| Background:Liver resection is the preferred treatment for a variety of primary and secondary liver tumours. However, liver resection is associated with severe stress response, tardy recovery and a high rate of postoperative morbidity and mortality. The document recorded that the incidence of postoperative complications is as high as 15% -48% with an average of 10-day hospital stay. In addition to attaching great importance to these main factors--- postoperative bleeding, bile leakage, intra-abdominal abscess formation, liver failure, renal insufficiency, pulmonary infection, wound infection and other complications that hinder the rehabilitation of patients with liver resection, postoperative pain, slow recovery of gastrointestinal function, prolonged bed rest and other adverse effects on postoperative rehabilitation are also needed to be highly valued. Intensive perioperative management, reduction in physical and mental stress of perioperative patients, abatement of postoperative adverse reactions and complications are of great significance of rapid recovery after hepatectomy.Fast track surgery (Fast tract surgery, FTS) refers to the preoperative, intraoperative and postoperative, using perioperative optimization measures by a series of evidence based medicine to mitigate or reduce physical and mental stress of the patients, promote rapid postoperative recovery. To reduce the trauma and perioperative stress response, diminish postoperative complications, thereby contributing to the rapid recovery of surgical patients is the core of FTS. FTS optimize interventions include strengthening the preoperative education, abolishing of preoperative bowel preparation, shortening preoperative fasting water time; intraoperative wanning, intraoperative epidural anesthesia combined with general endotracheal anesthesia in order to reduce the use of opioid; no indwelling stomach tube postoperatively, postoperative indwelling abdominal cavity drainage tube, avoid overloading and exuding the liquid, eating early and full analgesia postoperatively, early postoperative ambulation activities, etc.. FTS was studied by Henrik Kehlet foremost. Since 2001 when the concept of FTS was firstly proposed by him, FTS has been successfully applied to gastrointestinal surgery, thoracic surgery, joint surgery, urology and other fields. Studies have shown that FTS concept can effectively be applied to and promote the recovery of gastrointestinal function, reduce postoperative pain, abate postoperative complications, shorten postoperative hospital stay after surgery. Currently the concept of FTS has become the new standard for colorectal surgery perioperative process.In 2008, MacKay, G first applied FTS to liver resection patients. Discharged under the same standards, patients was shortened the median postoperative hospital stay from eight days to six days. The study shows that the concept of fast track surgery applied to liver resection patients is safe and effective, which can promote recovery as well ad shorten hospital stay. Subsequently, FTS began to raise a widespread concern among the hepatobiliary-surgery experts. Therefore, a number of relevant experts from different countries studied on the effect of fast track surgery for liver resection patients postoperatively. Research shows that patients can benefit a lot from fast track surgery, such as promoting the recovery of gastrointestinal function, reducing postoperative pain, abating postoperative complications, and promoting postoperative recovery, shortening hospital stay, increasing patient satisfaction, etc..In recent years, although there are a small number of reports on some of the measures used successfully in patients with liver resection of fast track surgery, the concept applied to fast track surgery on patients with liver resection is still in the exploratory stage. As some ideas between the perioperative surgical treatment in FTS and traditional treatment becomes contradictory and even contrary, a number of measures still have not been accepted and applied to the clinical application in fact. Traditional measures like overnight fasting, bowel preparation routine preoperative, intraoperative conventional indwelling peritoneal drainage tube, postoperative conventional indwelling stomach tube, postoperative delay of food intake and other traditional measures are still routinely used in patients with liver resection in most hospitals.Overall, the concept applied researches on FTS hepatectomy perioperative treatment is still very few. The core of FTS is to abate perioperative physical and mental stress of patients, while most of the existing clinical trial studies are on the impact of the length of postoperative hospital stay, postoperative complications, discharge time, pain, etc. of patients after liver resection of FTS. There is still no clinical trial study on the impact of stress response index of hepatectomy patients by FTS. In addition, FTS is an open concept; all beneficial postoperative rehabilitation interventions for patients should be included. In recent years, studies have shown that preoperative use of a large dose of hormones can help to reduce the stress response of postoperative liver resection patients and maintain liver function. Oral probiotic bacteria help to maintain gastrointestinal flora balance, reduce intestinal infection complications, increase immunity, protect the liver function and promote liver regeneration. For patients undergoing liver resection, on one hand, perioperative oral probiotic bacteria can stimulate recovery of gastrointestinal function. On the other hand, perioperative oral probiotic bacteria can promote the recovery of liver function, abate postoperative complications, promote postoperative recovery, and shorten the length of hospital stay.Therefore, the clinical trials attempt to enrich and improve the FTS concept by a large dose of methylprednisolone before surgery and oral probiotic drinks after surgery. The trials also study on safety and effectiveness in the perioperative liver resection treatment of FTS, focusing on the evaluation of preoperative thirst hunger, achieving the expected discharge time, the length of postoperative hospital stay, changes of perioperative stress index, postoperative pain, postoperative recovery of gastrointestinal function, the lasting time of indwelling catheter, The period of peritoneal drainage, the impacts of postoperative complications as well.Purpose:To explore and discuss on the safety, effectiveness and impact of stress after hepatectomy in perioperative treatment of FTS, for the promotion of the idea of FTS providing evidence of surgical application of based medicine in patients with liver resection.Methods:60 cases of patients undergoing liver resection or deadline are