本文選題：加速康復(fù)外科 + 腹腔鏡��； 參考：《中國人民解放軍醫(yī)學(xué)院》2017年博士論文

【摘要】：研究背景及目的:老年胃癌(Gastric cancer,GC)患者生理機(jī)能減退,全身臟器功能下降,對創(chuàng)傷應(yīng)激、營養(yǎng)不良耐受性差,影響術(shù)后恢復(fù)。加速康復(fù)外科(Enhanced recovery after surgery , ERAS; Fast track surgery, FTS)主張選取多種優(yōu)化的綜合措施,以達(dá)到減輕患者心理、生理創(chuàng)傷和應(yīng)激反應(yīng),達(dá)到術(shù)后快速恢復(fù)的目的。而腹腔鏡創(chuàng)傷小、可促進(jìn)術(shù)后康復(fù)等優(yōu)點(diǎn)迎合ERAS理念。本課題采用加速康復(fù)外科與腹腔鏡技術(shù)相結(jié)合治療老年胃癌患者,研究其安全性、有效性,探討其對老年胃癌患者營養(yǎng)狀況、應(yīng)激反應(yīng)的影響,旨在為胃癌患者、尤其是老年患者尋求創(chuàng)傷小、內(nèi)環(huán)境穩(wěn)定、營養(yǎng)狀況好、應(yīng)激反應(yīng)小、術(shù)后康復(fù)快的圍手術(shù)期處理流程。方法:選取2015年9月至2016年8月我院收治并病理確診為胃癌的老年(年齡均≥60歲)患者,評估后選取無手術(shù)禁忌、能耐受手術(shù)的共84例,隨機(jī)分為四組:A組(ERAS+腹腔鏡21例)、B組(ERAS+開腹21例)、C組(傳統(tǒng)圍手術(shù)期管理+腹腔鏡21例)、D組(傳統(tǒng)圍手術(shù)期管理+開腹21例)。各組遵循相應(yīng)程序?qū)嵤┪赴└涡g(shù),分別記錄各組患者性別、年齡、體重指數(shù)(BMI)、手術(shù)方式、吻合方式、病理分期等一般資料。從以下方面觀察研究:(1)安全性、有效性指標(biāo):分別記錄四組的手術(shù)持續(xù)時間、出血量、切口長度、清除淋巴結(jié)個數(shù)、肛門排氣時間、術(shù)后住院日、住院總費(fèi)用、并發(fā)癥發(fā)生情況等;(2)營養(yǎng)狀況指標(biāo):術(shù)前采用NRS2002營養(yǎng)篩查法評價并指導(dǎo)營養(yǎng)治療。記錄對比四組術(shù)前1天、術(shù)后第1天、術(shù)后第4天、術(shù)后第7天血白蛋白(ALB)、前白蛋白(PA)、轉(zhuǎn)鐵蛋白(TRF)水平;計(jì)算并記錄四組術(shù)前1天、術(shù)后4天、術(shù)后7天的營養(yǎng)評價指數(shù)(NCI),進(jìn)行對比觀察;(3)應(yīng)激反應(yīng)指標(biāo):記錄對比四組術(shù)前1天、術(shù)后1天、術(shù)后4天、術(shù)后7天時間點(diǎn)的C反應(yīng)蛋白(CRP)、白細(xì)胞介素-6(IL-6)、血清淀粉樣蛋白A (SAA)水平。結(jié)果:(1)四組的年齡、性別、BMI、合并癥、TNM分期、手術(shù)切除方式、吻合方式、清掃淋巴結(jié)個數(shù)均無顯著差異。腹腔鏡(A組、C組)手術(shù)組比開腹(B組、D組)手術(shù)組手術(shù)持續(xù)時間明顯延長、出血量明顯減少、切口長度明顯縮短(P均0.05)。(2)術(shù)后恢復(fù)指標(biāo):①首次肛門排氣時間、住院時間:A組最短,D組最長(P0.05)。②住院總費(fèi)用:腹腔鏡手術(shù),ERAS處理的A組住院總費(fèi)用明顯低于傳統(tǒng)方法管理的C組;開腹手術(shù),ERAS處理的B組住院總費(fèi)用明顯低于傳統(tǒng)方法管理的D (P均0.05)。③術(shù)后并發(fā)癥:四組并發(fā)癥無明顯差異(P0.05)。(3)營養(yǎng)狀況指標(biāo):四組患者術(shù)前ALB、PA;TRF水平無顯著差異(P均0.05),均略低于正常水平,存在輕度營養(yǎng)不良。術(shù)后四組患者的NCI指數(shù)均出現(xiàn)不同程度的降低,其中A組下降最小、回升最快,D組降低最快,恢復(fù)最慢(P0.05)。(4)應(yīng)激反應(yīng)水平:術(shù)后1天,四組CRP、IL-6、SAA水平均出現(xiàn)明顯上升,其中,A組上升幅度最小,D組上升幅度最大(P均0.05)。術(shù)后4天,四組CRP、SAA水平繼續(xù)上升,A組上升幅度最小,D組上升幅度最高;而IL-6水平開始出現(xiàn)下降,A組同樣表現(xiàn)出下降最快,D組下降最慢(P均0.05)。術(shù)后7天,四組CRP、IL-6、SAA 均明顯下降(P 均0.05),A 組 CRP、IL-6、SAA 水平最低,D組最高(P均0.05)。結(jié)論:1加速康復(fù)外科聯(lián)合腹腔鏡治療老年胃癌患者是安全、可行的,有助于促進(jìn)術(shù)后腸功能恢復(fù)、縮短住院時間、減少住院總費(fèi)用,加速術(shù)后恢復(fù)。2加速康復(fù)外科與腹腔鏡聯(lián)合治療老年胃癌患者,術(shù)后營養(yǎng)狀況好,能夠加速病人康復(fù)。3傳統(tǒng)圍手術(shù)期管理與開腹手術(shù)對老年胃癌患者造成的創(chuàng)傷重、應(yīng)激反應(yīng)大,加速康復(fù)外科聯(lián)合腹腔鏡手術(shù)可有效減輕機(jī)體創(chuàng)傷、降低應(yīng)激反應(yīng)水平。4加速康復(fù)外科或腹腔鏡單獨(dú)應(yīng)用于老年胃癌患者,亦能促進(jìn)術(shù)后康復(fù)、利于營養(yǎng)、減輕應(yīng)激反應(yīng),二者效果無差異,聯(lián)用作用更好。
[Abstract]:Background and purpose: the elderly gastric cancer (Gastric cancer, GC) patients with impaired physiological function, systemic organ function decline, trauma stress, poor malnutrition tolerance, the effect of postoperative recovery. Accelerated rehabilitation surgery (Enhanced recovery after surgery, ERAS; Fast track surgery, FTS) to select a variety of comprehensive measures to reduce. This subject uses accelerated rehabilitation surgery and laparoscopy to treat the elderly patients with gastric cancer, to study the safety and effectiveness of the patients with gastric cancer, and to explore the nutrition of the elderly patients with gastric cancer, and to explore the nutrition of the elderly patients with gastric cancer. The effect of stress response is aimed at seeking for the gastric cancer patients, especially the elderly patients, to seek a small wound, a stable internal environment, good nutritional status, a small stress response and a quick recovery in the perioperative period. Methods: to select the elderly patients who were diagnosed as gastric cancer in our hospital from September 2015 to August 2016 and have a pathological diagnosis of gastric cancer (older than 60 years old). A total of 84 patients with no operation taboo and tolerance were randomly divided into four groups: group A (21 cases of ERAS+ laparoscopy), group B (21 cases of open abdomen), group C (traditional perioperative management + 21 cases), group D (traditional perioperative management + 21 cases). The groups followed the corresponding procedure to carry out radical gastrectomy, and recorded the sex, age and weight of each group respectively. General data (BMI), surgical methods, anastomosis and pathological staging. (1) safety