背景:机器人手术和ERAS协议护理都是突出的发展,并已成为全球趋势。然而,机器人手术和ERAS护理联合应用于结直肠切除术的效果和学习曲线尚未得到很好的验证.本研究旨在介绍我们的实际经验,并建立在结直肠切除术的微创手术中实施ERAS计划所需的学习曲线。同时还评估了机器人技术的发展对ERAS结果的影响。
方法:共有155名患者接受了选择性,微创手术,包括腹腔镜手术和机器人手术,本回顾性分析包括2019年6月至2021年9月期间的ERAS护理.患者按时间顺序分为五组(每五分之一31例)。患者人口统计学,肿瘤特征,围手术期数据,ERAS合规性,和手术结果都在五分位数之间进行了比较。根据ERAS顺应性和最佳回收率评估学习曲线,由没有重大并发症组成,术后住院时间(LOS)不超过5天,30天内不能再入院.使用多变量逻辑回归模型评估与术后LOS相关的因素。
结果:在人口统计学和肿瘤特征参数方面,总体或五分之一组之间没有统计学上的显着差异。共有79名患者(51%)接受了机器人手术,机器人组的比例按时间顺序从第一个五分之一的零上升到第五个五分之一的90.3%(p<0.001)。总体ERAS方案的中位符合率为83.3%,第一五分之一为72.2%,第二至第五五分之一为83.3%(p<0.001)。共有85例患者接受了手术后的最佳恢复,第一个五分之一中的四名患者,第二个五分之一的11名患者,分别为第3-5个五分位数的21、24、25名患者(p<0.001)。术后LOS从早期组到晚期组有显著改善(p<0.001)。此外,手术结果包括手术后24小时内首次口服,首次大便时间和静脉输液的提前终止显示,五分位患者的首次大便时间有显著改善.多变量逻辑回归模型表明,机器人手术在术后LOS时优于腹腔镜手术(比值比=5.029,95%置信区间[CI]=1.321至19.142;p=0.018)。
结论:我们的经验表明,在微创结直肠手术中有效实施ERAS计划需要31名患者达到更高的依从性,并且需要更多的病例达到成熟阶段以实现最佳恢复。我们认为,开发机器人平台不会影响ERAS实施的学习曲线。此外,对于接受结直肠切除术的患者,通过ERAS护理和机器人手术的组合,对手术的术后长度有有益的影响.
BACKGROUND: Robotic surgery and ERAS protocol care are both prominent developments and have each become global trends. However, the effects and learning curves of combining robotic surgery and ERAS care in colorectal resection have not yet been well validated. This study aimed to present our real-world experience and establish the learning curves necessary for the implementation of an ERAS program in minimally-invasive surgery for colorectal resection, while also evaluating the impact that the development of the robotic technique has on ERAS outcomes.
METHODS: A total of 155 patients who received elective, minimally-invasive surgery, including laparoscopic and robotic surgery for colorectal resection, with ERAS care during the period June 2019 to September 2021 were included in this retrospective analysis. Patients were divided chronologically into five groups (31 cases per quintile). Patient demographics, tumor characteristics, perioperative data, ERAS compliance, and surgical outcomes were all compared among the quintiles. Learning curves were evaluated based on ERAS compliance and optimal recovery, which are composed of an absence of major complications, postoperative length of stay (LOS) of no more than five days, and no readmission within 30 days. A multivariable logistic regression model was used to assess factors associated with postoperative LOS.
RESULTS: There were no statistically significant differences seen overall or between the quintile groups in regards to demographic and tumor characteristic parameters. A total of 79 patients (51%) received robotic surgery, with the ratio of robotic groups rising chronologically from zero in the first quintile to 90.3% in the fifth quintile (p < 0.001). The median compliance rate of total ERAS protocol was 83.3% overall, 72.2% in the first quintile and 83.3% in the 2nd-5th quintiles (p < 0.001). A total of 85 patients underwent optimal recovery after surgery, four patients in the first quintile, 11 patients in the second quintile, and 21, 24, 25 patients in the 3rd-5th quintiles respectively (p < 0.001). There were significant improvements from early to later groups upon postoperative LOS (p < 0.001). In addition, the surgical outcomes including first oral intake within 24 hours after surgery, time to first stool and early termination of intravenous fluid administration showed significant improvement among the quintiles. A multivariable logistic regression model demonstrated that robotic surgery was superior to laparoscopic surgery upon postoperative LOS (odds ratio = 5.029, 95% confidence interval [CI] = 1.321 to 19.142; p = 0.018).
CONCLUSIONS: Our experience demonstrated that an effective implementation of the ERAS program in minimally-invasive colorectal surgery requires 31 patients to accomplish the higher compliance and requires more cases to reach the maturation phase for optimal recovery. We believe that developing a robotic platform would have no impact on the learning curve of ERAS implementation. Moreover, there is a beneficial effect on the postoperative length of surgery provided through the combination of ERAS care and robotic surgery for patients undergoing colorectal resection.