基于加速康复外科理念的肝癌围术期营养管理专家共识（2025版）

1 编写说明

1.1 成立编写工作组

本共识由中国康复医学会社区康复工作委员会联合复旦大学附属华山医院康复医学科于2025年5月发起,并于2025年7月正式启动制订。共识工作组包括专家委员会、制订小组和秘书组,成员由肝胆肿瘤外科、肝胆肿瘤内科、康复医学科、营养科以及相关领域的多学科专家组成。在本共识启动前,工作组已完成计划书的撰写及上传工作,并完成国际实践指南注册与透明化平台的注册(注册号: PREPARE-2025CN1558)。

1.2 确定共识内容

共识专家组通过开放式讨论的方式提出基于ERAS理念的肝癌患者围术期营养管理的一系列问题,在全面评鉴国内外文献、共识、指南和专家临床经验的基础上,结合基于ERAS理念的肝癌患者围术期营养管理现状,形成共识初稿。经过多轮专家讨论和修改,最终确定了本共识关注的3个维度的内容。本共识的使用者是肝胆肿瘤外科、肝胆肿瘤内科、消化道肿瘤科、康复医学科和社区医院等相关科室,应用目标人群为肝癌围术期患者。

1.3 证据总结

主要检索词: 加速康复外科/Enhanced Recovery After Surgery、肝癌/hepatocellular carcinoma、围术期/perioperative period、营养管理/nutritional support 等。检索数据库: 英文数据库(PubMed、Web of Science、EMBASE、Ovid、Cochrane Library、Scopus)、中文数

据库(中国知网、万方数据知识服务平台、维普网、中国生物医学文献服务系统)、美国国立指南库、苏格兰校际指南网、美国肿瘤护理学会官网、Joanna Briggs Institute 循证卫生保健中心网站、Up To Date、BMJ Best Practice 以及医脉通等。文献纳入类型包括随机对照试验、系统评价、Meta分析、回顾性系统研究、临床病例系列研究、病例报告、指南和专家意见。通过阅读文献摘要筛选与基于ERAS理念的肝癌围术期营养管理有关的文献，对纳入的文献进行评价，将支持共识形成的重要文献证据整理到证据汇总表。专家组通过对研究证据公开讨论形成共识稿，依据评价结果及专家们提出的意见，对共识草案进行了完善，并经过多轮讨论与修改，形成本专家共识。

1.4 文献质量评价

使用指南评价工具Ⅱ(Appraisal of Guidelines for Research and Evaluation II, AGREE II)对检索纳入的指南进行质量评价,采用AMSTAR(A Measurement Tool to Assess Systematic Reviews)评价清单对纳入的系统评价进行质量评价,采用JBI专家共识评价工具对纳入的专家共识进行质量评价,采用JBI循证卫生保健中心随机对照试验评价标准(2016)对纳入的RCT研究进行评价,通过追测证据所依据的原始文献对临床决策、证据总结等文献的质量根据文献类型选择相应的评价标准进行评价[13-14]。

1.5 共识传播、实施、更新

本共识将通过学术交流、解读、新媒体推文、学术期刊等多种途径传播,促进本共识在肝脏肿瘤相关科室及社区医院实施。专家组成员将定期评估最新研究证据和临床需求,必要时对共识内容进行更新。

2 共识内容

2.1 肝癌患者营养筛查和评估

肝癌患者常因代谢紊乱、摄入减少及肿瘤消耗等因素,导致较高的营养不良发生率[15-16]。研究指出,肝癌患者营养不良是术后并发症与死亡的独立危险因素[17-19]。精准的营养筛查和评估对指导围术期营养管理至关重要,可显著降低感染风险、促进伤口愈合、缩短住院时间并改善临床结局[20-21]。

2.1.1 营养风险的筛查

肝癌患者营养风险筛查能够帮助快速识别需要进一步营养评估与支持的对象,所有肝癌患者应在入院后24h内完成初次筛查[22-23]。对于筛查结果阳性的患者,需要进行进一步的营养评估[24]。