divided randomly into FTS group and the control group (30 cases).The patients in FTS group received optimization treatment in perioperative period under the guidance of FTS, while using traditional perioperative treatment in the control group. These two groups of patients share common discharge standards---comparative analysis of thirst hunger before surgery, achieving the expected discharge time, the length of postoperative hospital stay, changes of perioperative stress index, postoperative pain, postoperative recovery of gastrointestinal function, the lasting time of indwelling catheter, the period of peritoneal drainage, and postoperative complications.The optimization treatment of FTS group:strengthening the preoperative education to patients; orally taking Celecoxib 200mg 3 days before the operation, twice a day; no bowel preparation before surgery; preoperative fasting 6 hours, 2-hour water deprivation, orally taking 250ml of 5% glucose solution 2 hours before surgery; giving 500mg methylprednisolone by intravenous drip 30 minutes in preoperative period; no conventional indwelling stomach tube during operation; strictly maintain body temperature within the normal range during operation; target-oriented fluid infusion; venous pressure control from 4 to 5mmHg during operation; selective indwelling abdominal drainage tube depending on the patient in intraoperative period; drinking water is allowed 6 hours after operation, having liquid diet one day after operation, chewing gum from the first in postoperative period; having probiotic bacteria drinks, a gradual transition to a normal diet; In order to recovery, enhancing exercises, like on-bed movement or off-bed activity are allowed 6 hours or a day after operation, routine indwelling venous analgetic pump 2 days after operation; regular injection of parecoxib 40mg during the first three days after operation, twice a day; 200mg oral celecoxib from the fourth day in the postoperative time, twice a day; removing gastric tube after anesthesia; removing catheter the first day after operation; removing peritoneal drainage tube as soon as possible.Traditional group treatment:preoperative routine conversation; fasting 12 hours after operation, water deprivation 6 hours in the postoperative period; routine preoperative conventional bowel preparation; conventional indwelling stomach tube; routinely drinking water after deflating; voluntary ambulation to the patients in the second or third day after operation; routine indwelling venous analgetic pump 2 days after operation, if necessary, additional temporary opioid analgesics is acceptable; removing gastric tube after deflating; removing catheter after off bed; removing peritoneal drainage tube when the amount of clear peritoneal fluid is less than 100ml.Results:60 cases of patients completed the experiment successfully. They were divided into two groups,30 patients in FTS group, and 30 patients in traditional group. The results of this study are presented as follows:1.In the following different aspects including gender distribution, age, BMI, ASA grade, Child classification of the liver function, lesion nature, tumor size, operative method, cirrhosis of liver, operation, intraoperative blood loss, rate of blood transfusion had no statistical significance.2.Preoperative thirst and hunger:The incidence of thirst in FTS group in preoperative time was (3/30 vs.22/30, P<0.001), and the incidence of hunger was (5/30 vs.19/30, P<0.001), which decreased significantly compared with traditional group.3.Postoperative time to discharge from hospital:The postoperative median discharge from hospital was 5 days in FTS group, while 7 days in traditional group. Compared with traditional group, it was significantly shorter in FTS group. The difference was statistically significant.4.Postoperative length of stay(LOS):The postoperative median length of stay was 7 days in FTS group, while 9 days in traditional group. Compared with traditional group, it was significantly shorter in FTS group. The difference was statistically significant.5.Postoperative stress index:Compared with traditional group, CRP and IL-6 decreased significantly in FTS group in the third, fourth and fifth day in the postoperative period. Growth hormone declined in the first day in the postoperative period. Cortisol decreased in the first and fifth day in postoperative time. The differences were statistically significant. In these two groups, there were no statistically significant differences in postoperative prolactin, leukocyte, blood glucose.6.Postoperative pain:The median score of VAS in the first and second day in postoperative time in FTS group were 2 points, while in traditional group the median score of VAS in the first and second day in postoperative time were 3 points. Compared with traditional group, patients’pain in FTS group were more alleviated. The differences were statistically significant (P<0.05). The median score of VAS in the third, fourth and fifth day in postoperative time in FTS group were 1 point, while in traditional group the median score of VAS in the third,fourth day in postoperative time were 2 points and 1 point in the fifth day. The difference was not statistically significant in both group (P> 0.05).7.Recovery of gastrointestinal function:the first exhaust time of patients in FTS group in the postoperative period was (2.1±1.4 vs.3.2±2.1 days, P=0.02),and the first defecation time was (3.3±1.3 vs.4.9±1.8 days, P<0.001).Both of the first exhaust time and defecation time were apparently shorter than in traditional group. Compared with traditional group, the incidence of abdominal distension, vomiting, reinsertion of a gastric tube was no statistical significance in FTS group.8.The lasting time of indwelling catheter:The average time of FTS group was 18.4h while the average time of traditional group was 47.5h. Compared with the period of peritoneal drainage in traditional group, FTS group was shorter (P<0.01).9.The period of peritoneal drainage:The average time of FTS group was 1.8d, while the average time of traditional group was 3.7d. Compared with the period of peritoneal drainage in traditional group, FTS group was shorter (P<0.01)lO.Postoperative complications:The totle postoperative complications was significantly decreased in the FTS group compared to traditional group (Dindo-Clavien classification).Conclusions:The idea of applying FTS to perioperative liver resection is of safety and effectiveness. As a result, patients can abate stress response in postoperative period, accelerate the process of rehabilitation and shorten the length of hospital stay. The application of FTS is of high reference value to planning the clinical pathway in liver resection. |
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