本文選題：胃癌 + 加速康復(fù)�。� 參考：《廣西醫(yī)科大學(xué)》2017年碩士論文

【摘要】：第一部分胃癌加速康復(fù)外科臨床實(shí)踐可行性與安全性探討1.目的:驗(yàn)證加速康復(fù)外科在胃癌根治術(shù)患者中應(yīng)用的有效性及安全性。2.方法:回顧性研究我科2016年1月至2016年12月收治的172例胃癌根治術(shù)患者,根據(jù)患者圍術(shù)期處理方案將患者分為傳統(tǒng)組(Standard care group,SC組)及加速康復(fù)外科組(Enhanced Recovery After Surgery group,ERAS組)。在172例患者中,傳統(tǒng)開放手術(shù)組(open gastrectomy with SC group,OG+SC組)44例,開放手術(shù)聯(lián)合加速康復(fù)外科組(open gastrectomy with ERAS group,OG+ERAS組)57例,腹腔鏡聯(lián)合加速康復(fù)外科組(laparoscopic gastrectomy with ERAS group,LG+ERAS組)50例,機(jī)器人聯(lián)合加速康復(fù)外科組(robot-assisted gastrectomy with ERAS,RG+ERAS組)21例。采用首次肛門排氣時(shí)間、經(jīng)口進(jìn)食時(shí)間、下床活動(dòng)時(shí)間、住院費(fèi)用、術(shù)后住院時(shí)間、并發(fā)癥發(fā)生率及疼痛評分變化情況等作為觀察指標(biāo)。并發(fā)癥采用Clavin-Didno分級(jí)方式進(jìn)行分級(jí)。3.結(jié)果與OG+SC組相比,OG+ERAS組、LG+ERAS組、RG+ERAS患者術(shù)后首次肛門排氣時(shí)間、經(jīng)口進(jìn)食時(shí)間及術(shù)后下床活動(dòng)時(shí)間均顯著縮短(P0.001)。OG+SC組、OG+ERAS組、LG+ERAS組、RG+ERAS組術(shù)后首次肛門排氣時(shí)間分別為84.09±24.73h、44.93±13.02h、44.68±15.33h、43.52±13.64h;經(jīng)口進(jìn)食時(shí)間分別為116.91±31.22h、39.63±13.92h、41.12±14.16h、37.19±11.79h;術(shù)后下床活動(dòng)時(shí)間分別為78.73±27.70h、28.07±10.61h、28.28±13.56h、26.81±11.35h。在住院費(fèi)用方面,與OG+SC組相比,OG+ERAS組、LG+ERAS組住院費(fèi)用顯著降低,而RG+ERAS組住院費(fèi)用顯著增高(P0.001)。OG+SC組、OG+ERAS組、LG+ERAS組、RG+ERAS組住院費(fèi)用分別為71011.82±13505.14元、61276.32±6814.46元、61252.36±6444.84元、74269.86±9165.08元。與OG+SC組相比,OG+ERAS組、LG+ERAS組、RG+ERAS組術(shù)后住院時(shí)間顯著縮短(P0.001)。OG+SC組、OG+ERAS組、LG+ERAS組、RG+ERAS組術(shù)后住院時(shí)間分別為11.05±4.02d、7.88±1.88d、7.64±2.30d和7.67±4.49d。OG+SC組、OG+ERAS組、LG+ERAS組、RG+ERAS組總并發(fā)癥發(fā)生率無顯著差異(P0.05)。各組并發(fā)癥總發(fā)生率分別為6.8%、5.3%、6.0%、4.8%。在術(shù)后疼痛評分方面,與OG+SC組相比,OG+ERAS組、LG+ERAS組、RG+ERAS組術(shù)后疼痛評分均有所降低。OG+SC組、OG+ERAS組、LG+ERAS組、RG+ERAS組術(shù)后疼痛評分在術(shù)后第一日2.32±0.82、1.07±1.01、1.28±1.00、1.29±1.12,第二日1.95±0.42、0.51±0.73、0.78±0.86、0.86±0.94,第三日1.70±0.69、0.32±0.65、0.38±0.69、0.24±0.61,及第四日0.98±0.81、0.05±0.29、0.06±0.31、0±0比較差異具有統(tǒng)計(jì)學(xué)意義(P0.001)。4.結(jié)論加速康復(fù)外科在胃癌患者圍術(shù)期應(yīng)用是可行且安全的。第二部分胃癌加速康復(fù)外科臨床評估體系初探1.目的:初步探討患者主觀感受評估系統(tǒng)的應(yīng)用價(jià)值,比較不同圍術(shù)期處理方式對胃癌患者術(shù)后短期生活質(zhì)量的影響。2.方法:回顧性分析我科2016年8月至2016年12月收治的行胃癌根治術(shù)患者68例,其中OG+SC組21例,OG/LG+ERAS組26例、RG+ERAS組21例。應(yīng)用Qo R-40評分系統(tǒng)對三組患者術(shù)前、術(shù)后d3及術(shù)后三周的主觀感受情況進(jìn)行評分。包括:情緒狀態(tài)(45分)、身體舒適度(60分)、患者支持(35分)、自理能力(25分)及疼痛情況(35分)5個(gè)領(lǐng)域,每個(gè)條目根據(jù)程度的不同,分別對應(yīng)1-5分的分值,總分越高,則生存質(zhì)量越高。根據(jù)Qo R-40評分高低評估患者的術(shù)后生活質(zhì)量水平。3.結(jié)果與OG+SC組相比,OG/LG+ERAS組、RG+ERAS組術(shù)前生存質(zhì)量評分無統(tǒng)計(jì)學(xué)差異(P0.05),術(shù)后d3及術(shù)后3周的Qo R-40評分顯著升高(P0.001)。OG+SC組、OG/LG+ERAS組、RG+ERAS組術(shù)前Qo R-40評分分別為175.15±2.82分、176.19±3.50分、175.71±2.46分;術(shù)后d3Qo R-40評分分別為147.06±4.45分、157.47±2.05分、166.53±0.93分;術(shù)后第三周評分分別為162.62±1.59、170.21±2.49、173.33±5.76。術(shù)后第三周時(shí),應(yīng)用加速康復(fù)外科路徑的病例生活質(zhì)量基本恢復(fù)至術(shù)前。4.