筛查工具:现有多种有效工具可用于肝癌患者的营养风险筛查,根据其特点可分为通用工具和肝病专用工具。(1)营养风险筛查2002(NRS 2002):此通

GP 中国全科医学

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用工具在预测营养相关并发症方面具有较高灵敏度,总分≥3分即提示存在营养风险[25-27]。然而,其计算BMI的要求使其不适用于存在腹水、肝性脑病或无法站立的肝癌患者[28-29]。(2)简化版微型营养评估量表(MNA-SF):此工具适用于老年患者,评估内容涵盖体质量变化、膳食摄入量、活动能力以及心理状态等[30-31]。(3)皇家自由医院营养优先工具(RFH-NPT):此肝病专用工具被欧洲临床营养与代谢学会(ESPEN)指南推荐为首选的肝病营养风险筛查工具[32][33],其专门纳入了体质量变化因素并考虑对液体潴留状态下患者的评估校正,该工具对于肝病特别是肝癌、肝硬化患者的营养风险识别灵敏度优于NRS 2002[34]。(4)肝病营养不良筛查工具(LDUST):该工具能够快速筛查肝病患者中常见的肌肉/脂肪损耗以及液体潴留问题,对肝癌、肝硬化等肝病相关营养不良的检出率较高[35-36]。

需注意的是,晚期癌症患者及65岁以上的老年患者在使用部分筛查工具时存在较高的假阴性风险[37][38]。因此,无论筛查结果如何,这两类患者均需完善更详细的营养评估。

【推荐意见】 所有新入院肝癌患者须在24h内由护士主导完成营养风险筛查，首选NRS 2002或肝病专用的RFH-NPT或LDUST工具，初筛阳性者直接进入营养评估流程；癌症晚期及≥65岁老年患者无论初筛结果如何均应常规进行营养评估。

2.2 营养状况的评估

针对营养风险筛查阳性或存在高危因素(如癌症晚期、年龄≥65岁、危重症)的肝癌患者,需由临床医师或营养师在入院48h内完成系统的营养状况评估,以精准指导营养干预[39-40]。

评估量表:推荐对肝癌患者采用结构化量表进行营养状况评估。(1)主观整体评估量表(SGA):作为营养评估量表的金标准,该量表操作简单,涵盖体质量变化、膳食摄入、症状、功能状态及体格检查等条目,并且不易受患者水钠潴留的干扰,尤其适用于肝硬化及肝癌患者[41-42];(2)患者主观整体评估量表(PG-SGA量表):该量表是肿瘤患者首选的营养状况评估工具,通过结合患者自评与医护评估进行定量评分,分为0~1分提示无需干预、2~3分需进行营养干预、≥4分需营养师介入辅助干预,该量表能够指导临床医护人员进行精准分级干预,具有较高的灵敏度[27,43-44];(3)皇家自由医院改良SGA量表(RFH-SGA):这是专为终末期肝病患者设计的营养评估量表,在传统SGA量表的基础上引入上臂围(MAC)、肱三头肌皮褶厚度(TSF)及上臂肌围(MAMC)等评估维度,其公式为MAMC=MAC-3.14×TSF,MAMC<第5百分位时提示患者存在营养不良[34,45];(4)全球营养不良标准(GLIM):

能够通过表型指标,如体质量下降、低BMI和肌肉减少等,结合病因及实验室检查指标,实现对营养不良的快速诊断,但在实际使用时需要结合患者肌肉量进行实测验证[46-48]。

针对存在水钠潴留的肝癌患者,建议增加额外的营养评估指标以获得更加全面、准确的营养评估结果[49],包括:(1)动态非优势手握力(HGS):该指标灵敏度可达81%,能直接反映肌肉功能衰退情况及营养相关并发症发生风险,显著优于传统握力测量方法[50];(2)小腿围(CC);三头肌皮褶厚度(TSF)及上臂围(MAC):患者肌肉或脂肪等身体组织的流失程度可直接反映营养损耗程度,能够有效规避液体潴留对营养状况评估的影响[51-52]。

【推荐意见】 营养风险阳性或高危肝癌患者须由营养师/医师在入院48h内完成结构化评估:首选SGA或PG-SGA量表评估(肝癌患者必须行PG-SGA量表评估,评分≥4分即需营养师介入进行营养干预),通过动态监测非优势手握力及小腿围等指标进一步完善患者的营养状况评估。

