【摘要】：目的比較氣管插管全身麻醉下上消化道不同部位病變行內(nèi)鏡黏膜下剝離術(shù)(ESD)術(shù)中消化道蠕動情況并探討處理方法。方法序貫收入浙江大學(xué)醫(yī)學(xué)院附屬第一醫(yī)院2014年2—7月在全身麻醉下行上消化道病變ESD的患者76例,依據(jù)病變部位不同分為胃竇胃角組(25例)、胃體胃底組(21例)、食管和食管胃交界組(30例)�；颊呖焖凫o脈麻醉誘導(dǎo)后行氣管插管,術(shù)中以持續(xù)靜脈泵注丙泊酚、間斷靜脈注射芬太尼維持麻醉深度。應(yīng)用內(nèi)鏡影像系統(tǒng)記錄ESD操作過程,對胃食管蠕動情況進(jìn)行胃蠕動評分(食管和食管胃交界組無該項評分)和操作評分,胃蠕動評分2分定義為劇烈蠕動,操作評分2分定義為影響操作。當(dāng)操作評分2分時即刻靜脈注射消旋山莨菪堿10mg作為補救措施。記錄手術(shù)結(jié)束至拔除氣管導(dǎo)管的時間(拔管時間)和拔除氣管導(dǎo)管至被準(zhǔn)許返回病房的時間[麻醉后監(jiān)測治療室(PACU)時間]。記錄在PACU和術(shù)后24h的藥物不良反應(yīng)和患者情況。結(jié)果胃體胃底組、食管和食管胃交界組的手術(shù)時間和麻醉時間均顯著長于胃竇胃角組(P值均0.05),3組間拔管時間、PACU時間、丙泊酚用量的差異均無統(tǒng)計學(xué)意義(P值均0.05)。在胃蠕動評分方面,胃竇胃角組劇烈蠕動的發(fā)生率為68.0%(17/25),顯著高于胃體胃底組的9.5%(2/21,P0.05);胃竇胃角組的胃蠕動評分亦顯著高于胃體胃底組(P0.01)。在操作評分方面,胃竇胃角組影響操作的發(fā)生率為68.0%(17/25),顯著高于胃體胃底組的4.8%(1/21)、食管和食管胃交界組的3.3%(1/30,P值均0.05);胃竇胃角組的操作評分亦顯著高于胃體胃底組、食管和食管胃交界組(P值均0.01)。因劇烈蠕動影響操作的患者在給予消旋山莨菪堿后蠕動均得到明顯抑制(操作評分≤2分),順利完成手術(shù)。3組間患者在PACU中視力模糊和腹痛發(fā)生率,以及術(shù)后24h咽痛、腹痛、發(fā)熱、排尿困難和惡心嘔吐發(fā)生率的差異均無統(tǒng)計學(xué)意義(P值均0.05)。結(jié)論氣管插管全身麻醉下上消化道病變行ESD術(shù)中消化道劇烈蠕動易發(fā)生于胃竇胃角處病變的手術(shù)過程中,術(shù)中靜脈注射消旋山莨菪堿10mg能有效抑制蠕動,有利于手術(shù)操作。
[Abstract]:Objective to compare the peristalsis of digestive tract during endoscopic submucosal exfoliation (ESD) under general anesthesia in different parts of upper gastrointestinal tract under tracheal intubation and to explore the management methods. Methods 76 patients with upper gastrointestinal disease ESD under general anesthesia from February to July 2014 in the first affiliated Hospital of Medical College of Zhejiang University were divided into two groups: gastric antrum group (25 cases), body gastric fundus group (21 cases), gastric antrum angle group (25 cases) and gastric body gastrofundus group (21 cases). Esophagogastric junction group (30 cases). After induction of rapid intravenous anesthesia, tracheal intubation was performed. Propofol was continuously injected intravenously and fentanyl was intermittently injected intravenously to maintain the depth of anesthesia. Endoscopic imaging system was used to record the procedure of ESD, and the gastroesophageal peristalsis was evaluated by gastric peristalsis score (not in the esophagus-stomach junction group) and operation score. The gastric peristalsis score was defined as severe peristalsis by the gastric peristalsis score. An operation score of 2 is defined as affecting the operation. When the operation score was 2, racemic anisodamine 10mg was injected intravenously as a remedy. Record the time between the end of the operation and the extubation of the trachea (extubation time) and the time between the extubation of the trachea catheter and the permitted return to the ward [(PACU) time in the post-anesthesia monitoring treatment room]. Adverse drug reactions and patients were recorded at PACU and 24 h after operation. Results the operation time and anesthesia time in the body stomach fundus group, esophagus and stomach junction group were significantly longer than those in the gastric antrum angle group. The extubation time and PACU time between the three groups were significantly longer than those in the gastric antrum angle group. There was no significant difference in the dosage of propofol (P < 0.05). In gastric peristalsis score, the incidence of severe peristalsis in gastric antrum angle group was 68.0% (17 / 25), which was significantly higher than that in body gastric fundus group (9.5%) (2 / 21, P0.05). Gastric peristalsis score of gastric antrum angle group was also significantly higher than that of body gastric fundus group (P0.01). In terms of operation score, the incidence of affecting operation in antral horn group was 68.0% (17 / 25), which was significantly higher than that in body gastric fundus group (4.8%) and esophagus / stomach junction group (3.3% (1 / 30), P < 0.01). (P < 0.05); The operation score of gastric antrum and gastric horn group was also significantly higher than that of body gastric fundus group, esophageal and gastroesophageal junction group (P < 0.01). The peristalsis of patients with severe peristalsis was significantly inhibited after administration of racemic anisodamine (operation score 鈮，

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