Clinical Application Of ERAS In Laparoscopic Splenectomy Combined With Pericardial Devascularization

Part ⅠThe cliniacal application of goal directed fluid therapy in salvage fluid resuscitation for acute upper gastrointestinal bleeding secondary to HBV/HCV portal hypertension and liver cirrhosisObjectiveTo evaluate the clinaical effect of the goal directed fluid therapy(GDFT)in salvage fluid resuscitation for the patients with acute upper gastrointestinal bledding secondary to HBV/HCV portal hypertension and liver cirrhosis prospectively comparing with traditional fluid therapy.MethodsA single-blind,randomized,controlled study was pergformed.The cliniacal data of 45 patients with acute upper gastrointestinal bledding secondary to HBV/HCV portal hypertension and liver cirrhosis were prospectively analyzed from January 2013 to December 2015 at the People’s Hospital of Zhengzhou University.22 patients were divided into the traditional fluid therapy(control)group with CVP 5～12mmHg and MAP 65-90mmHg,23 patients were divided into the goal directed fluid therapy(GDFT)group with CI 2.5～4L/min×m2,SVV<13%and urine output>0.5ml/(kg h),based on a random number table.The time of salvage fluid resuscitation,fluid volume,tansfusion volume,number of patients with rebleeding and complications which occurred 72 hours after goals of salvage liquid resuscitation were compared between the control group and the GDFT group.The clinical effects of GDFT and traditional fluid therapy on the blood test,coagulation function,hemodynamic,hepatic function and perfusion,and oxygen metabolism were evaluated before treatment(TO),the timet of achiving resuscitation and 24 hours after goals of salvage liquid resuscitation(T2).Results(1)42 patients were included into the research with 2 cases excluded for emergency operation in control group and 1 case excluded for death in GDFT group before the goals of salvage liquid resuscitation.There were 20 patients in the control group and 22 patients in the GDFT group.There was no significant difference between the control group and the GDFT group(P>0.05).(2)To achive the goals of salvage liquid resuscitation,the control group needed 51.95±1.64h,fluid 3495.45±56.23ml and blood transfusion 912.05±35.95ml.And the GDFT group needed 34.09±2.16h,fluid 2800.05±56.27ml and blood transfusion 912.05±35.95ml,showing statistically differences(P<0.05).At the time of 72 hours after goals of salvage liquid resuscitation,there wre 9 patients and 3 patients with rebleeding in the control group and the GDFT group,respectively,showing statistically differences(P<0.05);There were 9 patients with respiratory complications,11 patients with cardiovascular complications and 3 patients with other complications in the control group;and there were 5 patients with respiratory complications,4 patients with cardiovascular complications and 4 patients with other complications in the GDFT group,showing statistically differences(P<0.05).(3)After the salvage liquid resuscitation,the blood test and coagulation function were inproved.There was no significant difference in blood test and coagulation function between the GDFT group and traditional group(P>0.05).(4)The hemodynamic was improved and stabilized after salvage fluid resuscitation.The rate of heart declined gradually,and the MAP and CVP were promoted gradually,the levels of HR,MAP and CVP were better in the GDFT group than those in the control group,with statistically significant differences in changing trends(P<0.05).There was no statistically difference between the control group and the GDFT,group with the level of HR,MAP and CVP in TO(P<0.05).In T1 and T2,the levels of HR,MAP and CVP were better in the GDFT group than those in the control group,showing statistically differences(P<0.05).There were 12 patinets who needed noradrenalin with mean dosage 0.20±0.02·g/kg·min in the control group and 6 patinets with mean dosage 0.13±0.01μg/kg·min in the GDFT group,showing statistically differences(P<0.05).(5)There was no difference in liver function between the GDFT group and control group in the changing trends.The level of ICG-R15 was higher than normal in both groups in T0.With the salvage fluid resuscitation,the level of ICG-R15 declined gradually and the hepatic perfusion was promoted,better in the GDFT group than that in the control group,with statistically significant differences in changing trends(P<0.05).There was no statistically difference between the control group and the GDFT group with the level of ICG-R15 in TO(P<0.05).In T1 and T2,the level of ICG-R15 was better in the GDFT group than those in the control group,showing statistically differences(P<0.05).