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中华结直肠疾病电子杂志

中华结直肠疾病电子杂志 ›› 2018, Vol. 07 ›› Issue (05) : 447 -452. doi: 10.3877/cma.j.issn.2095-3224.2018.05.008

所属专题： 文献；

论著

腹腔镜下"无管化"结直肠手术的临床研究
郑立君1, 胡臻2, 常涛2, 蒋逊1, 卢列盛1, 王峰1, 刘忠臣1,†()   
  1. 1. 200072　上海市第十人民医院胃肠外科
    2. 200072　上海市第十人民医院麻醉科
  • 收稿日期:2017-12-27 出版日期:2018-10-25
  • 通信作者: 刘忠臣

Clinical study of laparoscopic ″tube-free″ colorectal surgery

Lijun Zheng1, Zhen Hu2, Tao Chang2, Xun Jiang1, Liesheng Lu1, Feng Wang1, Zhongchen Liu1,†()   

  1. 1. Department of Gastrointestinal Surgery, Shanghai Tenth People′s Hospital, Shanghai 200072, China
    2. Department of Anaesthesia, Shanghai Tenth People′s Hospital, Shanghai 200072, China
  • Received:2017-12-27 Published:2018-10-25
  • Corresponding author: Zhongchen Liu
  • About author:
    Corresponding author: Liu Zhongchen, Email:
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郑立君, 胡臻, 常涛, 蒋逊, 卢列盛, 王峰, 刘忠臣. 腹腔镜下"无管化"结直肠手术的临床研究[J/OL]. 中华结直肠疾病电子杂志, 2018, 07(05): 447-452.

Lijun Zheng, Zhen Hu, Tao Chang, Xun Jiang, Liesheng Lu, Feng Wang, Zhongchen Liu. Clinical study of laparoscopic ″tube-free″ colorectal surgery[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2018, 07(05): 447-452.

目的

通过改善围手术期处理实现腹腔镜下结直肠手术"无管化"；将腹腔镜下"无管化"结直肠手术与传统术后留置鼻胃管、腹腔引流管和导尿管腹腔镜下的结直肠手术在术后恢复和并发症方面进行对照研究，进一步论证腹腔镜下"无管化"结直肠手术的可行性和安全性。

方法

将49例结、直肠恶性肿瘤患者随机分为常规留置"三管"手术组（对照组）（23例）、"无管化"手术组（TF组）（26例）。比较患者基线特征指标、术后恢复指标、生活质量量表（QoR-40）评估、术后安全性指标。

结果

"无管化"手术组有3人术后发生尿潴留；"无管化"手术组与对照组相比，其术后阿片类镇痛药物的使用天数（Z=5.241，P<0.001）和住院天数明显缩短（t=3.21，P=0.002），差异均有统计学意义。两组患者在吻合口漏、肠梗阻、切口感染、肺部感染、心力衰竭、深静脉血栓和心脑血管意外等并发症的发生率方面差异无明显统计学意义（均P>0.05）。"无管化"手术组术后48 h QoR-40总分明显高于对照组（Z=5.774，P<0.01）；其中"无管化"手术组在身体舒适度、自理能力和疼痛方面的评分明显优于对照组（P<0.01）。

结论

在结直肠手术后常规留置鼻胃管、导尿管和腹腔引流管并不能使患者获益；而"无管化"结直肠手术通过减少患者术后不适，明显改善患者术后恢复质量，且不增加术后短期并发症的发生；是一种安全、可行的治疗措施。

关键词: 结直肠肿瘤, 腹腔镜, 鼻胃管, 腹腔引流, 导尿管
Objective

To achieve ″tube-free″ by improving the perioperative management of laparoscopic colorectal surgery. The laparoscopic ″tube-free″ colorectal surgery and conventional laparoscopic colorectal surgery which indwelled nasogastric tube, peritoneal drainage tube and urinary catheter postoperative were compared in the postoperative recovery and complications to proof the feasibility and safety of laparoscopic ″tube-free″ colorectal surgery.

Methods

Forty-nine patients with colorectal cancer were randomly divided into conventional indwelling three tube operation group (control group) (twenty-three cases) and "tube-free" operation group (TF group) (twenty-six cases). The baseline characteristics of the patients, the postoperative recovery index, 40-item quality of recovery scoring system (QoR-40) assessment and the postoperative safety index were compared.

