劉 寧 徐永強(qiáng) 李海軍

腹腔鏡大腸癌根治術(shù)與傳統(tǒng)開放式手術(shù)術(shù)后恢復(fù)指標(biāo)比較研究

劉 寧①徐永強(qiáng)①李海軍①

目的：通過(guò)監(jiān)測(cè)腹腔鏡大腸癌根治術(shù)與傳統(tǒng)開放式手術(shù)術(shù)后恢復(fù)指標(biāo)，進(jìn)行比較評(píng)估。方法：選取醫(yī)院收治的96例大腸癌患者，根據(jù)隨機(jī)數(shù)字表法將患者分為觀察組和對(duì)照組，每組48例。觀察組應(yīng)用腹腔鏡大腸癌根治術(shù)，對(duì)照組給予傳統(tǒng)開放式手術(shù)。對(duì)比分析兩組患者圍手術(shù)期情況、腹痛等臨床表現(xiàn)、恢復(fù)狀況、并發(fā)癥的發(fā)生發(fā)展?fàn)顩r、手術(shù)前后營(yíng)養(yǎng)狀況以及生活質(zhì)量。結(jié)果：觀察組大腸癌患者手術(shù)時(shí)間、術(shù)中平均出血量、術(shù)后排氣時(shí)間及住院時(shí)間少于對(duì)照組，兩組比較差異有統(tǒng)計(jì)學(xué)意義(t=5.583，t=48.934，t=7.347，t=4.862；P＜0.05)。觀察組腹腔并發(fā)癥發(fā)生率為8.3%，低于對(duì)照組的27.1%，差異有統(tǒng)計(jì)學(xué)意義(x2=5.79，P＜0.05)。觀察組出現(xiàn)切口延遲愈合發(fā)生率6.3%，低于對(duì)照組的20.8%，差異有統(tǒng)計(jì)學(xué)意義(x2=4.36，P＜0.05)。術(shù)后1周觀察組與對(duì)照組患者的血清白蛋白(ALB)、前白蛋白(PA)和淋巴細(xì)胞計(jì)數(shù)(LC)均高于術(shù)前，觀察組各項(xiàng)血清指標(biāo)均明顯高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(t=4.628，t=3.642，t=3.412；P＜0.05)。觀察組和對(duì)照組治療后身體功能、角色功能、情緒功能、認(rèn)知功能及社會(huì)功能等各項(xiàng)指標(biāo)均有明顯改善，且觀察組各項(xiàng)生活質(zhì)量改善高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(t=-12.845，t=-7.634，t=0.5001，t=-4.096，t=-2.647，P＜0.05)。結(jié)論：應(yīng)用腹腔鏡對(duì)大腸癌根治術(shù)與傳統(tǒng)開放式手術(shù)進(jìn)行大腸癌根治術(shù)相比較，術(shù)后恢復(fù)的效果更佳、更明顯和更有效。

開放式手術(shù)；腹腔鏡；大腸癌；術(shù)后恢復(fù)

劉寧,男,(1963- ),本科學(xué)歷，副主任醫(yī)師。宜賓市第二人民醫(yī)院肛腸科，從事普外肛腸工作。

大腸癌是常見的惡性腫瘤之一，根治性切除術(shù)仍然是治療大腸癌最主要和最有效的治療方法，但傳統(tǒng)開放式手術(shù)治療會(huì)導(dǎo)致嚴(yán)重創(chuàng)傷，因此不能被所有患者所接受[1-2]。目前，輔以腹腔鏡的大腸癌根治術(shù)的短期療效和部分中遠(yuǎn)期療效優(yōu)勢(shì)明顯，已被臨床廣泛應(yīng)用[3]。為此，本研究探討傳統(tǒng)開放式手術(shù)與應(yīng)用腹腔鏡對(duì)大腸癌根治術(shù)術(shù)后恢復(fù)的不同情況，對(duì)比分析兩種手術(shù)方法圍手術(shù)期情況、患者的體征即腹痛等臨床表現(xiàn)的恢復(fù)狀況以及并發(fā)癥的發(fā)生發(fā)展?fàn)顩r，觀察并記錄手術(shù)前后營(yíng)養(yǎng)狀況及生活質(zhì)量，比較選擇最佳治療方案。

