快速康復(fù)外科理念在先天性巨結(jié)腸癥手術(shù)中的應(yīng)用價值
發(fā)布時間：2019-06-21 20:08
【摘要】：目的:快速康復(fù)外科(Fast track surgery,FTS)理念是采用一系列有循證醫(yī)學(xué)證據(jù)的優(yōu)化圍手術(shù)期處理措施,以減少或降低手術(shù)所致生理、心理創(chuàng)傷應(yīng)激反應(yīng)及并發(fā)癥發(fā)生,使病人獲得快速康復(fù)。本研究通過比較FTS理念和傳統(tǒng)圍手術(shù)期管理在先天性巨結(jié)腸癥(Hirschsprung's disease,HD)的手術(shù)時間、術(shù)中出血量、術(shù)后腸功能恢復(fù)情況、住院時間及并發(fā)癥發(fā)生率等方面的差異,評估FTS理念在HD治療中的臨床應(yīng)用價值,并且通過檢測FTS理念下腹腔鏡手術(shù)前后外周靜脈血免疫和蛋白質(zhì)代謝指標(biāo)的變化,探討微創(chuàng)手術(shù)對小兒機體應(yīng)激反應(yīng)的影響和創(chuàng)傷程度。方法:1 FTS應(yīng)用:回顧分析河北醫(yī)科大學(xué)第二醫(yī)院小兒外科于2001年1月至2003年12月和2016年1月至2016年12月間收治的63例HD病例資料,根據(jù)圍手術(shù)期處理方式的不同,將2001年1月至2003年12月間予以傳統(tǒng)圍手術(shù)期處理開放手術(shù)治療的32例HD患兒作為對照組;將2016年1月至2016年12月間予以FTS理念指導(dǎo)下的腹腔鏡手術(shù)治療的31例HD患兒作為FTS組,比較兩組患兒手術(shù)時間、術(shù)中出血量、引流管留置時間、術(shù)后腸功能恢復(fù)時間、住院時間和并發(fā)癥發(fā)生等情況。2 FTS應(yīng)激反應(yīng):(1)細(xì)胞免疫檢測:分別于術(shù)前、術(shù)后24h、術(shù)后72h采取外周靜脈血檢測淋巴細(xì)胞亞群T細(xì)胞(CD3+)百分比、輔助性T細(xì)胞(CD3+CD4+)百分比、殺傷性T細(xì)胞(CD3+CD8+)百分比、CD4/CD8、B細(xì)胞(CD3-CD19+)百分比、NK細(xì)胞(CD3-CD16+CD56+)百分比。(2)體液免疫檢測:分別于術(shù)前、術(shù)后24h、術(shù)后72h采取外周靜脈血檢測免疫球蛋白IgG、IgM、IgA,補體C3、C4。(3)蛋白質(zhì)代謝檢測:分別于術(shù)前、術(shù)后24h、術(shù)后72h采取外周靜脈血檢測C-反應(yīng)蛋白(C-reactive protein,CRP)和血清前白蛋白(prealbumin,PA)。采用SPSS 21.0進(jìn)行統(tǒng)計學(xué)分析,觀察機體免疫及蛋白質(zhì)代謝指標(biāo)在FTS應(yīng)用的變化情況。結(jié)果:1 HD手術(shù)相關(guān)指標(biāo):兩組HD患兒均遵循各自圍手術(shù)期處理措施,順利完成手術(shù)治愈出院,無死亡病例。1.1手術(shù)時間:fts組平均手術(shù)時間145.48±90.07min,對照組平均手術(shù)時間187.03±53.14min,fts組手術(shù)時間明顯短于對照組,有顯著統(tǒng)計學(xué)差異(p0.05)。1.2術(shù)中出血量:fts組術(shù)中出血量10.16±6.87ml,對照組術(shù)中出血量40.72±23.58ml,fts組術(shù)中出血量明顯少于對照組,有顯著統(tǒng)計學(xué)差異(p0.05)。1.3引流管留置時間:(1)鼻胃管:fts組術(shù)后留置鼻胃管時間37.09±11.89h,對照組術(shù)后留置鼻胃管時間77.91±20.57h,兩組比較,p0.05,有統(tǒng)計學(xué)差異。(2)尿管:fts組尿管留置時間17.55±3.83h,對照組尿管留置時間78.88±19.91h,兩組比較,p0.05,有統(tǒng)計學(xué)差異;(3)肛管:fts組術(shù)后留置肛管1~3d,平均2.06±1.09d;對照組經(jīng)肛門留置的環(huán)形吻合鴨嘴鉗于術(shù)后4~13d自行脫落,平均留置7.56±3.05d,兩組比較,p0.05,有統(tǒng)計學(xué)差異。1.4術(shù)后腸功能恢復(fù)時間:fts組術(shù)后腸功能恢復(fù)時間36.55±13.89h,對照組術(shù)后腸功能恢復(fù)時間43.75±16.98h,兩組比較,p0.05,無統(tǒng)計學(xué)差異(p=0.074)。1.5術(shù)前腸道準(zhǔn)備時間:fts組術(shù)前灌洗腸道準(zhǔn)備時間平均5.09±2.10d,對照組術(shù)前灌洗腸道準(zhǔn)備時間平均15.02±4.99d,兩組比較,p0.01,有統(tǒng)計學(xué)差異。1.6術(shù)后住院時間:fts組術(shù)后住院時間5.65±1.08d,對照組術(shù)后住院時間15.63±4.32d,兩組比較,p0.01,有統(tǒng)計學(xué)差異。1.7總住院時間:fts組總住院時間11.74±1.91d,對照組總住院時間31.84±6.97d,兩組比較,p0.01,有統(tǒng)計學(xué)差異。1.8并發(fā)癥:fts組中出現(xiàn)腹腔殘余感染1例,占3.2%;對照組中出現(xiàn)吻合口狹窄1例、腸梗阻1例、吻合口裂開2例和腹部切口感染3例,占21.9%,兩組比較,p0.05,有統(tǒng)計學(xué)差異;2fts組免疫反應(yīng)與蛋白質(zhì)代謝2.1淋巴細(xì)胞亞群變化:(1)t細(xì)胞百分比:術(shù)后24h較術(shù)前降低,p0.05,有統(tǒng)計學(xué)差異。術(shù)后72h較術(shù)后24h升高,p0.05,有統(tǒng)計學(xué)差異。至術(shù)后72h基本恢復(fù)接近術(shù)前水平,無統(tǒng)計學(xué)差異(p=0.273);(2)輔助性t細(xì)胞百分比:術(shù)后24h較術(shù)前下降,P0.05,有統(tǒng)計學(xué)差異。至術(shù)后72h較術(shù)后24h升高,P0.05,有統(tǒng)計學(xué)差異,且基本恢復(fù)至術(shù)前水平,無統(tǒng)計學(xué)差異(P=0.899);(3)殺傷性T細(xì)胞百分比:術(shù)前、術(shù)后24h及術(shù)后72h組間比較,無統(tǒng)計學(xué)差異(P=0.270),均處于正常水平范圍;(4)CD4/CD8:術(shù)前、術(shù)后24h及術(shù)后72h組間比較,無統(tǒng)計學(xué)差異(P=0.193);(5)B細(xì)胞百分比:術(shù)后24h較術(shù)前升高,P0.05,有統(tǒng)計學(xué)差異。術(shù)后72h較術(shù)后24h無明顯變化(P=0.151),但較術(shù)前升高,P0.05,有統(tǒng)計學(xué)差異;(6)NK細(xì)胞百分比:術(shù)后24h較術(shù)前無明顯變化(P=0.349)。術(shù)后72h較術(shù)后24h下降,P0.05,有統(tǒng)計學(xué)差異。2.2體液免疫指標(biāo)變化:(1)IgG:術(shù)前、術(shù)后24h及術(shù)后72h組間比較,無統(tǒng)計學(xué)差異(P=0.209);(2)Ig M:術(shù)前、術(shù)后24h及術(shù)后72h組間比較,無統(tǒng)計學(xué)差異(P=0.744);(3)IgA:術(shù)前、術(shù)后24h及術(shù)后72h組間比較,無統(tǒng)計學(xué)差異(P=0.945);(4)補體C3:術(shù)后24h和術(shù)后72h較術(shù)前均無明顯變化(P=0.113);(5)補體C4:術(shù)后24h和術(shù)后72h較術(shù)前均無明顯變化(P=0.380)。2.3 CRP:術(shù)后24h較術(shù)前明顯升高,P0.01。術(shù)后72h較術(shù)后24h下降,P0.01,但較術(shù)前亦有升高,P0.01。2.4 PA:術(shù)前、術(shù)后24h及術(shù)后72h組間比較,無統(tǒng)計學(xué)差異(P=0.242)。結(jié)論:1 FTS應(yīng)用于HD圍手術(shù)期能明顯縮短患者的住院時間及引流管留置時間,降低術(shù)后并發(fā)癥發(fā)生率,采用腹腔鏡微創(chuàng)手術(shù)可減少手術(shù)時間及術(shù)中出血量,加快患兒術(shù)后機體的恢復(fù),具有較好的臨床應(yīng)用價值。2 FTS指導(dǎo)下采用腹腔鏡微創(chuàng)技術(shù)能有效減輕HD患兒圍手術(shù)期應(yīng)激反應(yīng),對機體免疫及蛋白質(zhì)代謝影響較小,加速了患兒術(shù)后康復(fù)。