結(jié)論(1)加速康復(fù)外科能使患者術(shù)后生活質(zhì)量更快恢復(fù)至術(shù)前水平;(2)機(jī)器人手術(shù)術(shù)后患者生活質(zhì)量優(yōu)于其他術(shù)式。第三部分胃癌加速康復(fù)外科術(shù)中液體管理等問題探討1.目的:探究年齡及術(shù)中控制輸液量對胃癌患者術(shù)后恢復(fù)的影響。2.方法:回顧性研究我科2016年1月至2016年12月收治的128例實(shí)施加速康復(fù)外科方案的胃癌根治術(shù)患者。將納入研究的患者分為3個(gè)年齡組:小于40歲為低年齡組(Young Age Group,YAG)、40-59歲為中年齡組(Middle Age Group,MAG)、大于60歲為高年齡組(Old Age Group,OAG)。按照患者單位體積單位時(shí)間液體入量進(jìn)行四分位分組,小于第25百分位數(shù)為低入量組(Low Volume Group,LVG),介于第25-75百分位數(shù)(Medium Volume Group,LVG)為中入量組,大于第75百分位數(shù)為高入量組(High Volume Group,HVG)。3.結(jié)果YAG組、MAG組、OAG組術(shù)后肛門排氣時(shí)間分別為45.90±15.42h、44.61±13.97h、43.98±13.53h;術(shù)后下床活動(dòng)時(shí)間分別為26.65±8.99h、28.73±12.87h、27.33±11.62h;術(shù)后進(jìn)食時(shí)間分別為39.85±10.93h、41.73±13.48h、36.79±14.79h;術(shù)后住院日分別為6.60±1.57h、7.85±2.98h、8.14±2.24h,各組結(jié)果比較,差異均無統(tǒng)計(jì)學(xué)意義(P0.05)。并發(fā)癥方面,OAG組、MAG組、YAG組術(shù)后并發(fā)癥發(fā)生率分別為10%、3%、7.1%,三組比較無顯著差異(P0.05)。LVG組、MVG組、HVG組術(shù)后肛門排氣時(shí)間分別為45.91±14.93h、45.82±12.72h、40.71±15.14h;術(shù)后下床活動(dòng)時(shí)間分別為30.72±13.56h、27.98±11.27h、25.00±10.94h;術(shù)后進(jìn)食時(shí)間分別為38.59±15.49h、40.35±12.94h、39.94±13.49h;術(shù)后住院日分別為8.03±2.57d、7.62±2.93d、7.74±1.88d,各組結(jié)果比較,差異均無統(tǒng)計(jì)學(xué)意義(P0.05)。并發(fā)癥方面,OAG組、MAG組、YAG組術(shù)后并發(fā)癥發(fā)生率分別為6.3%、4.6%、6.5%,三組比較無顯著差異(P0.05)。4.結(jié)論年齡及術(shù)中液體入量可能不對加速康復(fù)外科患者術(shù)后恢復(fù)產(chǎn)生影響。
[Abstract]:The first part of the study on the feasibility and safety of accelerated rehabilitation surgery for gastric cancer 1. Objective: to verify the effectiveness and safety of accelerated rehabilitation surgery in patients with radical gastrectomy for gastric cancer: a retrospective study of 172 cases of radical gastrectomy in our department from January 2016 to December 2016, according to the perioperative treatment plan of the patients will be affected by.2.. The patients were divided into the traditional group (Standard care group, group SC) and the accelerated rehabilitation surgery group (Enhanced Recovery After Surgery group, ERAS group). In the 172 cases, the traditional open operation group (open gastrectomy) was 44 cases, and the open surgery combined accelerated rehabilitation surgery group was 57 cases. 50 cases (laparoscopic gastrectomy with ERAS group, LG+ERAS group), robot combined accelerated rehabilitation surgery group (robot-assisted gastrectomy with ERAS, RG+ERAS group) 21 cases, using the first anus exhaust time, oral feeding time, bed activity time, hospitalization expenses, postoperative hospitalization time, complications Compared with the OG+SC group, the results of the Clavin-Didno classification of the complications were compared with the OG+SC group. The first anus exhaust time of the OG+ERAS group, the LG+ERAS group, the RG+ERAS patients after operation, the time of oral feeding and the activity time after the operation were significantly shortened (P0.001).OG+SC group, OG+ERAS group, LG+ERAS group, RG+. The