1 資料與方法

1.1 一般資料

選取2014年6月至2016年6月宜賓市第二人民醫(yī)院收治的96例大腸癌患者，按照隨機(jī)數(shù)字表法分為觀察組和對(duì)照組，每組48例。在96例患者中男性51例，女性45例；年齡52～76歲，平均年齡(65.1±3.5)歲。參照大腸癌改良Dukes分期：B期42例、C期54例。觀察組中男性26例，女性22例；年齡52～74歲，平均年齡(64.8±3.6)歲；Dukes分期B期22例，C期26例。對(duì)照組中男性25例，女性23例；年齡54～76歲，平均年齡(65.3±34)歲；Dukes分期B期19例，C期28例。對(duì)兩組腫瘤臨床分期、年齡、性別、腫瘤分期和營(yíng)養(yǎng)狀況等進(jìn)行比較無(wú)差異，具有可比性。

1.2 納入與排除標(biāo)準(zhǔn)

(1)納入標(biāo)準(zhǔn)：①所有患者均經(jīng)病理診斷為大腸癌；②伴有不同程度腹痛或糞便性狀變化可耐受手術(shù)。

(2)排除標(biāo)準(zhǔn)：①嚴(yán)重性肝腎等器質(zhì)性疾?。虎诤喜⑼耆c道梗阻；③合并其他部位腫瘤、手術(shù)禁忌證及其他惡性腫瘤疾病等。

1.3 儀器設(shè)備

應(yīng)用腹腔鏡應(yīng)用史賽克1288HD高清腹腔鏡(美國(guó)史塞克公司)；強(qiáng)生GEN11持超聲刀(美國(guó)強(qiáng)生公司)進(jìn)行手術(shù)。

1.4 治療方法

(1)患者入院后對(duì)其進(jìn)行常規(guī)心肺功能和營(yíng)養(yǎng)狀況評(píng)估，完成術(shù)前灌腸、清潔腸道等準(zhǔn)備，采取全身麻醉進(jìn)行手術(shù)。

(2)觀察組輔以腹腔鏡，采用5孔法，對(duì)患者大腸癌根治術(shù)治療。由患者臍部作切口構(gòu)建氣腹，控制腹壓于13～15 kPa(1 mm Hg=0.133 kPa)范圍內(nèi)[4]。為觀察患者盆腔情況，腹腔鏡套管后通過(guò)臍孔放置于腹腔，根據(jù)實(shí)際情況調(diào)整其余4孔，以確定最終手術(shù)部位[5]。手術(shù)采用超聲刀分離患者腸系膜根部，依據(jù)患者腫瘤位置分離、夾閉和離斷腸系膜血管，注意對(duì)患者輸尿管的保護(hù)[6]。分離至腸壁邊緣時(shí)再利用超聲刀將腸外側(cè)腹膜進(jìn)行分離，切除標(biāo)本并送檢，標(biāo)本采用保護(hù)套實(shí)時(shí)保護(hù)[7]。將患者腹壁切開約5 cm，取出腫瘤并將腸管殘端一同拖出腹腔，體外吻合后還入腹腔，放置引流管，快速縫合切口。

(3)對(duì)照組采用傳統(tǒng)開放式手術(shù)治療。先評(píng)估手術(shù)切除可能性，根據(jù)腫瘤部位，在患者一側(cè)旁正中切口入腹，切口保護(hù)后探查患者腹腔臟器及腫瘤。再通過(guò)傳統(tǒng)方法切除腫瘤，并進(jìn)行淋巴結(jié)清掃[8]。

(4)術(shù)后兩組患者均使用抗生素并給予營(yíng)養(yǎng)支持，密切觀察兩組營(yíng)養(yǎng)狀況及術(shù)后恢復(fù)情況。

1.5 觀察指標(biāo)

觀察兩組患者圍手術(shù)期手術(shù)時(shí)間、術(shù)中出血量、術(shù)后排氣時(shí)間及住院時(shí)間等情況，比較兩組患者的體征(腹痛)臨床表現(xiàn)的恢復(fù)狀況、并發(fā)癥的發(fā)生發(fā)展?fàn)顩r、手術(shù)前后營(yíng)養(yǎng)狀況及生活質(zhì)量等情況。術(shù)前與術(shù)后1周收集患者靜脈血液，檢測(cè)患者血清前白蛋白(PA)、血清白蛋白(ALB)及淋巴細(xì)胞計(jì)數(shù)(LC)。采用癌癥患者生命質(zhì)量測(cè)定量表(QLQ－C30)進(jìn)行生活質(zhì)量評(píng)分并進(jìn)行比較，患者生命質(zhì)量越好則得分越高[9]。

1.6 統(tǒng)計(jì)學(xué)方法

采用SPSS 18.0統(tǒng)計(jì)軟件對(duì)數(shù)據(jù)進(jìn)行處理，計(jì)量資料結(jié)果以均值±標(biāo)準(zhǔn)差(x-±s)表示，組間比較采用t檢驗(yàn)，百分率比較采用x2檢驗(yàn)，以P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 兩組圍手術(shù)期情況比較