[Abstract]:Objective: Fast track surface surgery (FTS) is a series of perioperative management measures with evidence of evidence-based medicine to reduce or reduce the physiological, psychological and psychological trauma stress caused by the operation and the occurrence of complications, so that the patient can get a quick recovery. In this study, the operative time, the intraoperative blood loss, the postoperative intestinal function recovery, the hospital stay and the incidence of complications were compared by comparing the FTS concept with the traditional perioperative management in Hirschsprung's disease (HD). To evaluate the clinical application value of the FTS concept in HD treatment, and to explore the effect of minimally invasive surgery on the stress response of children and the degree of trauma by detecting the changes of the immune and protein metabolism indexes of the peripheral venous blood before and after the laparoscopic operation under the concept of FTS. Methods: 1FTS application: The data of 63 cases of HD from January 2001 to December 2003 and January 2016 to December 2016 were retrospectively analyzed. According to the different treatment methods of the perioperative period, 32 patients with HD who were treated with open surgery in the traditional perioperative period from January 2001 to December 2003 were used as the control group, and 31 HD children who were treated with the laparoscopic surgery under the guidance of the FTS in January 2016 and December 2016 were used as the FTS group, and the operation time of the two groups was compared. Intraoperative blood loss, drainage tube retention time, postoperative intestinal function recovery time, hospital stay and complications, etc. 2FTS stress response: (1) cellular immunity test: before and after operation,24 hours after operation, respectively. The percentage of T cells (CD3 +), the percentage of T cells (CD3 + CD4 +), the percentage of T cells (CD3 + CD8 +), the percentage of CD4/ CD8, B cells (CD3-CD19 +), and the percentage of NK cells (CD3-CD16 + CD56 +) were measured by peripheral venous blood. (2) Humoral immunity: The peripheral venous blood was used to detect the immunoglobulin IgG, IgM, IgA, complement C3 and C4 after 24 h after operation and 72 hours after operation. (3) Protein metabolism test: The C-reactive protein (CRP) and prealbumin (PA) were detected by peripheral venous blood at 24 h after operation and 72 hours after operation. Statistical analysis was performed using SPSS 21.0 to observe the changes of the body immunity and protein metabolism index in the FTS application. Results:1 HD operation related index: The two groups of HD children follow the treatment measures in the perioperative period, and the operation was completed successfully. The operation time was 145.48-90.07 min. The average operation time of the control group was 187.03-53.14min. The operative time of the fts group was significantly shorter than that of the control group, and there was a significant difference (p0.05). The amount of blood loss during the operation was 10.16-6.87 ml, the amount of blood loss in the control group was 40.72-23.58ml, and the amount of blood loss in the fts group was significantly lower than that of the control group, and there was a significant difference (p0.05). (1) The time of the nasogastric tube: the time of the indwelling nasogastric tube after operation was 37.09-11.89h, and the time of the