胃癌患者围手术期加速康复外科临床路径的优化

发布时间：2018-05-11 16:52

本文选题：胃癌 + 围手术期处理　；参考：《青岛大学》2017年硕士论文

【摘要】：研究目的:随着加速康复外科(ERAS)理念的迅速发展,使得胃癌患者围手术期治疗、护理模式发生了很大的变化。越来越多的证据也已经证实,围手术期加速康复外科方案的实施,能够有效的降低胃癌患者术后并发症发生、加快患者术后康复。但是,指南中仍有一些存在争议的围手术期处理措施。本研究将会对存在争议的ERAS措施进行严格的系统评价,进一步证实其安全、有效性,并对每一条方案的证据质量和推荐级别进行论证。最终,形成一套有循证医学证据支持的,更加优化的胃癌患者围手术期ERAS临床路径。研究方法:我们通过标准数据库,全面检索与胃癌患者围手术期ERAS方案相关的临床研究,尤其是高质量的临床随机对照研究(RCTs)和Meta分析。对存在争议的方案,应用Rev Man5.3软件进行系统评价,进一步证实其临床应用的安全、有效性。最后,我们依据“The Grading of Recommendations,Assessment,Development and Evaluation(GRADE)评分系统,对每一条措施的循证医学证据质量和推荐级别进行论证。研究结果:本研究对胃癌患者ERAS方案中,有争议的部分进行了进一步的系统评价。Meta分析结果显示:(1)术前口服碳水化合物能够明显的降低患者术后第一天血糖水平、缩短住院时间,不会增加患者术后并发症的发生风险;(2)术后早期经口进食能够明显缩短患者术后住院时间,而不增加围手术期并发症的发生风险;(3)围手术期目标导向性液体治疗(GDFT)可以减少患者术后并发症的发生风险,缩短患者术后住院时间。最后,我们根据GRADE评分系统,对胃癌患者围手术期ERAS每项措施的证据质量和推荐等级进行了论证。并将每条措施的证据级别分为高、中等、低和极低,将推荐强度分为强和弱。研究结论:通过对几项有争议的方案进行Meta分析,结果证实术前口服碳水化合物、术后早期经口进食以及围手术期有效的液体管理等,都可以安全、有效的应用于临床,加速患者术后康复。此外,我们对ERAS方案中每一条措施进行了证据质量和推荐强度的论证,形成一条适用于胃癌患者的ERAS临床路径,为胃癌患者围手术期处理提供了证据指南。但是,我们还需要更多高质量的、多中心临床研究,去完善胃癌患者围手术期临床路径的管理。
[Abstract]:Objective: with the rapid development of the idea of accelerated rehabilitation surgery (ERASS), the nursing mode of gastric cancer patients has changed greatly in perioperative period. More and more evidence has also confirmed that the implementation of perioperative accelerated rehabilitation surgery can effectively reduce postoperative complications in patients with gastric cancer and accelerate postoperative rehabilitation. However, there are still some controversial perioperative procedures in the guidelines. This study will make a strict systematic evaluation of the controversial ERAS measures to further verify their safety and effectiveness, and demonstrate the quality of evidence and the recommended level of each scheme. Finally, a set of more optimized perioperative ERAS clinical pathways for gastric cancer patients supported by evidence-based medical evidence was developed. Methods: we searched the clinical studies related to perioperative ERAS regimen in gastric cancer patients by standard database, especially in high quality randomized controlled clinical trials (RCTs) and Meta analysis. Rev Man5.3 software was used to evaluate the controversial scheme, which confirmed the safety and effectiveness of its clinical application. Finally, we demonstrate the quality of evidence-based medical evidence and the level of recommendation for each measure according to the The Grading of recommendations Development and Evaluation system. Results: in this study, the controversial parts of ERAS regimen in patients with gastric cancer were further systematically evaluated. Meta-analysis results showed that oral carbohydrates before operation significantly decreased blood glucose levels on the first day after operation in patients with gastric cancer. Shortening the hospitalization time and not increasing the risk of postoperative complications. (2) early oral feeding after operation can significantly shorten the postoperative hospitalization time of the patients. The GDFTs can reduce the risk of postoperative complications and shorten the postoperative hospitalization time. Finally, according to the GRADE scoring system, we demonstrated the quality of evidence and the recommended grade of each measure of ERAS in patients with gastric cancer during perioperative period. The evidence levels of each measure are classified as high, medium, low and very low, and the recommended strength is divided into strong and weak. Conclusion: through Meta analysis of several controversial protocols, the results show that oral carbohydrates preoperatively, early oral feeding after surgery and effective fluid management during perioperative period can be safely and effectively applied in clinical practice. Accelerate the patient's postoperative recovery. In addition, we have demonstrated the quality of evidence and the recommended strength of each measure in the ERAS scheme, and formed a ERAS clinical path suitable for gastric cancer patients, which provides evidence guidance for the perioperative management of gastric cancer patients. However, we need more high-quality, multi-center clinical studies to improve the management of perioperative clinical pathways in patients with gastric cancer.
【学位授予单位】：青岛大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.2

【参考文献】