Randomized Controlled Study Of Enhanced Recovery After Surgery Concept In Patients Undergoing Endometrial Adenocarcinoma Surgery With Da Vinci Robot

BackgroundFast track surgery(FTS)refers to enhanced recovery after surgery(ERAS),which was first proposed by Kehlet.Effective perioperative management measures proved by various studies are adopted to reduce inflammatory stress response,complications,readmission rate and mortality rate,and promote the recovery process.The concept of ERAS includes preoperative consultation and education,avoidance of mechanical enema,combined anesthesia,application of minimally invasive surgery,strengthening heat preservation,standardizing liquid management,multi-mode combined analgesia,early oral feeding and other aspects.At present,the application of ERAS concept in the field of gynecology is relatively rare,and no consensus has been reached on standardized treatment measures of various gynecological surgeries.Endometrial cancer is one of the common malignant tumors of the female reproductive system,and surgery is still the first choice for treatment at present.Staging surgery for endometrial cancer is a level-four surgery,which has a large scope of operation,great trauma,heavy inflammatory stress response,high incidence of complications and high medical costs.Therefore,it is particularly important to optimize treatment process to reduce the inflammatory stress response,reduce the incidence of complications and hospitalization costs,and promote early recovery.ObjectiveApplying ERAS management measures to leonardo Da Vinci robots in endometrial adenocarcinoma patients perioperative treatment,Through observation of clinical indicators,investigate whether the ERAS management measures can effectively reduce inflammation stress reaction,reduce the incidence of complications and promote early recovery.Methods1.Data source A total of 96 patients who received stage operation for endometrial adenocarcinoma with Da Vinci robot in the First Affiliated Hospital of Zhengzhou University from January 2019 to June 2020 were selected and equally divided into ERAS group and routine group by random number table method.2.Patient management mode of the two groups ① ERAS group:Individualized preoperative education and detailed communication;6h of fasting and 2h of drinking were forbidden before surgery,and 250ml of 5%glucose or fructose was taken orally 2h before surgery.Avoid mechanical enema;Heating blanket,heater and other equipment were used during the operation,and the intraoperative liquid was pretreated by heating.During the operation,the principle of target-oriented fluid replacement was adopted with both crystal and colloid.Avoid the long-term use of analgesic pumps,and use non-steroidal analgesics routinely.After waking up,the patients drank water,eat soft and liquid food before exhaust,and return to normal diet after 24h without abdominal distension.After waking up after the operation,the patients were required to extend their limbs and turn over,and 24h later they got out of bed.When the total amount of 24 hours drainage in the drainage tube was less than 300ml and the color was clear,it was removed.② Routine group:Preoperative routine education;Abstain from water after twelve o ’clock he night before surgery;An enema was performed the night before surgery,cleaning enema in the morning,oral ShuTaiQing and other drugs;No special insulation measures were taken during the operation.The traditional principle of intraoperative fluid replacement(amount lost+amount required+amount transferred to the third space);Routine postoperative analgesia pump was used;Ban on eating before intestinal exhaust,After the exhaust,and the transition from fluidic to semi-fluidic to normal food was followed.The amount of activity after operation depends on their own conditions,and no special requirements are required.When the total amount of 24 hours drainage in the drainage tube was less than 100ml,it was removed.3.Analysis indicators ①Inflammation stress and nutritional status indexes:Blood from the median cubit vein of the patients was collected at 6:00 a.m on first day before surgery,first and third day after surgery..C-reactive protein(CRP)and Procalcitonin(PCT)were measured by electrochemiluminescence method.Hydrocortisone(COR),adreno-cortico-tropic-hormone(ACTH),Albumin(ALB)and Prealbumin(PAB)were determined by enzyme-linked immunosorbent assay.