(6)There was no significant difference in PH between the GDFT group and control group(P>0.05),The level of lactate declined gradually,urine output and ScvO2 increased signigicantly,better in the GDFT group than those in the control group,with statistically significant differences in changing trends(P<0.05).There was no statistically difference between the control group and the GDFT group with the level of lactate,urine output and ScvO2 in TO(P<0.05).In T1 and T2,the levels of lactate,urine output and ScvO2 were better in the GDFT group than those in the control group,showing statistically differences(P<0.05).ConclusionThe goal directed fluid therapy(GDFT)could promeoted effectively the hemodynamic,improved the tissue microcirculation and oxygen metabolism,and promeoted the hepatic perfusion in the patients with acute upper gastrointestinal bleeding secondary to HBV/HCV portal hypertension and liver cirrhosis comparing with the traditional therapy in the salvage liquid resuscitation.PartⅡThe clinical application of laparoscopic splenectomy for massive splenomegaly in patients with HBV/HCV portal hypertension and liver cirrhosisObjectiveTo investigate the clinical application value of the spleen bed approach laparoscopic splenectomy for massive splenomegaly in patients with HBV/HCV portal hypertension and liver cirrhosis comparing with anterior approach laparoscopic splenectomy.MethodsA retrospective cohort study was adopted.The cliniacal data of 32 patients with massive splenomegaly secondary to HBV/HCV portal hypertension and liver cirrhosis were prospectively analyzed from January 2013 to December 2015 at the People’s Hospital of Zhengzhou University.15 patients undergoing the anterior approach laparoscopic splenectomy were allocated to the control group,17 patients undergoing the spleen bed approach laparoscopic splenectomy were allocated to the case group.The general information,blood test,liver function,coagulation function,reason of splenomegaly and diameter of spleen were observed.The operation time,blood loss,blood transfusion,number of patients with blood transfusion,conversion rate,hemorrhage of gastric short vein,gastric fistula,pancreatic fistula,rebleeding,and duration of hospital stay were collected and analyzed.Results(1)There was no significant difference in general information,blood test,liver function,coagulation function,reason of splenomegaly and diameter of spleen between the control group and case group(P>0.05).(2)There was no death in both groups.The time of operation was 209.33±22.75 min vs 168.82+24.40 min,the volume of intraoperative blood loss was 480.00±106.57 ml vs 350.00±95.20 ml,the volume of blood transfusion was 382.93±66.62 ml vs 219.94±44.05 ml in the control group and the case group,respectively,showing statistically differences(P<0.05).There were 7 patients with hemorrhage of gastric short vein in the control group and 2 patients in the case group,with statistically differences(P<0.05).There were 6 patients with conversion in the control group and 1 patients in the case group,with statistically differences(P<0.05).There were 7 patients with blood transfusion in the control group and 2 patients in the case group,with statistically differences(P<0.05).There were 6 patients with pancreatic fistula and cured with grade A 3 patients,grade B 2 patients and grade C 1 patients in the control group and 3 patients with pancreatic fistula and cured with grade A 3 patients in the case group,showing statistically differences(P<0.05).There were 4 patients with postoperative rebleeding and cured(3 patinents with conservative treatment and 1 patients with emergency operation)in the control group and 0 patient with postoperative rebleeding,showing statistically differences(P<0.05).The duration of hospital stay was 11.40±0.74d in the control group and 6.53±0.72d in the case group,with statistically differences(P<0.05).There were 2 patients with gastric fistula and cured with conservative treatment in the control group and 0 patient in the case group,showing no differences(P>0.05).Conclusion.The the spleen bed approach laparoscopic splenectomy for massive splenomegaly in patients with HBV/HCV portal hypertension and liver cirrhosis was safter and more effective comparing with the anterior approach laparoscopic splenectomyPartⅢThe clinical application of ERAS in