【作者】 胡金晨；

【导师】 胡三元；

【作者基本信息】 山东大学 ， 外科学， 2012， 博士

【摘要】 背景加速康复外科(fast track surgery, FTS)是指对于择期手术的患者,采用一系列有循证医学证据的、有效可行的、围手术期处理的优化措施,减少手术应激及其并发症,加快患者术后的康复。它是在多学科协助治疗下产生的最佳结果,其内容贯穿于整个围手术期。加速康复外科理念已成功应用于普外科、骨科、泌尿外科、妇科等众多专业领域的疾病中,可明显缩短住院日、减少并发症、降低再住院率,而不影响手术安全性,并对器官功能具有保护和促进作用。FTS方案的成功实施要求良好而完善的组织实施和多学科的密切协作,不仅包括外科医生、麻醉师、康复治疗师、护士,也包括病人及家属的积极参与,更加强调病人在FTS方案中的主动性及医师、护士及病人间的合作互动。Kehlet最近指出,更进一步的FTS术后临床效果依赖于程序的全面发展,尤其是应集中于微创外科、有效的多模式止痛措施及减少应激药理学措施等方面的发展。对于腹腔镜技术,自问世以来,其优势有目共睹,如创伤小、视野清晰、出血少、切口感染少、术后肠粘连轻、肠梗阻发生率低、术后恢复快等,其对病人术后炎症应激反应、免疫功能以及心肺、胃肠道等其它脏器功能的影响明显轻于开腹手术。关于胃肠外科的腹腔镜FTS程序,目前国内外报道较多的是腹腔镜结直肠癌手术的FTS程序,认为二者的联合是安全、可行的。有报道显示FTS程序下的腹腔镜结肠手术明显优于传统围手术期处理的腹腔镜术式。近年来,腹腔镜技术已应用于胃癌患者,虽然对于其手术操作难度大、术中吻合及淋巴结清扫困难、肿瘤安全性等问题一直存在争议,但腹腔镜胃癌手术已越来越被临床医师及患者所接受。FTS与腹腔镜技术的联合应用将为进一步探索治疗胃癌及其术后快速康复提供新的思路和依据。目的1.观察加速康复外科理念在腹腔镜辅助远端胃癌根治术中的可行性及临床效果。2.探索更为合理、安全、有效、切实可行的胃癌术后快速康复外科程序。3.观察加速康复外科理念下腹腔镜辅助远端胃癌根治术后患者的营养状况。方法选择烟台毓璜顶医院2009年1月至2010年11月期间入院接受手术治疗的82例远端胃癌患者,随机分为4组：FTS+LADG组(19例)、LADG组(22例)、FTS+ODG组(21例)和ODG组(20例)。FTS+LADG组行LADG,并给予FTS方案进行围手术期处理；LADG组行LADG,给予传统围手术期处理；FTS+ODG组行ODG,并给予FTS方案进行围手术期处理；ODG组行ODG,给予传统围手术期处理。1.术前：记录患者年龄、性别、体重、BMI,检测术前1天(D0)血清白蛋白、血清尿素氮水平。2.术中：记录吻合方式、术中总出血量、淋巴结清扫数目。3.术后：记录患者pTMN分期、肠蠕动恢复时间、术后住院时间、住院费用、并发症发生情况；检测术后第4天(D4)、第7天(D7)血清白蛋白、血清尿素氮水平。4.随访4周,评价患者术后恢复情况。结果1.4组患者的年龄、性别、体重、BMI、吻合方式、淋巴结清扫数目及肿瘤pTNM分期无显著性差异(P均>0.05)。2.手术前后ALB水平,FTS+LADG组高于其他3组,FTS+LADG组、FTS+ODG组一直维持于一较高且稳定的水平；在D4、D7FTS+LADG组明显高于LADG组(P<0.05、P<0.01)；D0至D4ALB水平变化,FTS+LADG组、FTS+ODG组明显低于LADG组(P<0.001、P<0.05),术后ODG组各时相ALB水平均明显低于其他3组(P均P<0.01)。3.腹腔镜手术组(FTS+LADG组与LADG组)比常规开腹手术组(FTS+ODG组与ODG组)手术时间明显延长(P均<0.001)、术中总出血量明显减少(P均<0.05)。4.ODG组与其他3组相比,术后肠蠕动恢复时间更晚(P均<0.001)、术后住院时间更长(P<0.001,P<0.05,P<0.05)；其中,FTS+LADG组术后肠蠕动恢复时间明显早于LADG组、FTS+ODG组(P<0.05,P<0.05)；在平均住院费用方面,FTS+LADG组比LADG组明显降低(P=0.003),但仍明显高于FTS+ODG组(P<0.001),FTS+ODG组最低,与LADG组和ODG组比较具有显著性差异(P<0.001,P=0.002)。5.4组患者术后并发症的发生情况无显著性差异(P>0.05)。结论1.加速康复外科理念应用于腹腔镜辅助远端胃癌根治术是安全、有效、可行的。2.加速康复外科理念下腹腔镜辅助远端胃癌根治术可以促进患者术后胃肠道功能的恢复、缩短住院时间、加速病人康复,与传统围手术期处理的腹腔镜辅助远端胃癌根治术、加速康复外科处理的开腹手术相比具有一定的优势。3.加速康复外科理念下腹腔镜辅助远端胃癌根治术可以进一步改善患者围手术期的营养状态,但就目前情况,加速康复外科理念下的常规胃癌根治术可能是一种更为经济、有效的选择。背景外科手术被认为是治疗肿瘤的最重要手段,但手术创伤导致的术后免疫功能受损和炎症反应增强,常常是术后引发感染等并发症的重要原因。另外肿瘤的发生、发展、复发及转移亦均与免疫功能有关,术后更为快速的免疫功能恢复,将进一步抑制肿瘤的复发、转移。近年来,加速康复外科理念与腹腔镜技术已应用于胃肠外科,与传统外科相比,二者均可减轻患者术后炎症反应、保护免疫功能。目的1.观察比较FTS、腹腔镜手术及二者联合应用对胃癌患者术后体液免疫功能的影响。2.观察比较FTS、腹腔镜手术及二者联合应用对胃癌患者术后炎症应激反应的影响。3.观察胃癌患者不同处理方式下围手术期应激反应、体液免疫功能的变化方法选择烟台毓璜顶医院2009年1月至2010年11月期间入院接受手术治疗的82例远端胃癌患者,随机分为4组：FTS+LADG组(19例)、LADG组(22例)、FTS+ODG组(21例)和ODG组(20例)。FTS+LADG组行LADG,并给予FTS方案进行围手术期处理；LADG组行LADG,给予传统围手术期处理；FTS+ODG组行ODG,并给予FTS方案进行围手术期处理；ODG组行ODG,给予传统围手术期处理。1.术前1天(D0)抽血检测血清CRP、C3、C4、IgG、IgA、IgM。2.术后第1天(D1)、第4天(D4)、第7天(D7)抽血检测血清CRP、C3、C4、IgG、IgA、IgM。结果1. FTS+LADG组围手术期CRP水平低于其他3组,变化更平缓,在D4、D7明显低于FTS+ODG组(P<0.05、P<0.05)。术后ODG组在各时间点CRP水平均明显高于其他3组(P均≤0.001)。对于CRP水平的变化幅度,FTS+LADG组与FTS+ODG组在D1至D4间具有显著性差异(P<0.05),在D4至D7间P=0.05。2.C3、C4水平在FTS+LADG组于D1明显高于ODG组(P<0.05、P<0.05),余各组间无显著性差异。C3水平变化,在D0至D1间、D1至D4间FTS+LADG组、LADG组、FTS+ODG组明显低于ODG组(P<0.001、P<0.05、P<0.001；P<0.001、P<0.05、P=0.005),在D1至D4间FTS+LADG组明显低于FTS+ODG组(P<0.01)。C4水平变化,在D0至D1间FTS+LADG组明显低于LADG组(P<0.05),FTS+LADG组、FTS+ODG组明显低于ODG组(P<0.001、P<0.001),在D4至D7间FTS+LADG组明显低于ODG组(P<0.05)。3.与ODG组比较,其他3组围手术期IgG、IgA水平更高更为平缓,且在D1至D4其水平变化均明显低于ODG组(P均<0.001)。在D4至D7FTS+LADG组、LADG组IgA水平变化明显低于ODG组(P<0.001,P<0.05),在Dl至D4FTS+LADG组IgM水平变化明显低于ODG组(P<0.001)。结论1.传统的开腹胃癌根治术及相应的常规围手术期处理方法创伤大,术后炎症应激反应重,FTS围手术期处理和腹腔镜技术均可减轻围手术期炎症应激反应,FTS联合腹腔镜技术可进一步减轻病人的应激反应,但作用有限。2.在减轻围手术期炎症应激反应方面,传统的开腹胃癌根治术患者通过FTS围手术期处理可以达到与腹腔镜手术相似的效果。3.术后患者补体系统遭受明显的抑制作用,单纯的FTS围手术期处理或腹腔镜手术处理在减轻手术创伤对补体系统影响的作用微弱,FTS处理与腹腔镜技术的联合应用存在一定程度上的优势。4.FTS围手术期处理组或腹腔镜手术处理组的患者术后早期的体液免疫功能状态明显好于传统开腹手术组,提示两种处理方式对于胃癌患者术后早期体液免疫功能具有一定的保护作用,但二者联合应用无明显进一步优势。更多还原

