快速康复外科理念在先天性巨结肠症手术中的应用价值
发布时间：2019-06-21 20:08
【摘要】：目的:快速康复外科(Fast track surgery,FTS)理念是采用一系列有循证医学证据的优化围手术期处理措施,以减少或降低手术所致生理、心理创伤应激反应及并发症发生,使病人获得快速康复。本研究通过比较FTS理念和传统围手术期管理在先天性巨结肠症(Hirschsprung's disease,HD)的手术时间、术中出血量、术后肠功能恢复情况、住院时间及并发症发生率等方面的差异,评估FTS理念在HD治疗中的临床应用价值,并且通过检测FTS理念下腹腔镜手术前后外周静脉血免疫和蛋白质代谢指标的变化,探讨微创手术对小儿机体应激反应的影响和创伤程度。方法:1 FTS应用:回顾分析河北医科大学第二医院小儿外科于2001年1月至2003年12月和2016年1月至2016年12月间收治的63例HD病例资料,根据围手术期处理方式的不同,将2001年1月至2003年12月间予以传统围手术期处理开放手术治疗的32例HD患儿作为对照组;将2016年1月至2016年12月间予以FTS理念指导下的腹腔镜手术治疗的31例HD患儿作为FTS组,比较两组患儿手术时间、术中出血量、引流管留置时间、术后肠功能恢复时间、住院时间和并发症发生等情况。2 FTS应激反应:(1)细胞免疫检测:分别于术前、术后24h、术后72h采取外周静脉血检测淋巴细胞亚群T细胞(CD3+)百分比、辅助性T细胞(CD3+CD4+)百分比、杀伤性T细胞(CD3+CD8+)百分比、CD4/CD8、B细胞(CD3-CD19+)百分比、NK细胞(CD3-CD16+CD56+)百分比。(2)体液免疫检测:分别于术前、术后24h、术后72h采取外周静脉血检测免疫球蛋白IgG、IgM、IgA,补体C3、C4。(3)蛋白质代谢检测:分别于术前、术后24h、术后72h采取外周静脉血检测C-反应蛋白(C-reactive protein,CRP)和血清前白蛋白(prealbumin,PA)。采用SPSS 21.0进行统计学分析,观察机体免疫及蛋白质代谢指标在FTS应用的变化情况。结果:1 HD手术相关指标:两组HD患儿均遵循各自围手术期处理措施,顺利完成手术治愈出院,无死亡病例。1.1手术时间:fts组平均手术时间145.48±90.07min,对照组平均手术时间187.03±53.14min,fts组手术时间明显短于对照组,有显著统计学差异(p0.05)。1.2术中出血量:fts组术中出血量10.16±6.87ml,对照组术中出血量40.72±23.58ml,fts组术中出血量明显少于对照组,有显著统计学差异(p0.05)。1.3引流管留置时间:(1)鼻胃管:fts组术后留置鼻胃管时间37.09±11.89h,对照组术后留置鼻胃管时间77.91±20.57h,两组比较,p0.05,有统计学差异。(2)尿管:fts组尿管留置时间17.55±3.83h,对照组尿管留置时间78.88±19.91h,两组比较,p0.05,有统计学差异;(3)肛管:fts组术后留置肛管1~3d,平均2.06±1.09d;对照组经肛门留置的环形吻合鸭嘴钳于术后4~13d自行脱落,平均留置7.56±3.05d,两组比较,p0.05,有统计学差异。1.4术后肠功能恢复时间:fts组术后肠功能恢复时间36.55±13.89h,对照组术后肠功能恢复时间43.75±16.98h,两组比较,p0.05,无统计学差异(p=0.074)。1.5术前肠道准备时间:fts组术前灌洗肠道准备时间平均5.09±2.10d,对照组术前灌洗肠道准备时间平均15.02±4.99d,两组比较,p0.01,有统计学差异。1.6术后住院时间:fts组术后住院时间5.65±1.08d,对照组术后住院时间15.63±4.32d,两组比较,p0.01,有统计学差异。1.7总住院时间:fts组总住院时间11.74±1.91d,对照组总住院时间31.84±6.97d,两组比较,p0.01,有统计学差异。1.8并发症:fts组中出现腹腔残余感染1例,占3.2%;对照组中出现吻合口狭窄1例、肠梗阻1例、吻合口裂开2例和腹部切口感染3例,占21.9%,两组比较,p0.05,有统计学差异;2fts组免疫反应与蛋白质代谢2.1淋巴细胞亚群变化:(1)t细胞百分比:术后24h较术前降低,p0.05,有统计学差异。术后72h较术后24h升高,p0.05,有统计学差异。至术后72h基本恢复接近术前水平,无统计学差异(p=0.273);(2)辅助性t细胞百分比:术后24h较术前下降,P0.05,有统计学差异。至术后72h较术后24h升高,P0.05,有统计学差异,且基本恢复至术前水平,无统计学差异(P=0.899);(3)杀伤性T细胞百分比:术前、术后24h及术后72h组间比较,无统计学差异(P=0.270),均处于正常水平范围;(4)CD4/CD8:术前、术后24h及术后72h组间比较,无统计学差异(P=0.193);(5)B细胞百分比:术后24h较术前升高,P0.05,有统计学差异。术后72h较术后24h无明显变化(P=0.151),但较术前升高,P0.05,有统计学差异;(6)NK细胞百分比:术后24h较术前无明显变化(P=0.349)。术后72h较术后24h下降,P0.05,有统计学差异。2.2体液免疫指标变化:(1)IgG:术前、术后24h及术后72h组间比较,无统计学差异(P=0.209);(2)Ig M:术前、术后24h及术后72h组间比较,无统计学差异(P=0.744);(3)IgA:术前、术后24h及术后72h组间比较,无统计学差异(P=0.945);(4)补体C3:术后24h和术后72h较术前均无明显变化(P=0.113);(5)补体C4:术后24h和术后72h较术前均无明显变化(P=0.380)。2.3 CRP:术后24h较术前明显升高,P0.01。术后72h较术后24h下降,P0.01,但较术前亦有升高,P0.01。2.4 PA:术前、术后24h及术后72h组间比较,无统计学差异(P=0.242)。结论:1 FTS应用于HD围手术期能明显缩短患者的住院时间及引流管留置时间,降低术后并发症发生率,采用腹腔镜微创手术可减少手术时间及术中出血量,加快患儿术后机体的恢复,具有较好的临床应用价值。2 FTS指导下采用腹腔镜微创技术能有效减轻HD患儿围手术期应激反应,对机体免疫及蛋白质代谢影响较小,加速了患儿术后康复。
[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.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R726.5
本文编号：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.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R726.5
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