, 37)	21(14, 32)	-1.510	0.121
AST(U/L)	25(19, 34)	25(19, 35)	-0.431	0.667
ALB(g/L))	41(38, 443)	42(39, 45)	-1.460	0.144
TB(μmol/L)	11(8, 14)	12(9, 15)	-1.731	0.083
DB(μmol/L)	4(3, 6)	4(3, 6)	-0.268	0.788
Scr(μmol/L)	70(61, 81)	70(61, 78)	-0.500	0.617
BUN(μmol/L)	5(4, 6)	5(4, 6)	-0.537	0.592
PT(s)	14(13, 14)	14(13, 14)	-1.319	0.187
PTA(%)	91(85, 99)	93(84, 99)	-1.169	0.242
APTT(s)	38(36, 40)	37(35, 41)	-0.098	0.922

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