2.3 营养状况的诊断

针对营养风险高危的肝癌患者,需通过多维度整合评估实现精准的营养诊断,为个体化干预及预后改善提供依据。实现营养诊断的手段包含功能评估、实验室检查、影像学检查。

2.3.1 功能评估

综合评估患者生理功能及心理状态是营养诊断的基础。(1) Karnofsky 功能状态评分:可用于临床系统量化患者日常活动能力与自理程度[53]。(2) 医院焦虑抑郁量表(HADS):能够重点筛查抑郁症状及老年认知功能障碍,尤其适用于合并合理应激的高龄患者[54-55]。(3) 体能测试:通过客观指标反映机体功能储备,包括6分钟步行试验、30s座椅站立测试和单腿站立测试,可分别反映患者心肺耐力水平、下肢肌群耐力以及静态平衡能力[56-57]。

2.3.2 实验室检查

通过多维度整合实验室检查结果可以辅助营养诊断,主要包括以下几项检查指标。(1)营养预测指标:包括炎症与预后指标(CPR)和格拉斯哥预后评分(GPS)。CRP水平升高对肝癌患者营养预后的预测价值显著优于白蛋白[58][59]; GPS评分为1~2分是肝切除术后生存率下降的独立危险因素,但需排除非特异性炎症干扰[60]。(2)蛋白质代谢指标:包括肌酐身高指数和前白蛋白。肌酐身高指数通过连续收集患者3d的尿液,计算出平均肌酐值,并将其与相同性别和身高人群的标准肌酐值进行比较,得出百分比,<60%提示重度蛋白质缺乏,且不受水钠潴留影响,但要求被测患者肾功能

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Chinese General Practice

GP

正常且无急性感染[61];前白蛋白t1/2仅1.9d,因此对营养变化的灵敏度优于白蛋白,但仍受肝功能异常及液体负荷干扰[62-63]。另外需注意因肝癌患者普遍存在低白蛋白血症,白蛋白单独诊断的价值有限,需结合其他参数[64]。(3)免疫营养指标:预后预营养指数(PNI)。PNI通过公式[白蛋白(g/L)+5×淋巴细胞计数(x10g/L)]计算,低数值与术后生存期缩短有关[65-66],但因淋巴细胞易受脾功能亢进或感染抑制而可能使其准确度下降[67]。(4)身体成分与细胞双功能指标:如生物电阻抗分析(BIA)。BIA可同步获取肌肉量、脂肪量及相位角数据,其中相位角能够直接反映细胞膜完整性,术前低相位角患者术后感染率及死亡率显著升高,其营养状况及生存预测效力超越传统白蛋白指标[68-70]。

2.3.3 影像学检查

(1) 双能X线吸收测量法(DXA):可精确定量全身肌肉组织与脂肪分布[71]。(2) 腹部CT或MRI:通过第三腰椎水平骨骼肌横截面积测量实现对患者肌肉量的标准化评估。此类技术是患者身体成分分析和营养诊断的全标准,但成本较高、操作复杂且具有辐射暴露风险[72-75]。

【推荐意见】 对于接受营养诊断的肝癌患者，应完成基础评估组合，包括：(1) 通过术前常规影像检查（如CT或MRI）量化骨骼肌含量；(2) 标准化体能状态评分 Karnofsky 测试和抑郁风险筛查HADS量表。

此外,对于常规实验室检查需优先选择与肝癌预后强相关的核心指标,包括CRP检测、前白蛋白、BIA相位角。资源受限时,应确保至少完成CT影像学肌肉量分析、前白蛋白及CRP检测。

3 基于ERAS理念的肝癌围术期营养管理

肝癌患者的围术期营养管理应基于ERAS理念,贯穿术前、术中、术后及出院后的管理延续阶段。通过动态营养筛查与评估对患者的营养状况进行诊断,为患者的个性化营养支持方案提供依据,减少术后并发症、加速康复并改善预后。基于ERAS理念的肝癌围术期营养管理路径如图1。

3.1 术前管理

院前预康复:对于门诊经营养风险筛查呈阳性的肝癌患者,应在入院前实施为期7d的家庭营养预康复方案,可每日于早、中、晚3个固定时段口服营养补充剂进行营养补充,每次摄入剂量为250~300mL,并同步开展每日线上随访评估,动态监测患者执行情况与营养状况[75-77]。