【Abstract】 BackgroundFast track surgery (FTS), through application of multimodal rehabilitation for selective operations, has significantly relieved postoperative stress, reduced the morbidity associated with complications, and accelerated recovery. FTS requires multidisciplinary teamwork to reach an optimal outcome, and covers the whole perioperative period. It has been successfully applied to general, orthopedic, urological, gynecological, cardiovascular and thoracic surgery.Laparoscopic surgery has definite advantages and has been used widely since its advent. Compared with traditional surgery, it can alleviate inflammation, immune inhibition, and interference with respiratory function. So it can also accelerate postoperative recovery. In recent years, the advantages of laparoscopic surgery have been recognized in gastric cancer. Despite some continuing controversies about oncological safety, difficulties in performance, anastomosis, and lymph node dissection, laparoscopic surgery for gastric cancer is becoming more popular and more acceptable to patients. FTS combined with laparoscopy-assisted distal gastrectomy (LADG) might provide some clinical and theoretical support on exploring the better treatments for gastric cancer.ObjectiveThe aims of this study were (1) to evaluate the feasiblity and effectiveness of FTS combined with LADG for gastric cancer,(2) to explore more reasonable, safe, effective and feasible FTS procedure,(3) to observe postoperative nutritional status,(4) to observe the short-term oncological outcomes.MethodsEighty-two patients were admitted to Yantai Yuhuangding Hospital with distal gastric cancer from January2009to November2010, and were randomly divided into four groups:(1) FTS+LADG (n=19), treated with LADG and FTS treatments;(2) LADG (n=22), treated with LADG and traditional treatments;(3) FTS+ODG (n=21), treated with ODG and FTS treatments; and (4) ODG (n=20), treated with ODG and traditional treatments. FTS included preoperative avoidance of mechanical bowel cleansing, no nasogastric tube decompression, restrictive intravenous fluids intraoperatively and postoperatively, and early ambulation and oral diet. The following clinical parameters were recorded:age, sex, BMI, body weight, anastomotic mode, pathological tumor stage, operation time, intraoperative blood loss, number of lymph node dissection, time of first flatus (index of peristalsis recovery), postoperative hospital stay, medical cost, and postoperative complications. Blood samples were collected at1day before surgery (DO) and4(D4) and7(D7) days after surgery. Serum concentrations of ALB and BUN were determined. Follow-up was usually once weekly for4weeks.Results1. There were no differences statistically between the four groups at age, sex, BMI, body weight, anastomotic mode and pathological tumor stage (all P>0.05). 