indwelling nasogastric tube in the control group was 77.91-20.57h. (2) In the control group, the retention time was 17.55-3.83h, the retention time of the control group was 78.88-19.91 h, the two groups were compared, p0.05, there was a statistical difference, and (3) the anal canal: the anal canal was 1 ~ 3 days after the operation, and the average was 2.06-1.09d. The postoperative intestinal function recovery time was 36.55-13.89h after operation, and the recovery time of the intestinal function was 43.75-16.98h after operation. Comparison of the two groups, p0.05, no statistical difference (p = 0.074). 1.5 Pre-operative intestinal preparation time: the average bowel preparation time was 5.09-2.10 d before the operation of the fts group, the average bowel preparation time of the control group was 15.02-4.99d, the two groups were compared, p0.01, and there was a statistical difference. 1.6 Post-operative hospital stay: The hospital stay was 5.65-1.08d after the operation, 15.63-4.32d in the control group and 15.63-4.32d in the control group. The total length of the hospital stay was 11.74-1.91 d, the total hospital stay was 31.84-6.97d in the control group, and the total length of the control group was 31.84-6.97d. There were 1 case of intra-abdominal residual infection (3.2%) in the fts group,1 case of anastomotic stricture in the control group,1 case of intestinal obstruction,2 cases of anastomotic dehiscence and 3 cases of abdominal incision infection (21.9%). (1) percentage of t-cells:24-hour post-operation decreased before operation and p0.05, there was a statistical difference. The post-operation of 72 h was higher than that of 24 h after operation, and p0.05, there was a statistical difference. There was no statistical difference (p = 0.273), (2) the percentage of auxiliary t-cells:24 h after operation and the pre-operation level, P0.05, there was a statistical difference. The results showed that there was no statistical difference (P = 0.899). (3) The percentage of anti-personnel T cells: no statistical difference (P = 0.270) between the pre-operative,24-hour and 72-h post-operation group, all of which were in the normal level; (4) CD4/ CD8: no statistical difference (P = 0.193), (5) percentage of B cells:24 h after operation, P0.05, and statistical difference. There was no significant change (P = 0.151) at 72 h after operation, but higher than that before operation (P = 0.151). The percentage of NK cells was significantly higher than that before operation (P = 0.349). There was no statistical difference (P = 0.209), (2) Ig M: pre-operation,24 h after operation and 72 h after operation, no statistical difference (P = 0.744), (3) IgA: The results showed no significant difference (P = 0.113), (5) complement C4:24 h after operation and 72 h after operation. (P = 0.380). P0.01. There was no statistical difference (P = 0.242) between the pre-operation,24 hours after operation and 72 h after operation. Conclusion: The application of 1FTS in HD perioperative period can shorten the hospital stay time and the indwelling time of the drainage tube obviously, reduce the postoperative complication rate, reduce the operation time and the intraoperative blood loss by using the laparoscopic minimally invasive procedure, and accelerate the recovery of the body after the operation of the child. It has good clinical application value. Under the guidance of the FTS, the laparoscopic minimally invasive technique can effectively relieve the stress reaction of the perioperative period of the children with HD, and the effect on the body immunity and the protein metabolism is small, and the postoperative rehabilitation of the child is accelerated.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R726.5