营养筛查:动态营养筛查可早期识别营养不良风险,降低术后并发症发生率[78]。在肝癌患者入院后采用NRS 2002或PG-SGA量表完成营养风险筛查,快速评估肝癌患者的营养状况,指导后续的营养管理措施[12, 79]。通过“筛查-评估-诊断”的3级营养诊断模型,

![graph TD\n A1[门诊] --> A2[入院]\n A1 --> A3[复诊]\n A2 --> A4[24小时内营养风险筛查：首选RFF-NPT或NRS200]\n A3 --> A7[出院]\n A4 -->|有风险| A5[7天内家庭营养评估：每日两次口服营养补充剂，每次250-300ml]\n A4 -->|无风险| A2\n A5 --> A6[入院]\n A7 --> A8[延续高蛋白日粮营养补充至术后1个月，每日3次，每次25g-50g；同步开展肠内饮食（如鱼油及血磷胆固醉）]\n A7 --> A9[出院时营养风险筛查：首选RFF-NPT或NRS200]\n A9 --> A10[无风险]\n A9 --> A11[高风险]\n A10 --> A12[营养护理]\n A11 --> A7\n A12 --> A13[营养状况诊断：营养风险检查（如CT或MRI）量化营养不良和/或影像学检查；标准人体测量评估Kamofsky测试和能指数HADAS-W）；实验室检查优选选择：CRP检测/前白蛋白/BAA相位；①资源受限时，应确保至少完成CT检查肌肉量分析、前白蛋白及CRP检测。]\n A14[48小时内营养不良评估：首选SGA或PG-SGA筛查] -->|营养不良| A12\n A14 -->|无风险| A12\n](1/parseimages/figured4f2a54739874a3e92b51bfe0270629e_0_14.png) GP 中国全科医学

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可以早期识别营养不良高风险患者[17, 80]。

营养支持:存在营养不良的患者,应在术前接受口服营养补充,严重吞咽功能障碍或胃肠功能障碍者可改用管饲肠内营养(EN)或肠外营养(PN)[17, 80-82]。有研究显示,术前1周开始每日400~600 kcal高蛋白/免疫营养口服营养补充剂,可改善患者术后营养状况[83-84];术前5d补充精氨酸及ω-3脂肪酸可降低感染风险[85-86];术前3d添加肠内营养混悬剂(TP-MCT)进行营养补充(500-1000 mL/d,含蛋白质≥25g),可显著缩短肝切除患者术后首次排气时间[84, 87];术前1晚口服支链氨基酸(BCAA)能预防肝切除术患者术后白蛋白水平降低,改善患者血氨水平[88-89]。对于含糖尿病的肝癌患者,推荐在术前3d改用胰岛素替代药物治疗以优化血糖控制[90-91]。

运动指导:术前建议由多学科团队定制运动训练方案,方案可以吹气球等呼吸心肺训练为核心,2~3次/d,15 min/次,增强心肺功能储备,预防术后肺部并发症[92-94]。

心理护理：由临床护士主导，与患者建立互信的护患关系[95-96]。耐心倾听并正视患者焦虑，为患者提供清晰、真实且明了的手术信息和预期，解释术前准备和术后康复要点，提升患者术前心理准备度。关注患者睡眠与疼痛情况，出现失眠障碍或疼痛时及时处理[97]。

【推荐意见】 肝癌患者术前营养管理应以营养风险筛查为先导，同步执行运动指导和心理护理。营养风险动态筛查：在门诊和入院后均采用量表对患者进行营养状况筛查，对门诊筛查的营养不良高风险人群，启动7d家庭营养预康复：3次/d口服营养补充剂，250~300mL/次；对入院后筛查的营养不良高风险人群，需在术前3d补充肠内营养制剂，500mL/d，术前1晚口服50g支链氨基酸。对于合并糖尿病的患者，需提前3d改用胰岛素控制血糖。