laparoscopic splenectomy combined with pericardial devascularizationObjectiveTo evaluate the clinical application of ERAS in laparoscopic splenectomy combined with pericardial devascularization for patients with HBV/HCV portal hypertension and liver cirrhosis comparing with traditional therapy.MethodsA single-blind,randomized,controlled study was pergformed.The clinical data of 43 patients with portal hypertension secondary to HBV/HCV liver cirrhosis were prospectively analyzed from January 2014 to December 2015 at the People’s Hospital of Zhengzhou University.All patients underwent laparoscopic splenectomy combined with pericardial devascularization.20 patients were allocated to the control group with the traditional therapy,23 patients were allocated to the ERAS group with the ERAS therapy,based on a random number table.The general information,operation time,volume of intraoperative blood and number of patients receiving blood transfusion,time of gastric tube removal,time of catheter removal,time of abdominal tube,time to flatus,time of food intake,duration of postoperative infusion,duration of postoperative hospital stay and numeric rating scale,complications and quality of life were collected and analyzed.Results(1)There was no significant difference in the general information,operation time,volume of intraoperative blood and number of patients receiving blood transfusion,between the control group and ERAS group(P>0.05).(2)The time of gastric tube removal,catheter removal,abdominal tube,flatus,food intake,and duration of postoperative infusion and postoperative hospital stay were shorter in the ERAS group than the control group,showing statistically differences(P<0.05).(3)The scores of QOL from pre-operation to postoperative month 6 and 12 were:vitality,social functioning,role emotional,mental health,physical functioning,role physical,bodily pain,general health were higher in the ERAS group than the control group,with statistically significant differences in changing trends(P<0.05).ConclusionERAS managements in the perioperative period of laparoscopic splenectomy combined with pericardial devascularization reduced the duration of hospital stay and incidence of postoperative complications.ERAS was safe and beneficial to postoperative recovery of patients.PartⅣThe effect of ERAS on the early postoperative acute inflammatory stress of patients undergoing laparoscopic splenectomy combined with pericardial devascularizationObjectiveTo compare the effect of ERAS on the early postoperative acute inflammatory stress of the patients undergonging laparoscopic splenectomy combined with pericardial devascularization with traditional therapy.MethodsA single-blind,randomized,controlled study was pergformed.The clinical data of 43 patients with portal hypertension secondary to HBV/HCV liver cirrhosis were prospectively analyzed from January 2014 to December 2015 at the People’s Hospital of Zhengzhou University.All patients underwent laparoscopic splenectomy combined with pericardial devascularization,20 patients were allocated to the control group with the traditional therapy,23 patients were allocated to the ERAS group with the ERAS therapy,based on a random number table.The level of IL-6,TNF-α,CRP and HSP70,blood glusose,insulin and insulin resistance index of peripheral blood between the ERAS group and control group within 5 days after surgery were compared.Results(1)There was no significant difference in general information between the control group and ERAS group(P>0.05).(2)The changes of blood glucose,insulin and insulin resistance index were similar between the control group and ERAS group.On POD 1,the level of blood glucose,insulin and insulin resistance index increased,and to the peak on the the POD 3,then decreased gradually and higher in the control group than those in the ERAS group,with statistically significant differences in changing trends(P<0.05).There was no statistically difference between the control group and the ERAS group with the level of blood glucose,insulin and insulin resistance index on POD 0(P>0.05).On POD 1,POD 3 and POD 5,the level of blood glucose,insulin and insulin resistance index(IR)were lowever in the ERAS group than those in the control group,showing statistically differences(P<0.05).The changes of CRP and HSP70 were similar between the control group and the ERAS group,increased after operation and then decreased gradually,and higher than that on POD 0 in the control group and the ERAS group,with statistically