②Postoperative complications:infection,lower limb venous thrombosis,pulmonary embolism,lymphedema,urinary fistula,postoperative nausea and vomiting(PONV)were recorded.③ Pain degree:The numerical rating scale(NRS)was used to evaluate the pain degree at 24h and 24～48h after surgery.0 is painless,1～3 is mild(does not affect sleep),4-6 is moderate(between moderate and severe),7～9 is severe(unable to fall asleep or wake up in pain),and 10 is severe(intolerable).④Other indicators:the first postoperative exhaust time,length of hospital stay,hospitalization cost;The satisfaction scores are very satisfied(90～100 points),satisfied(70～80 points),approved(60～70 points),dissatisfied(30～60 points),and very dissatisfied(0～30 points).The overall satisfaction is(very satisfied+satisfied+approved)/the total number of people.Results1.Comparison of inflammatory stress indicators The CRP of ERAS group and routine group on first day before surgery;the first and third day after surgery were[(3.14±3.57);(30.73±22.23);(19.57± 17.88)]VS[(3.38±2.95);(42.13±21.24);(28.96±16.24)],respectively.The Cor of ERAS group and routine group on frrst day before surgery,the first and third day after surgery were[(8.87 ±3.43);(26.47± 10.19);(13.83±4.52)]VS[(8.94±3.81);(38.76±16.95);(23.55±11.25)],respectively.The ACTH of ERAS group and routine group on first day before surgery,the first and third day after surgery were[(24.37±11.34);(49.85±18.89);(30.90±12.69)]VS[(23.87±14.85);(62.63±28.37);(39.87±20.25)],respectively.There were no significant differences in CRP,COR and ACTH between the two groups on the first day before surgery(PCRP=0.978;PCor=0.930;PACTH=0.997).The CRP,COR and ACTH of ERAS group on the first and third day after surgery were all lower than those of the conventional group,and the differences were statistically significant[(PCRP=0.036;PCor=0.000;PACTH=0.034);(PCRP=0.026;PCor=0.000;PACTH=0.034)].2.Comparison of nutritional status indicators There was no statistical difference in ALB and PAB between the two groups on the first day before surgery,the first and third day after surgery(P>0.05).3.Comparison of incidence of complications The incidence of ERAS group and routine group in total complications,lower limb vein thrombosis,nausea and vomiting were[29.17%(14/48),0.00%(0/48),20.83%(10/48)VS[50%(24/48),12.50%(6/48),41.67%(20/48)],respectively;The incidence of total complications,lower limb venous thrombosis,nausea and vomiting in ERAS group was lower than that in the conventional group,and the differences were statistically significant[x2=4.356,P=0.037;x2=6.400,P=0.026;x2=4.848,P=0.028].There was no significant difference in the incidence of infection,pulmonary embolism,lymphedema and urinary fistula between the two groups(P>0.05).4.Comparison of pain severity At 24 hours after surgery,the proportions of mild,moderate,severe and intense pain in ERAS group and conventional group were[(25.00%(12/48),54.17%(26/48),14.58%(7/48),2.08%(1/48)]VS[16.68%(8/48),39.58%(19/48),33.33%(16/48),8.33%(4/48)],respectively.During 24-48 hours after surgery,the proportions of mild,moderate,severe and intense pain in ERAS group and conventional group were respectively[(50.00%(24/48),33.33%(16/48),4.17%(2/48),0.00%(0/48)]VS 31.25%[(15/48),37.50%(18/48),20.83%(10/48),4.17%(2/48)].The pain degree in the ERAS group was lower than that in the conventional group,and the difference was statistically significant(u24h=2.445,P24h=0.014;u48h=2.935,P48h=0.003).5.Compared with other indicators The first postoperative anal exhaust time,hospitalization time and hospitalization cost of ERAS group and routine group were:[(48.12±7.62)h,(10.25±2.26)d,(60536.78±8863.57)yuan]VS[(54.06±6.51)h,(12.25±2.67)d,(64083.28±7220.97)yuan];The first anal exhaust time and hospitalization time were shorter and the hospitalization cost was lower in ERAS group(t=2.946,P=0.004;t=3.951,P=0.000;t=2.149,P=0.034);The satisfaction of the ERAS group and the conventional group were[95.83%(46/48)VS 81.25%(39/48)],respectively.The satisfaction of the ERAS group was higher than that of the conventional group,the difference was statistically significant(x2=5.031,P=0.025).ConclusionERAS management measures benefit patients undergoing endometrial adenocarcinoma surgery with Da Vinci Robotics.The application of ERAS management measures can significantly reduce the inflammatory stress response,reduce the incidence of complications,shorten the length of hospital stay,reduce the cost of hospital stay,and improve the satisfaction.