3.2 术中管理

建立营养通路:术中建立专门用于营养液输注的静脉通路,做好管路维护,为术后肠外营养做准备[81, 98]。对于严重吞咽功能障碍,出现恶心、呕吐、腹胀等胃肠道功能障碍等无法经口进行营养补充的患者,术中可将鼻肠营养管精准放置于Treitz韧带远端20 cm空肠处,避免留置胃管(如放置则在麻醉清醒前拔除),为术后肠内营养早期启动提供安全通路[78, 99]。

维持生理稳态:严格限制术中静脉滴注总量在2000 mL内,避免液体过量[100-101]。全程对患者主动保温,术前调高手术室温度,非手术区域覆盖保温毯,静脉滴注液体及腹腔冲洗液加温至37.5℃[102-103]。维持患者血流动力学稳定,降低体温相关凝血功能障碍发生率及术后感染风险[104]。

心理护理:患者进入手术室后,对其进行环境介绍与心理安抚,缓解患者的紧张情绪,最大限度减少其生理应激反应,为术后快速康复奠定基础[78]。

【推荐意见】 肝癌术中需同步建立营养通路及维持生理稳态(限液+保温),同时辅以心理干预,以共同维持内环境稳定,减轻手术应激反应,为术后加速康复提供保障。

3.3 术后管理

营养支持:对于术后一般情况良好、营养不良风险较低(NRS 2002量表评分<3分、PG-SGA量表评分<2分,前白蛋白水平正常)的患者,推荐早期经口进食[105-106]。术后口径进口食推荐按“清流质$\rightarrow$流质$\rightarrow$半流质$\rightarrow$软食$\rightarrow$普食”顺序分阶段推进。术后当天在清醒后试饮温水10mL/次并逐渐过渡到200mL,若无不适则予高热量清流质[107];术后第1天予清流质,如藕粉、米汤等,日总量≤500mL[84];术后第2天予流质50~100mL/2~3h,联合高压蛋白/免疫营养配方的口服营养制剂(ONS)[108];术后第3天予半流质,如小米粥、蛋羹,辅以ONS 200mL/次、3次/d;术后第4天起予软食持续至术后1个月,餐间可补充ONS[109]。此流程可减少胃肠刺激,保障营养摄入[83],ONS可显著改善患者的营养状态,促进其肠道功能恢复[79]。对于存在营养不良风险的患者,建议根据患者情况,在有或无经口进食的基础上补充肠外、肠内营养[81, 110]。可遵循“肠外营养(PN)$\rightarrow$肠内外联合$\rightarrow$肠内营养(EN)”的阶梯式过渡原则,对于无明显口服禁忌证的患者,推荐将口服营养补充作为肠内营养的首选方式[82, 110]。无法进行口服营养补充的患者可经鼻肠管滴注10%葡萄糖注射液500mL/12h,随后逐步滴注肠内营养乳剂,从250mL/12h递增[111]。有研究推荐肝癌患者术后第1天给予100%PN;术后2~3d调整为50%EN+50%PN;术后4~5d过渡至70%EN+30%PN;术后6~7d实现100%EN。此方案可满足肝癌患者术后不同恢复阶段的能量与蛋白质需求,加速肠道功能恢复,降低并发症风险[90, 112]。

早期活动：术后6 h 可指导患者进行床上活动，如踝泵运动、翻身等；术后第1天视患者恢复情况可协助其下床活动，≥3次/d，15~20 min/次；术后第2天起循序渐进增加活动量，如行走训练、抗阻运动等[113-114]。早期下床活动可加速胃肠蠕动，缩短首次排气时间，降低并发症发生风险[92]。

胃肠道功能调节:术后6h起可口服乳果糖10~15mL次,1~2次/d,联合益生菌,如双歧杆菌三联活菌制剂、乳杆菌或混合酸奶服用,直至排气排便,可修复肠道菌群失衡。此外,有研究指出术后第1天咀嚼口香糖、按摩足三里穴,可协同改善胃肠动力,预防肠麻痹[107, 114-117]。

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Chinese General Practice

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【推荐意见】术后营养管理推荐把握2大核心:(1)阶梯式营养过渡——对于营养不良低风险患者,术后24h内从清流质逐步过渡至半流质、普食,24h后可同步补充口服营养制剂(3次/d, 200 mL/次);对于存在营养不良风险的患者,术后24h内启动肠外营养,7d内从肠外营养逐步过渡至全肠内营养。(2)胃肠道功能恢复——术后6h起可联合乳果糖与益生菌调节肠道菌群,24h内协助患者下床活动。该策略可满足肝癌患者术后不同恢复阶段的能量与蛋白质需求,缩短首次排气时间,提升白蛋白水平,加速康复进程。