本文編號：2504315
[Abstract]:Objective: Fast track surface surgery (FTS) is a series of perioperative management measures with evidence of evidence-based medicine to reduce or reduce the physiological, psychological and psychological trauma stress caused by the operation and the occurrence of complications, so that the patient can get a quick recovery. In this study, the operative time, the intraoperative blood loss, the postoperative intestinal function recovery, the hospital stay and the incidence of complications were compared by comparing the FTS concept with the traditional perioperative management in Hirschsprung's disease (HD). To evaluate the clinical application value of the FTS concept in HD treatment, and to explore the effect of minimally invasive surgery on the stress response of children and the degree of trauma by detecting the changes of the immune and protein metabolism indexes of the peripheral venous blood before and after the laparoscopic operation under the concept of FTS. Methods: 1FTS application: The data of 63 cases of HD from January 2001 to December 2003 and January 2016 to December 2016 were retrospectively analyzed. According to the different treatment methods of the perioperative period, 32 patients with HD who were treated with open surgery in the traditional perioperative period from January 2001 to December 2003 were used as the control group, and 31 HD children who were treated with the laparoscopic surgery under the guidance of the FTS in January 2016 and December 2016 were used as the FTS group, and the operation time of the two groups was compared. Intraoperative blood loss, drainage tube retention time, postoperative intestinal function recovery time, hospital stay and complications, etc. 2FTS stress response: (1) cellular immunity test: before and after operation,24 hours after operation, respectively. The percentage of T cells (CD3 +), the percentage of T cells (CD3 + CD4 +), the percentage of T cells (CD3 + CD8 +), the percentage of CD4/ CD8, B cells (CD3-CD19 +), and the percentage of NK cells (CD3-CD16 + CD56 +) were measured by peripheral venous blood. (2) Humoral immunity: The peripheral venous blood was used to detect the immunoglobulin IgG, IgM, IgA, complement C3 and C4 after 24 h after operation and 72 hours after operation. (3) Protein metabolism test: The C-reactive protein (CRP) and prealbumin (PA) were detected by peripheral venous blood at 24 h after operation and 72 hours after operation. Statistical analysis was performed using SPSS 21.0 to observe the changes of the body immunity and protein metabolism index in the FTS application. Results:1 HD operation related index: The two groups of HD children follow the treatment measures in the perioperative period, and the operation was completed successfully. The operation time was 145.48-90.07 min. The average operation time of the control group was 187.03-53.14min. The operative time of the fts group was significantly shorter than that of the control group, and there was a significant difference (p0.05). The amount of blood loss during the operation was 10.16-6.87 ml, the amount of blood loss in the control group was 40.72-23.58ml, and the amount of blood loss in the fts group was significantly lower than that of the control group, and there was a significant difference (p0.05). (1) The time of the nasogastric tube: the time of the indwelling nasogastric tube after operation was 37.09-11.89h, and the time of the indwelling nasogastric tube in the control group was 77.91-20.57h. (2) In the control group, the retention time was 17.55-3.83h, the retention time of the control group was 78.88-19.91 h, the two groups were compared, p0.05, there was a statistical difference, and (3) the anal canal: the anal canal was 1 ~ 3 days after the operation, and the average was 2.06-1.09d. The postoperative intestinal function recovery time was 36.55-13.89h after operation, and the recovery time of the intestinal function was 43.75-16.98h after operation. Comparison of the two groups, p0.05, no statistical difference (p = 0.074). 