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Abstract：
BACKGROUND: For open fetal spina bifida (fSB) repair, a maternal laparotomy is required. Hence, enhanced maternal recovery after surgery (ERAS) is paramount. A revision of our ERAS protocol was made, including changes in operative techniques and postoperative pain management. This study investigates eventual benefits.
METHODS: Our study included 111 women with open fSB repair at our center. The old protocol group (group 1) either received a transverse incision of the fascia with transection of the rectus abdominis muscle (RAM) or a longitudinal incision of the fascia without RAM transection, depending on placental location. The new protocol required longitudinal incisions in all patients (group 2). Postoperative pain management was changed from tramadol to oxycodone/naloxone. Outcomes of the two different protocol groups were analyzed and compared regarding the primary endpoint, the length of hospital stay (LOS) after fetal surgery, as well as regarding the following secondary endpoints: postoperative pain scores, day of first mobilization, removal of urinary catheter, bowel movement, and the occurrence of maternal and fetal complications.
RESULTS: Out of 111 women, 82 (73.9%) were in group 1 and 29 (26.1%) were in group 2. Women in group 2 showed a significantly shorter LOS (18 [14-23] days vs. 27 [18-39] days, p = 0.002), duration until mobilization (3 [2-3] days vs. 3 [3-4] days, p = 0.03), and removal of urinary catheter (day 3 [3-3] vs. day 4 [3-4], p = 0.004). Group 2 less often received morphine subcutaneously (0% vs. 35.4%, p < 0.001) or intravenously (0% vs. 17.1%, p = 0.02) but more often oxycodone (69.0% vs. 18.3%, p < 0.001). No significant differences were seen regarding pain scores, bowel movement, and maternal and/or fetal complications.
CONCLUSIONS: The new ERAS protocol that combined changes in surgical technique and pain medication led to better outcomes while reducing LOS. Continuous revisions of current ERAS protocols are essential to improve patient care continuously.
METHODS: Our study included 111 women with open fSB repair at our center. The old protocol group (group 1) either received a transverse incision of the fascia with transection of the rectus abdominis muscle (RAM) or a longitudinal incision of the fascia without RAM transection, depending on placental location. The new protocol required longitudinal incisions in all patients (group 2). Postoperative pain management was changed from tramadol to oxycodone/naloxone. Outcomes of the two different protocol groups were analyzed and compared regarding the primary endpoint, the length of hospital stay (LOS) after fetal surgery, as well as regarding the following secondary endpoints: postoperative pain scores, day of first mobilization, removal of urinary catheter, bowel movement, and the occurrence of maternal and fetal complications.
RESULTS: Out of 111 women, 82 (73.9%) were in group 1 and 29 (26.1%) were in group 2. Women in group 2 showed a significantly shorter LOS (18 [14-23] days vs. 27 [18-39] days, p = 0.002), duration until mobilization (3 [2-3] days vs. 3 [3-4] days, p = 0.03), and removal of urinary catheter (day 3 [3-3] vs. day 4 [3-4], p = 0.004). Group 2 less often received morphine subcutaneously (0% vs. 35.4%, p < 0.001) or intravenously (0% vs. 17.1%, p = 0.02) but more often oxycodone (69.0% vs. 18.3%, p < 0.001). No significant differences were seen regarding pain scores, bowel movement, and maternal and/or fetal complications.
CONCLUSIONS: The new ERAS protocol that combined changes in surgical technique and pain medication led to better outcomes while reducing LOS. Continuous revisions of current ERAS protocols are essential to improve patient care continuously.
摘要：
背景：对于开放性胎儿脊柱裂（fSB）修复，产妇需要剖腹手术。因此，提高产妇术后恢复(ERAS)至关重要.我们修改了ERAS协议,包括手术技术和术后疼痛管理的改变。这项研究调查了最终的好处。
方法：我们的研究包括111名在我们中心进行开放式fSB修复的女性。旧方案组（第1组）接受横切腹直肌（RAM）的筋膜横向切口或不横切RAM的筋膜纵向切口，取决于胎盘位置。新方案要求在所有患者中进行纵向切口（第2组）。术后疼痛管理从曲马多改为羟考酮/纳洛酮。分析并比较了两个不同方案组的主要终点，胎儿手术后的住院时间（LOS），以及以下次要终点：术后疼痛评分，第一次动员的日子，拔除导尿管,排便,以及母婴并发症的发生。
结果：在111名女性中，第1组82例（73.9%），第2组29例（26.1%）。第2组的女性LOS明显较短（18[14-23]天vs.27[18-39]天，p=0.002),直到动员的持续时间(3[2-3]天vs.3[3-4]天,p=0.03),和拔除导尿管（第3天[3-3]vs.第4天[3-4]，p=0.004)。第2组不太经常皮下接受吗啡(0%vs.35.4%,p<0.001)或静脉注射(0%vs.17.1%,p=0.02),但更常见的是羟考酮(69.0%vs.18.3%,p<0.001)。在疼痛评分方面没有发现显著差异，排便,以及母体和/或胎儿并发症。
结论：新的ERAS方案结合了手术技术和止痛药的变化，导致了更好的结果，同时降低了LOS。当前ERAS协议的持续修订对于持续改善患者护理至关重要。
方法：我们的研究包括111名在我们中心进行开放式fSB修复的女性。旧方案组（第1组）接受横切腹直肌（RAM）的筋膜横向切口或不横切RAM的筋膜纵向切口，取决于胎盘位置。新方案要求在所有患者中进行纵向切口（第2组）。术后疼痛管理从曲马多改为羟考酮/纳洛酮。分析并比较了两个不同方案组的主要终点，胎儿手术后的住院时间（LOS），以及以下次要终点：术后疼痛评分，第一次动员的日子，拔除导尿管,排便,以及母婴并发症的发生。
结果：在111名女性中，第1组82例（73.9%），第2组29例（26.1%）。第2组的女性LOS明显较短（18[14-23]天vs.27[18-39]天，p=0.002),直到动员的持续时间(3[2-3]天vs.3[3-4]天,p=0.03),和拔除导尿管（第3天[3-3]vs.第4天[3-4]，p=0.004)。第2组不太经常皮下接受吗啡(0%vs.35.4%,p<0.001)或静脉注射(0%vs.17.1%,p=0.02),但更常见的是羟考酮(69.0%vs.18.3%,p<0.001)。在疼痛评分方面没有发现显著差异，排便,以及母体和/或胎儿并发症。
结论：新的ERAS方案结合了手术技术和止痛药的变化，导致了更好的结果，同时降低了LOS。当前ERAS协议的持续修订对于持续改善患者护理至关重要。