significant differences in changing trends(P<0.05).There was no statistically difference between the control group and the ERAS group with the levels of CRP and HSP70 on POD 0(P>0.05).On POD 1,POD 3 and POD 5,the levels of CRP were lowever in the ERAS group than those in the control group,the levels of HSP70 were higher in the ERAS group than those in the control group,showing statistically differences(P<0.05).The changes of IL-6 and TNF-a were similar between the control group and ERAS group.On POD 1,the levels of IL-6 and TNF-a increased,and to the peak on the POD 3,then decreased gradually,and higher than that on POD 0,with statistically significant differences in changing trends(P<0.05).There was no statistically difference between the control group and the ERAS group with the levels of IL-6 and TNF-a on POD 0(P>0.05).On POD 1,POD 3 and POD 5,the levels of IL-6 and TNF-a were lowever in the ERAS group than those in the control group,showing statistically differences(P<0.05).ConclusionERAS managements optimized the perioperative management of preoperative,intraoperative and postoperative,and could reduce the early postoperative stress response of laparoscopic splenectomy combined with pericardial devascularization.PartⅤThe effect of ERAS on the early postoperative immune system of patients undergoing laparoscopic splenectomy combined with pericardial devascularizationObjectiveTo compare the effect of ERAS on the early postoperative immune system of the patients undergonging laparoscopic splenectomy combined with pericardial devascularization with traditional therapy.MethodsA single-blind,randomized,controlled study was pergformed.The clinical data of 43 patients with portal hypertension secondary to HBV/HCV liver cirrhosis were prospectively analyzed from January 2014 to December 2015 at the People’s Hospital of Zhengzhou University.All patients underwent laparoscopic splenectomy combined with pericardial devascularization.20 patients were allocated to the control group with the traditional therapy,23 patients were allocated to the ERAS group with the ERAS therapy,based on a random number table.The levels of CD3,CD4,CD8 T lymphocytes of peripheral blood and IgA,IgG and IgM of peripheral blood between the ERAS group and the control group within 5 days after surgery were compared.Results(1)There was no significant difference in general information between the control group and ERAS group(P>0.05).(2)The expression of CD3+T and CD4+T cells in the control group and the ERAS group decreased to the lowest on POD 1,then gradually recovered and higher in the ERAS group than those in the control group,with statistically significant differences in changing trends(P<0.05).There was no statistically difference between the control group and the ERAS group with the levels of CD3+T and CD4+T cells on POD 0(P>0.05).On POD 1,POD 3 and POD 5,the levels of CD3+T and CD4+T cells were higher in the ERAS group than those in the control group,showing statistically differences(P<0.05).There was no significant difference between the two groups in the expression of CD8+T cells(P>0.05).The expression of CD4+/CD8+T cells in the control group and the ERAS group decreased to the lowest on POD 1,then gradually recovered and higher in the ERAS group than those in the control group,with statistically significant differences in changing trends(P<0.05).There was no statistically difference between the control group and the ERAS group with the level of CD4+/CD8+T cells on POD 0(P>0.05).On POD 1,POD 3 and POD 5,the level of CD4+/CD8+T cells was higher in the ERAS group than those in the control group,and the level of CD4+/CD8+T cells was higher than that on POD 0,showing statistically differences(P<0.05).There was no significant difference between the two groups in the levels of IgA、IgG and IgM(P>0.05).The levels of IgA、IgG and IgM decreased on different degrees,to the lowest on POD 3,then gradually recovered and higher in the ERAS group than those in the control group,with statistically significant differences in changing trends(P<0.05).On POD 1,POD 3 and POD 5,the levels of IgA、IgG and IgM were higher in the ERAS group than those in the control group,and the levels of IgA、IgG and IgM were lower than that on POD 0,showing statistically differences(P<0.05).ConclusionERAS managements were more advantageous to reduce the early postoperativesuppression of immune function in laparoscopic splenectomy combined with pericardial devascularization compared with the traditional therapy.