1.5 Pre-operative intestinal preparation time: the average bowel preparation time was 5.09-2.10 d before the operation of the fts group, the average bowel preparation time of the control group was 15.02-4.99d, the two groups were compared, p0.01, and there was a statistical difference. 1.6 Post-operative hospital stay: The hospital stay was 5.65-1.08d after the operation, 15.63-4.32d in the control group and 15.63-4.32d in the control group. The total length of the hospital stay was 11.74-1.91 d, the total hospital stay was 31.84-6.97d in the control group, and the total length of the control group was 31.84-6.97d. There were 1 case of intra-abdominal residual infection (3.2%) in the fts group,1 case of anastomotic stricture in the control group,1 case of intestinal obstruction,2 cases of anastomotic dehiscence and 3 cases of abdominal incision infection (21.9%). (1) percentage of t-cells:24-hour post-operation decreased before operation and p0.05, there was a statistical difference. The post-operation of 72 h was higher than that of 24 h after operation, and p0.05, there was a statistical difference. There was no statistical difference (p = 0.273), (2) the percentage of auxiliary t-cells:24 h after operation and the pre-operation level, P0.05, there was a statistical difference. The results showed that there was no statistical difference (P = 0.899). (3) The percentage of anti-personnel T cells: no statistical difference (P = 0.270) between the pre-operative,24-hour and 72-h post-operation group, all of which were in the normal level; (4) CD4/ CD8: no statistical difference (P = 0.193), (5) percentage of B cells:24 h after operation, P0.05, and statistical difference. There was no significant change (P = 0.151) at 72 h after operation, but higher than that before operation (P = 0.151). The percentage of NK cells was significantly higher than that before operation (P = 0.349). There was no statistical difference (P = 0.209), (2) Ig M: pre-operation,24 h after operation and 72 h after operation, no statistical difference (P = 0.744), (3) IgA: The results showed no significant difference (P = 0.113), (5) complement C4:24 h after operation and 72 h after operation. (P = 0.380). P0.01. There was no statistical difference (P = 0.242) between the pre-operation,24 hours after operation and 72 h after operation. Conclusion: The application of 1FTS in HD perioperative period can shorten the hospital stay time and the indwelling time of the drainage tube obviously, reduce the postoperative complication rate, reduce the operation time and the intraoperative blood loss by using the laparoscopic minimally invasive procedure, and accelerate the recovery of the body after the operation of the child. It has good clinical application value. Under the guidance of the FTS, the laparoscopic minimally invasive technique can effectively relieve the stress reaction of the perioperative period of the children with HD, and the effect on the body immunity and the protein metabolism is small, and the postoperative rehabilitation of the child is accelerated.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R726.5
【參考文獻(xiàn)】
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1 蘆霞;賈海明;米泰宇;張文權(quán);李立新;;快速康復(fù)外科技術(shù)對腹腔鏡膽囊切除術(shù)患者應(yīng)激指標(biāo)的影響[J];中國現(xiàn)代醫(yī)生;2016年29期
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