and effectiveness indexes: the duration of operation, the amount of bleeding, the length of the incision, the number of lymph nodes, the time of anus exhaust, the hospitalization day after operation, the total hospitalization expenses, the occurrence of complications, etc. (2) nutritional status. Standard: preoperative NRS2002 nutrition screening method was used to evaluate and guide nutritional therapy. The blood albumin (ALB), prealbumin (PA), and transferrin (TRF) levels were recorded and compared in four groups, 1 days before operation, first days after operation, fourth days after operation, seventh days after operation, and four groups, 1 days before operation, 4 days after operation, and 7 day postoperative nutrition evaluation index (NCI). (3) Stress response index: the C reaction protein (CRP), interleukin -6 (IL-6), and serum amyloid A (SAA) level were recorded at 1 days before operation, 1 days after operation, 4 days after operation and 7 days after operation. Results: (1) there were no significant differences in age, sex, BMI, complication, TNM staging, surgical excision, anastomosis and cleaning lymph nodes in four groups. The operation duration of the laparoscopic (group A, group C) group was significantly longer than that in the open group (group B, group D), the amount of bleeding was significantly reduced and the length of the incision was significantly shortened (P 0.05). (2) the postoperative recovery index: 1. The first anus exhaust time, the length of hospitalization in the A group, the longest (P0.05) in group D (P0.05). The total hospitalization expenses of the laparoscopic operation and the ERAS treated A group were total. The cost of the C group was significantly lower than that of the traditional method of management; the total cost in the B group treated with laparotomy and ERAS treatment was significantly lower than that of the traditional method of D (P 0.05). (3) postoperative complications: there was no significant difference in the complications of the four groups (P0.05). (3) the nutritional status index: there was no significant difference in the level of ALB, PA, TRF (P 0.05) before operation in the four groups (P 0.05), all slightly below the normal level, There were slight dystrophy. The NCI index of the four groups of patients decreased in varying degrees, of which the A group had the least decline, the fastest recovery, the fastest decrease in the D group and the slowest (P0.05). (4) the level of stress reaction was increased significantly at 1 days after the operation, and the level of CRP, IL-6 and SAA in the group of A was the least, and the increase of the D group was the largest (P 0.05. 0.05 4 days after the operation, the level of CRP and SAA continued to rise, the increase in the A group was the least, the increase in the group D was the highest, while the IL-6 level began to decline, the A group also showed the fastest decline, and the D group declined the slowest (P 0.05). The four groups of CRP, IL-6, SAA were all significantly decreased (0.05), the lowest level (0.05). Conclusion: 1 the combination of accelerated rehabilitation surgery and laparoscopy in the treatment of elderly gastric cancer patients is safe and feasible. It helps to promote the recovery of postoperative intestinal function, shorten the time of hospitalization, reduce the total hospitalization expenses, accelerate the recovery of.2 and accelerate the rehabilitation surgery and laparoscopy in the treatment of elderly gastric cancer patients. The postoperative nutritional status is good and the patients can accelerate the rehabilitation of the traditional.3 hand. The effect of operation and laparotomy on the elderly patients with gastric cancer is heavy, stress response is large, accelerated rehabilitation surgery combined with laparoscopic surgery can effectively reduce the body trauma, reduce stress response level.4 accelerated rehabilitation surgery or laparoscopy alone should be used in elderly patients with gastric cancer, can also promote postoperative rehabilitation, nutrition, and relieve stress response, There is no difference in the effect of the two, and the combined use is better.
【學(xué)位授予單位】：中國人民解放軍醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R735.2

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