2. Compared with the ODG group, the level of ALB in the other three groups was higher at4and7days after surgery (all P<0.01), and perioperative variation was more moderate in the groups with FTS treatmen, especially in FTS+LADG group. The level of ALB was higher in FTS+LADG group than in LADG group at D4and D7(P<0.05, P<0.01). The variaiton of ALB from DO to D4was more significant in FTS+LADG group and FTS+ODG group than in LADG group (P<0.001,P<0.05).3. The groups with LADG treatment had longer operation time and less intraoperative blood loss than the groups with ODG treatment (all P<0.001).4. Compared with ODG group, the other three groups had earlier first flatus and shorter postoperative hospital stay (all P<0.01; all P<0.05), especially in FTS+LADG group. First flatus in FTS+LADG group was earlier than in LADG group and FTS+ODG group (P<0.05; P<0.05). The groups with LADG treatment had higher medical costs than the groups with ODG treatment (all P<0.001), and FTS+ODG group had lowest medical cost and LADG group had highest medical cost (all P<0.01; all P<0.01).5. As to postoperative complications, there were no differences between the four groups (all P>0.05).Conclusions4. The combination of FTS and LADG for gastric cancer is safe, feasible and effective.5. The combination of FTS and LADG can accelerate gastrointestinal peristalsis, reduce hospital stay, and accelerate rehabilitation postoperatively. But the advantages are limited compared with LADG and FTS+ODG.6. The FTS treatments for improving nutritional status are effective in patients with gastric cancer, and LADG can contribute to this. However, at present, FTS+ODG may be a more economic, effective and feasible treatment for gastric cancer.7. As to the short-term oncological outcomes, LADG combined with FTS was similar to the conventional surgery and treatments. It needs a larger series with longer follow-up evaluation for definitive conclusions. BackgroundAlthough surgery is considered as the most important means for cancer treatment, many studies have demonstrated that surgical stress has an inhibitory effect on immunity, which could have an adverse impact (e.g. infection) on prognosis. In addition, the immune function is correlated with development, progression, recurrence and prognosis of gastric cancer in the published literature. The better preserved immune function may restrain tumor nestling and distant metastases formation. In recent years, FTS and laparoscopic surgery have been applied in gastrointestinal surgery. And they both can lessen stress reaction and preserve immune function.ObjectiveThe aims of this study were (1) to observe the effect on humoral immune function and stress reaction of FTS combined with LADG for gastric cancer,(2) to observe perioperative variations of humoral immune function and stress reaction under different treatments (FTS, LADG or both together).MethodsEighty-two patients were admitted to Yantai Yuhuangding Hospital with distal gastric cancer from January2009to November2010, and were randomly divided into four groups:(1) FTS+LADG (n=19), treated with LADG and FTS treatments;(2) LADG (n=22), treated with LADG and traditional treatments;(3) FTS+ODG (open distal gastrectomy)(n=21), treated with ODG and FTS treatments; and (4) ODG (n=20), treated with ODG and traditional treatment. FTS includes perioperative avoidance of mechanical bowel cleansing, no nasogastric tube decompression, restrictive intravenous fluids intraoperatively and postoperatively, and early ambulation and oral diet. Blood samples were collected at1day before surgery (DO) and1day (D1),4(D4) and7(D7) days after surgery. Serum concentrations of C-reactive protein (CRP), C3, C4and immunoglobulin (G, A and M) were determined. Follow-up was usually once weekly for4weeks.Results1.Compared with ODG group, the levels of CRP in the other three groups after surgery were lower (all P≤0.001), especially more significantly in FTS+LADG group with smoother variation. The levels of CRP in FTS+LADG group were lower than in FTS+ODG group at D4and D7(P<0.05, P<0.05). The ampitude in FTS+LADG group was smaller than in FTS+ODG group from D1to D4(P<0.05) and from D4to D7(P=0.05).2.Compared with ODG group, the variations of C3and C4in the other three groups perioperatively were more smoother, especially in FTS+LADG group, and the levels of C3and C4in FTS+LADG group were higher at D1(P<0.05, P<0.05). As to the ampitude of variation about C3, FTS+LADG group, LADG group and FTS+ODG group were smaller than ODG group from DO to D1(P<0.001, P<0.05, P<0.001) and from D1to D4(P<0.001, P<0.05, P=0.005), and FTS+LADG group was smaller than FTS+ODG group from D1to D4(P<0.01). As to the ampitude of variation about C4, from DO to D1, FTS+LADG group and FTS+ODG group were smaller than ODG group (P<0.001, P<0.001) and FTS+LADG group was smaller than LADG group (P<0.05), and FTS+LADG group was smaller than ODG group from D4to D7(P<0.05).3.Compared with ODG group, the levels of IgG and IgA in the other three groups after surgery were higher with smoother variation. As to the ampitude of variation, compared with ODG group, FTS+LADG group, LADG group and FTS+ODG group at IgG and IgA were smaller from D1to D4(all P<0.001) and FTS+LADG group and LADG group were smaller at IgA from D4to D7(P<0.001, P<0.05). FTS+LADG group at IgM was smaller from D1to D4(P<0.001).Conclusions5. The traditional open gastrectomy and corresponding postoperative treatments can lead to more injury and more serious inflammatory response, whereas FTS treatments and laparoscopic surgery can reduce the inflammatory response perioperatively, and the combination of FTS and LADG can do it further but limited.6. As to lessening perioperativ stress response, FTS treatments applied in traditional open gastrectomy can reach the similar results to laparoscopic surgery for gastric cancer.7. The complement system is obviously suppressed postoperatively. FTS or laparoscopic surgery alone had neligible effects on lessening impact on complement system, and the combination of FTS and LADG has some advantages over the other two.8. The groups with FTS treatments or laparoscopic surgery have better postoperative early humoral immune status than those with traditional open surgery. This suggests the two treatments have definite protective effect on postoperative early humoral immune function, but the combineation of them has no significant improvement.更多还原