first anus exhaust time after operation in group ERAS was 84.09 + 24.73h, 44.93 + 13.02h, 44.68 + 15.33h, 43.52 + 13.64h, and the time of oral feeding was 116.91 + 31.22h, 39.63 + 13.92h, 41.12 + 14.16h, 37.19 + 11.79h, respectively, 78.73 + 27.70h, 28.07 + 10.61h, 28.28 + 13.56h. Compared with group OG+SC, the cost of hospitalization in group OG+ERAS and group LG+ERAS was significantly lower, while the hospitalization cost in group RG+ERAS increased significantly (P0.001).OG+SC group, and the hospitalization expenses of group OG+ERAS, LG+ERAS, and RG+ERAS were 71011.82 + 13505.14 yuan, 61276.32 + 6814.46 yuan, 61252.36 + 6444.84 yuan, 74269.86 + 9165.08 yuan, and OG+ERAS group and LG+ERAS group compared with OG+SC group. In group +ERAS, the time of hospitalization was significantly shortened (P0.001) in group.OG+SC, group OG+ERAS, group LG+ERAS, group LG+ERAS, and group RG+ERAS were 11.05 + 4.02d, 7.88 + 1.88d, 7.64 + 2.30d and 7.67 + 4.49d.OG+SC respectively. There was no significant difference in the incidence of complications in OG+ERAS group and LG+ERAS group. The total incidence of complications in each group was 6.8%, 5.3%, 6., respectively. 0%, 4.8%. in postoperative pain score, compared with group OG+SC, group OG+ERAS, group LG+ERAS, and group RG+ERAS had lower pain scores in group.OG+SC, OG+ERAS group, LG+ERAS group, and group RG+ERAS after operation. The postoperative pain score of group RG+ERAS was 2.32 + 0.82,1.07 + 1.01,1.28 + 1.00,1.29 + 1.12 on the first day after operation, and 1.95 + 1.95 + 0.94. Three days 1.70 + 0.69,0.32 + 0.65,0.38 + 0.69,0.24 + 0.61 and four days 0.98 + 0.81,0.05 + 0.29,0.06 + 0 the difference has statistical significance (P0.001).4. conclusion, accelerated rehabilitation surgery is feasible and safe in the perioperative application of gastric cancer patients. Second part of gastric cancer accelerated rehabilitation surgery clinical evaluation system 1. purposes: preliminary exploration To discuss the application value of the patient's subjective perception evaluation system and compare the effect of different perioperative treatment methods on postoperative short-term quality of life of gastric cancer patients.2.: a retrospective analysis of 68 patients with radical gastrectomy from August 2016 to December 2016, including 21 cases in group OG+SC, 26 cases in group OG/LG+ERAS, 21 cases in group RG+ERAS. The application of Qo R-40 The subjective feeling of three groups of patients before operation, postoperative D3 and three weeks postoperatively was scored, including emotional state (45 points), body comfort (60 points), patient support (35 points), self-care (25) and pain (35) in 5 fields, each item corresponding to 1-5 points, the higher the total score, the higher the total score, the quality of survival. According to the Qo R-40 score, the postoperative quality of life of the patients was evaluated by.3.. Compared with group OG+SC, there was no statistical difference between group OG/LG+ERAS and group RG+ERAS (P0.05), D3 and Qo R-40 score in 3 weeks after operation were significantly higher (P0.001).OG+SC group. 