觀察組大腸癌患者手術(shù)時(shí)間為(140.6±25.8) min，術(shù)與中平均出血量為(26.3±5.6)ml，術(shù)后排氣時(shí)間為(25.8±8.6)h及住院時(shí)間為(9.9±3.9)d，均少于對(duì)照組相應(yīng)的(171.4±28.2)min、(148.7±16.4) ml、(37.9±7.5)h及(15.1±6.3)d，兩組比較差異有統(tǒng)計(jì)學(xué)意義(t=5.583，t=48.934，t=7.347，t=4.862；P＜0.05)，見表1。

2.2 兩組并發(fā)癥和切口愈合比較

(1)觀察組與對(duì)照組大腸癌患者在術(shù)后均未有腹腔出血、吻合口出血等嚴(yán)重的并發(fā)癥發(fā)生。觀察組有4例腹腔并發(fā)癥發(fā)生，發(fā)生率為8.3﹪，對(duì)照組腹腔并發(fā)癥13例，占27.1﹪，觀察組低于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(x2=5.79，P＜0.05)。

(2)觀察組有3例切口延遲愈合發(fā)生，發(fā)生率為6.3﹪，對(duì)照組為10例，占20.8﹪，觀察組低于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(x2=4.36，P＜0.05)。

2.3 兩組血清ALB、PA 和LC指標(biāo)比較

觀察組與對(duì)照組患者手術(shù)前后血清ALB、PA和LC指標(biāo)比較，術(shù)后1周觀察組與對(duì)照組患者的血清指標(biāo)ALB、PA和LC均高于術(shù)前，且觀察組各項(xiàng)血清指標(biāo)均明顯高于對(duì)照組，差異具有統(tǒng)計(jì)學(xué)意義(t=4.628，t=3.642，t=3.412；P＜0.05)，見表2。

2.4 生活質(zhì)量改善情況

兩組患者術(shù)前各項(xiàng)生活指標(biāo)比較均無(wú)差異；治療后觀察組和對(duì)照組治療后各項(xiàng)生活質(zhì)量均明顯改善，觀察組身體功能、角色功能、情緒功能、認(rèn)知功能及社會(huì)功能等各項(xiàng)生活質(zhì)量改善高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(t=-12.845，t=-7.634，t=0.5001，t=-4.096，t=-2.647，P＜0.05)，見表3。

表1 實(shí)驗(yàn)觀察組與對(duì)照組患者圍手術(shù)期情況比較(±s)

表1 實(shí)驗(yàn)觀察組與對(duì)照組患者圍手術(shù)期情況比較(±s)

組別例數(shù)手術(shù)時(shí)間(min)術(shù)中平均出血量(ml)術(shù)后排氣時(shí)間(h)住院時(shí)間(d)陽(yáng)性淋巴結(jié)數(shù)量(個(gè))對(duì)照組48171.4±28.2148.7±16.437.9±7.515.1±6.3227.8±14.7觀察組48140.6±25.826.3±5.625.8±8.69.9±3.9227.9±13.7 t值5.583 48.934 7.347 4.862 0.034 P值<0.01<0.01<0.01<0.010.97

表2 實(shí)驗(yàn)組與對(duì)照兩組患者手術(shù)前后血清ALB、PA 和LC指標(biāo)營(yíng)養(yǎng)狀況比較(±s)

表2 實(shí)驗(yàn)組與對(duì)照兩組患者手術(shù)前后血清ALB、PA 和LC指標(biāo)營(yíng)養(yǎng)狀況比較(±s)

表3 實(shí)驗(yàn)兩組患者生活質(zhì)量改善情況比較(±s)

表3 實(shí)驗(yàn)兩組患者生活質(zhì)量改善情況比較(±s)

3 討論

傳統(tǒng)開放式手術(shù)與應(yīng)用腹腔鏡對(duì)大腸癌根治術(shù)患者生存率和復(fù)發(fā)率比較無(wú)統(tǒng)計(jì)學(xué)意義，兩種方法治療對(duì)切除腫瘤組織均有效[10]。通應(yīng)用腹腔鏡進(jìn)行大腸癌根治術(shù)是目前臨床上常用的治療大腸癌的方式，具有手術(shù)時(shí)間短、術(shù)中出血量少、術(shù)后恢復(fù)快等優(yōu)勢(shì)[11]。腹腔鏡輔助治療方法對(duì)于大腸癌的治療具有優(yōu)勢(shì)。