3.4 出院后管理和随访

营养支持延续：出院时对患者进行营养风险复筛，对高风险人群延续口服营养补充（ONS）干预：3次/d（9：30、15：00、21：30），250~300 mL/次高蛋白配方，持续补充至术后1个月。此措施可巩固住院期营养改善效果，提升白蛋白水平，降低再入院风险[74, 118-119]。

动态监测与管理；建立基于线上平台的远程营养随访体系，记录患者每日饮食的食物种类、摄入量及不良反应，给予个性化营养调整建议，如热量分配方案、蛋白质补充方案等，能够显著提高患者依从性，预防营养状况恶化[74, 120]。

门诊复诊营养评估：出院后2周安排印诊复诊，全面评估营养指标（体质量、白蛋白、前白蛋白）、胃肠功能恢复及并发症发生情况，根据评估结果调整营养管理方案[121-122]。对于营养状况达标者，可逐渐转为常规饮食指导；对于营养状况未达标者，延长其ONS使用周期或升级至管肠/肠外营养支持。通过动态营养管理方案调整，可实现个体化康复目标[74]。

【推荐意见】 肝癌患者出院后需实施风险分层营养管理。对于出院时复筛为营养高风险的患者，需要延续高蛋白口服营养补充至术后1个月，3次/d，250~300 mL/次；同步开展远程饮食监测及血糖追踪。此外，所有患者出院2周后进行复诊评估营养指标（体质、白蛋白、前白蛋白），动态调整营养管理方案，降低患者再入院风险。

4 多学科协作模式

通过组建包括营养师、临床医师、专科护士、康复师、麻醉师等多学科团队,根据营养师营养评估结果制订个体化营养管理方案,由专科护士执行营养支持计划,康复师指导运动,可显著改善肝癌患者的预后和营养恢复情况[74, 123]。

4.1 多学科团队构建与角色分工

肝癌围术期营养管理多学科协作团队通常由临床营养师、肝胆外科医师、专科护士、康复治疗师和麻醉科医师组成，各角色分工明确。

临床营养师:负责全程营养管理,包括术前采用营养评估和筛查在工具对肝癌患者进行营养风险评估;术中指导营养通路成功建立;术后设计分阶段营养管理方案,并联合康复治疗师调整运动量及蛋白质摄入量[32, 124]。

肝胆外科医师:作为核心决策者,主导围术期整体治疗方案,评估手术可行性,制订术中液体管理策略,并与麻醉师协作维持患者术中血糖稳定。通过控制中心静脉以减少患者术中出血量,降低术后并发症发生风险[125-126]。

专科护士: 执行营养支持操作,包括对肠外营养、以口服营养补充为核心的肠内营养及营养剂的剂量进行调整等;监测并发症发生情况,如腹胀、腹泻、腹水、血糖波动等;落实ERAS营养管理方案的相关措施,指导并协助患者记录饮食,确保营养管理方案精准落地[12, 127-128]。

康复治疗师:设计并执行患者术前和术后的运动康复计划,加速患者术后康复[129-130]。

麻醉科医生:术中实施以目的为导向的液体管理以及联合保温措施,降低患者术后低体温症发生率[102, 131]。

【推荐意见】 肝癌患者围术期需建立以肝胆外科医师为主导、临床营养师为纽带、专科护士为执行核心的多学科协作体系:外科医师统筹手术方案与液体管理;营养师把握贯穿全周期的营养调控;护士精准执行营养支持与进行并发症防控;康复师定制围术期运动方案促进患者功能恢复;麻醉师维持患者术中生理稳态。该模式通过角色互补与流程耦合,能够显著降低术后并发症发生率,加速患者康复进程。

4.2 协作流程与标准化营养管理路径

术前阶段：（1）营养师与外科医师共同筛查营养不良高危患者，制订术前营养强化等预康复方案；（2）护士与营养师协作开展健康教育，指导患者围术期的营养支持相关知识和措施；（3）康复师、外科医师根据患者情况联合制订术前运动康复方案，专科护士协助指导患者按照计划进行术前运动康复[32, 93, 132, 133]。