5 + 2.82 points, 176.19 + 3.50 points, 175.71 + 2.46 points, d3Qo R-40 scores were 147.06 + 4.45, 157.47 + 2.05, 166.53 + 0.93, and third weeks after the operation were 176.19 weeks after the surgery of 162.62 + 1.59170.21 + 2.49173.33 + 5.76. Rehabilitation surgery can make the patient's quality of life back to the preoperative level faster; (2) the quality of life of the patients after the robot surgery is better than that of other surgical procedures. Third part of the gastric cancer accelerated the recovery of the fluid management and other problems, 1. objectives: To explore the effect of age and intraoperative control of infusion on postoperative recovery of gastric cancer patients: a review of the.2. method: 128 patients who were treated with accelerated rehabilitation surgery from January 2016 to December 2016 were divided into 3 age groups: lower age group (Young Age Group, YAG), 40-59 years old age group (Middle Age Group, MAG), and higher age group than 60 years (Old Age Group, OAG). The unit volume per unit volume of the patient was divided into four sub groups, which were less than twenty-fifth percentiles as the low entry group (Low Volume Group, LVG), and the 25-75 percentile (Medium Volume Group, LVG) was the middle entry group, and the seventy-fifth percentile was the high entry group (High Volume Group, HVG). The exhaust time was 45.90 + 15.42h, 44.61 13.97h, 43.98 + 13.53h, and the activity time after operation was 26.65 + 8.99h, 28.73 + 12.87h, 27.33 + 11.62h, and the feeding time was 39.85 + 10.93h, 41.73 + 13.48h, 36.79 + 14.79h after operation, respectively. The postoperative hospital days were 6.60 + 1.57h, 7.85 + 2.98h, 8.14 + 2.24h. Statistical significance (P0.05). Complications, the incidence of postoperative complications in group OAG, group MAG, and group YAG was 10%, 3%, 7.1%, respectively. There was no significant difference in group three (P0.05).LVG, MVG group, and group HVG, 45.91 + 14.93h, 45.82 + 12.72h, 40.71 +, respectively, and 30.72 + 13.56h, 27.98 +, 25 after operation. 0 + 10.94h (38.59 + 15.49h, 40.35 + 12.94h, 39.94 + 13.49h) after operation were 8.03 + 2.57d, 7.62 + 2.93d, 7.74 + 1.88d, respectively, and the differences were not statistically significant (P0.05). The complications of group OAG, MAG, and YAG were 6.3%, 4.6%, 6.5%, and no significant difference. Differences (P0.05).4. conclusion age and intraoperative fluid intake may not affect postoperative recovery in patients undergoing accelerated rehabilitation surgery.

【學(xué)位授予單位】：廣西醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R735.2

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