腹腔鏡大腸癌根治術(shù)明顯減少患者的住院時(shí)間，能夠降低手術(shù)對(duì)患者組織的傷害，并且有助于患者術(shù)后的恢復(fù)，提高患者的免疫力，提高患者生活質(zhì)量，使患者盡快回歸社會(huì)[12]。

臨床研究發(fā)現(xiàn)，在治療惡性腫瘤時(shí)，應(yīng)用腹腔鏡進(jìn)行手術(shù)，局部腫瘤轉(zhuǎn)移發(fā)生率比傳統(tǒng)開放性手術(shù)更高[13]。近年來(lái)，隨著技術(shù)的更新，研究表明，通過(guò)對(duì)腫瘤進(jìn)行保護(hù)，可降低腫瘤轉(zhuǎn)移的發(fā)生率，達(dá)到較好的治療效果[14]。

本研究對(duì)48例患者實(shí)施腹腔鏡輔助大腸癌根治術(shù)，觀察組圍術(shù)期情況均比對(duì)照組良好，兩組大腸癌患者的圍術(shù)期陽(yáng)性淋巴結(jié)數(shù)目表明，應(yīng)用腹腔鏡輔助治療的患者術(shù)后恢復(fù)時(shí)間更短。對(duì)觀察組和對(duì)照組大腸癌患者的術(shù)后并發(fā)癥及生存情況進(jìn)行分析，兩組在術(shù)后均無(wú)嚴(yán)重并發(fā)癥發(fā)生。對(duì)于切口并發(fā)癥、腹腔并發(fā)癥及肺部感染等，觀察組發(fā)生率均低于對(duì)照組。觀察組和對(duì)照組大腸癌患者術(shù)前的靜脈血ALB、PA和淋巴細(xì)胞計(jì)數(shù)差異無(wú)統(tǒng)計(jì)學(xué)意義，而在術(shù)后1周檢測(cè)中，觀察組各項(xiàng)指標(biāo)均高于對(duì)照組，差異均具有統(tǒng)計(jì)學(xué)意義。

應(yīng)用腹腔鏡對(duì)大腸癌根治術(shù)與傳統(tǒng)開放式手術(shù)進(jìn)行大腸癌根治術(shù)相比較，其術(shù)后恢復(fù)的效果更佳、更明顯、更有效，有助于促使患者更快地回歸社會(huì)，能夠提高患者生活質(zhì)量。

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Comparison of postoperative recovery situation between laparoscopic radical resection and conventional open surgery for patients with colorectal cancer

LIU Ning, XU Yong-qiang, LI Hai-jun//
China Medical Equipment,2017,14(4):106-109.

Objective: To compare postoperative recovery situation between laparoscopic radical resection and conventional open surgery for patients with colorectal cancer and determine the optimal surgery scheme. Methods: 96 patients with colorectal cancer were divided into observation group (48 cases)and control group (48 cases) according to the random number table method. The patients of observation group were treated by using laparoscopic radical resection while the patients of control group were treated by conventional open surgery. A series of clinical manifestation, such as perioperative situation, abdominal pain, recovery situation, complication, pre-and post operative nutrition and quality of life, of these patients were compared between the two groups. Results: The operation time, average bleeding volume, postoperative exhaust time and hospitalization time of the observation group were significantly less than those of the control group (t=5.583, t=48.934, t=7.347, t=4.862; P<0.05). The incidence of abdominal complication of observation group (8.3%) was significantly lower than that of the control group (27.1%) (x2=5.79, P<0.05). The incidence of delayed healing of incision was 6.3% in observation group, which was significantly lower than that (20.8%) of control group (x2=4.36, P<0.05). For observation group or control group, the serum ALB, PA and LC of post-operation, respectively, was higher than those of pre-operation in 1 week after operation. And serum ALB, PA and LC of observation group, respectively, was significantly higher than that of control group (t=4.628, t=3.642, t=3.412; P<0.05). Compared with before operation, physical function, role function, emotional function, cognitive function and social functionthe quality of life of the two group were obviously improved, on the other hand, all of these aspects of the observation group were significantly higher than those of the control group (t=-12.845, t=-7.634, t=0.5001, t=-4.096, t=-2.647, P<0.05). Conclusion: Compared with the traditional open surgery for patients with colorectal cancer, the postoperative recovery of laparoscopic radical resection is better, more obvious and more effective for them.

Open surgery; Laparoscopy; Colorectal cancer; Postoperative recovery

10.3969/J.ISSN.1672-8270.2017.04.028

1672-8270(2017)04-0106-04

R735.34

A

2016-11-30

①宜賓市第二人民醫(yī)院肛腸科 四川 宜賓 644000

[First-author’s address] Anorectal Section, The Second People's Hospital of Yibin, Yibin 644000, China.