术中阶段：麻醉师与外科医师联合控制术中血糖，进行液体管理，落实术中保温措施[102]。

术后阶段：(1)康复师制订术后运动康复计划，专科护士协助指导患者按照计划进行术后运动康复；(2)营养师根据患者营养评估情况对患者调整相应的营养支持方案并与专科护士一同执行[12, 124, 130]。

出院后管理：专科护士和营养师在术后对患者进行电话或网络随访，对居家饮食及营养剂补充提供专业指导[74, 133]。

【推荐意见】 肝癌患者围术期营养管理需构建并

GP 中国全科医学

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·7·

执行贯穿术前、术中、术后及出院后居家阶段的多学科闭环协作路径。术前由营养师与外科医师联合筛查高危害患者并启动预康复, 护士落实健康教育; 术中麻醉师与外科医师协同实施血糖调控、限制性静脉滴注及体温维持, 同步建立营养通路; 术后康复师制订阶梯运动计划, 营养师动态调整营养支持方案, 护士执行; 患者出院后由护士及营养师通过线上平台对患者进行远程营养监测与指导。

5 小结

针对肝癌患者营养不良风险和发生率高的现实问题而拟订的基于ERAS理念的肝癌患者图术期营养管理方案,可显著改善肝癌患者术后营养状态,降低并发症发生率,缩短住院时间。其核心价值体现在建立动态监测和干预体系,采用不同的营养评估工具在围术期的不同时间节点进行营养筛查和评估,实施覆盖术前、术中、术后及出院后居家阶段的全周期营养干预。通过构建以外科医师为主导、营养师全程调控、护士精准执行、康复师运动指导、麻醉科术中稳态维持的多学科协作框架,形成标准化闭环路径。综上,本共识通过证据整合和全国33位专家的多轮论证,形成适用于医院标准化管理的肝癌患者围术期营养管理框架,为改善肝癌患者后提供了科学依据。本共识将推动基于ERAS理念的营养管理方案在临床实践中的规范化应用,并通过持续更新保持循证先进性。

本文无利益冲突。

《基于加速康复外科理念的肝癌围术期营养管理专家共识(2025年版)》制订专家组成员

主审专家：贾杰（复旦大学附属华山医院）

执笔专家:温湘祥(复旦大学附属华山医院);贾守梅(复旦大学护理学院);殷保兵(复旦大学附属华山医院)

制定专家(按姓氏笔画排名):于惠秋(吉林大学中日联谊医院);王俊(上海市仙霞街道社区卫生服务中心);付亏杰(河南医药大学第一附属医院);叶珊珊(福州市晋安区医院);叶桦(福州市晋安区医院);达瓦次仁(西藏自治区藏医院);李娟(复旦大学附属华山医院);许雅芳(复旦大学附属华山医院);刘晓丹(上海中医药大学);刘玉琪(福建医科大学附属第二医院);吕云(国药同煤总医院);吕颖葵(大连西岗白云民运社区卫生服务中心);许雷雷(河南省洛阳市中心医院康复科);杜国英(河北省第二荣军优抚医院);邱纪方(浙江康复医疗中心);吴建贤(安徽医科大学第二附属医院);吴雨梅(深圳平乐骨伤科医院);杨芳(浙江中医药大学);杨延辉(陕西省康复医院);

杨雪捷(广西中医药大学);余锦寿(祥云县人民医院;张舸(洛阳市中心医院);张为民(长春中医药大学附属第三临床医院);郁海琦(邻家康养健康养老服务合伙企业);侯迪(复旦大学附属华山医院国家老年疾病临床医学研究中心);姚黎清(昆明医科大学第二附属医院);赵盛惠(重庆市沙坪坝区陈家桥医院);赵月华(复旦大学附属华山医院静安分院);倪隽(福建医科大学附属第一医院康复科);徐燕忠(远东宏信集团首席专家);梁天佳(广西医科大学附属第二医院);蒋柳雅(复旦大学附属华山医院静安分院);魏新萍(上海市闵行区梅陇社区卫生服务中心)

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