加速康复外科联合腹腔镜治疗老年胃癌对营养及应激的影响

发布时间：2018-06-04 20:35

本文选题：加速康复外科 + 腹腔镜　；参考：《中国人民解放军医学院》2017年博士论文

【摘要】：研究背景及目的:老年胃癌(Gastric cancer,GC)患者生理机能减退,全身脏器功能下降,对创伤应激、营养不良耐受性差,影响术后恢复。加速康复外科(Enhanced recovery after surgery , ERAS; Fast track surgery, FTS)主张选取多种优化的综合措施,以达到减轻患者心理、生理创伤和应激反应,达到术后快速恢复的目的。而腹腔镜创伤小、可促进术后康复等优点迎合ERAS理念。本课题采用加速康复外科与腹腔镜技术相结合治疗老年胃癌患者,研究其安全性、有效性,探讨其对老年胃癌患者营养状况、应激反应的影响,旨在为胃癌患者、尤其是老年患者寻求创伤小、内环境稳定、营养状况好、应激反应小、术后康复快的围手术期处理流程。方法:选取2015年9月至2016年8月我院收治并病理确诊为胃癌的老年(年龄均≥60岁)患者,评估后选取无手术禁忌、能耐受手术的共84例,随机分为四组:A组(ERAS+腹腔镜21例)、B组(ERAS+开腹21例)、C组(传统围手术期管理+腹腔镜21例)、D组(传统围手术期管理+开腹21例)。各组遵循相应程序实施胃癌根治术,分别记录各组患者性别、年龄、体重指数(BMI)、手术方式、吻合方式、病理分期等一般资料。从以下方面观察研究:(1)安全性、有效性指标:分别记录四组的手术持续时间、出血量、切口长度、清除淋巴结个数、肛门排气时间、术后住院日、住院总费用、并发症发生情况等;(2)营养状况指标:术前采用NRS2002营养筛查法评价并指导营养治疗。记录对比四组术前1天、术后第1天、术后第4天、术后第7天血白蛋白(ALB)、前白蛋白(PA)、转铁蛋白(TRF)水平;计算并记录四组术前1天、术后4天、术后7天的营养评价指数(NCI),进行对比观察;(3)应激反应指标:记录对比四组术前1天、术后1天、术后4天、术后7天时间点的C反应蛋白(CRP)、白细胞介素-6(IL-6)、血清淀粉样蛋白A (SAA)水平。结果:(1)四组的年龄、性别、BMI、合并症、TNM分期、手术切除方式、吻合方式、清扫淋巴结个数均无显著差异。腹腔镜(A组、C组)手术组比开腹(B组、D组)手术组手术持续时间明显延长、出血量明显减少、切口长度明显缩短(P均0.05)。(2)术后恢复指标:①首次肛门排气时间、住院时间:A组最短,D组最长(P0.05)。②住院总费用:腹腔镜手术,ERAS处理的A组住院总费用明显低于传统方法管理的C组;开腹手术,ERAS处理的B组住院总费用明显低于传统方法管理的D (P均0.05)。③术后并发症:四组并发症无明显差异(P0.05)。(3)营养状况指标:四组患者术前ALB、PA;TRF水平无显著差异(P均0.05),均略低于正常水平,存在轻度营养不良。术后四组患者的NCI指数均出现不同程度的降低,其中A组下降最小、回升最快,D组降低最快,恢复最慢(P0.05)。(4)应激反应水平:术后1天,四组CRP、IL-6、SAA水平均出现明显上升,其中,A组上升幅度最小,D组上升幅度最大(P均0.05)。术后4天,四组CRP、SAA水平继续上升,A组上升幅度最小,D组上升幅度最高;而IL-6水平开始出现下降,A组同样表现出下降最快,D组下降最慢(P均0.05)。术后7天,四组CRP、IL-6、SAA 均明显下降(P 均0.05),A 组 CRP、IL-6、SAA 水平最低,D组最高(P均0.05)。结论:1加速康复外科联合腹腔镜治疗老年胃癌患者是安全、可行的,有助于促进术后肠功能恢复、缩短住院时间、减少住院总费用,加速术后恢复。2加速康复外科与腹腔镜联合治疗老年胃癌患者,术后营养状况好,能够加速病人康复。3传统围手术期管理与开腹手术对老年胃癌患者造成的创伤重、应激反应大,加速康复外科联合腹腔镜手术可有效减轻机体创伤、降低应激反应水平。4加速康复外科或腹腔镜单独应用于老年胃癌患者,亦能促进术后康复、利于营养、减轻应激反应,二者效果无差异,联用作用更好。
[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.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R735.2

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