Results

There were three patients who had postoperative urinary retention in the TF group. The postoperative days of opioid analgesics (Z=5.241, P<0.001) and days of hospitalization (t=3.2, P=0.002) in the TF group were significantly shorter than those in the control group. The difference was not statistically significant. There was no significant difference in the incidence of complications such as anastomotic leakage, intestinal obstruction, wound infection, pulmonary infection, heart failure, deep vein thrombosis and cardio cerebral vascular accident between the two groups (P>0.05). The total score of QoR-40 at forty-eight hours after operation in the TF group was significantly higher than that in the control group (Z=5.774, P<0.01), and the sub-score of comfort, self-care and pain in the TF group was significantly better than that in the control group (P<0.01).

Conclusion

Conventional indwelling nasogastric tube, catheter and drainage tube after colorectal surgery does not benefit the patients. Laparoscopic ″tube-free″ colorectal surgery which reduces postoperative discomfort, improves patient quality recovery after operation without increasing the occurrence of short-term postoperative complications is a safe and feasible treatment measures.

Key words: Colorectal neoplasms, Laparoscopes, Nasogastric tube, Abdominal drainage, Indwelling catheterization
表1 两组患者的一般资料（基线数据）比较（±s）
组别 纳入人数（n） 性别 年龄（岁） ASA分级 肿瘤部位
男性 女性 ? Ⅰ Ⅱ Ⅲ Ⅳ 回盲部 升结肠 横结肠 降结肠 乙状结肠 直肠
对照组 23 12 11 58.17±10.62 9 11 3 0 2 6 1 2 6 6
"无管化"手术组 26 15 11 61.04±9.78 13 10 3 0 3 6 2 2 6 7
t值/χ2值 ? 0.150 0.983 0.593 0.428
P值 ? 0.698 0.331 0.743 0.995
组别 TMN分期 手术类型 CCI
Ⅰ Ⅱ Ⅲ 右半结肠切除术 横结肠切除术 左半结肠切除术 乙状结肠癌根治术 直肠癌根治术 0 1 2 3 4
对照组 1 10 12 8 1 2 6 6 10 6 6 1 0
"无管化"手术组 2 10 14 9 2 2 6 7 10 10 3 2 1
t值/χ2值 0.593 0.428 3.162
P值 0.743 0.995 0.531
表2 两组患者术后恢复相关指标的比较（±s）
组别 例数（n） 术后导尿管留置（d） 术后鼻胃管留置（d） 术后首次排气时间（h） 术后首次进食流质（d） 术后首次排便时间（d） 术后阿片类镇痛药物使用（d） 术后住院天数（d）
对照组 23 2.78±0.90 2.43±0.59 36.52±10.21 2.86±0.97 3.73±1.29 2（1~4） 7.61±1.59
"无管化"手术组 26 0.38±1.10 0 33.80±11.06 2.58±0.86 3.50±1.14 0（0~3） 6.12±1.66
t值/Z值 ? 8.28 21.08 0.889 1.123 0.690 5.241 3.210
P值 ? <0.001 <0.001 0.379 0.267 0.494 <0.001 0.002
表3 两组患者术后安全性指标的比较[例（%）]
组别 例数（n） 并发症
吻合口漏 肠梗阻 切口感染 肺部感染 心力衰竭 深静脉血栓 心脑血管意外
对照组 23 1（4.35） 1（4.35） 2（8.70） 4（17.39） 1（4.35） 2（8.70） 2（8.70）
"无管化"手术组 26 0（0） 0（0） 2（7.69） 1（3.85） 2（7.69） 0（0） 1（3.85）
P值 ? 0.469 0.469 0.692 0.230 1.0 0.215 0.594
表4 两组患者术后48 h生活质量量表（QoR-40）评分的比较
组别 例数（n） 身体舒适度 情绪状态 心理支持 自理能力 疼痛 总评分
对照组 23 45（35~54） 36（27~43） 31（23~34） 12（9~19） 20（13~27） 150（133~165）
"无管化"手术组 26 52（41~59） 40（30~45） 30（26~35） 20（12~22） 27（21~30） 175（158~191）
Z值 ? 3.854 0.953 0.040 5.632 5.538 5.774
P值 ? <0.001 0.340 0.968 <0.001 <0.001 <0.001
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