快速康复外科在结直肠癌手术中的应用
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摘要
前言
自从上世纪90年代丹麦Kehlet最早提出了快速康复外科(fast track surgery,FTS)理念后,外科治疗理念就在逐步发生改变。FTS理念措施实施的目的是减轻围手术期病人的手术创伤,降低手术的应激反应,加快病人术后康复。本研究收集2009年1月至2009年10月期间收治的86例结直肠癌病人,分别应用FTS方案和传统对照方案,对两组病人的首次排气排便时间,术后住院费用,住院天数,术后并发症以及术后应激和免疫功能的恢复等进行对照研究。
目的
比较快速康复外科(FTS)治疗方案较传统方案治疗结直肠癌患者的优越性。
方法
对比研究86例结直肠肿瘤病人,分别采取快速康复外科治疗方案(n=31)和传统的治疗方案(n=55),比较两组病人术后住院时间、住院费用、首次排气排便时间和术后并发症的发生率,血清应激及免疫等临床指标。
结果
两组病人均痊愈出院。快速康复组病人与传统对照组相比,术后首次排气排便时间均明显提前,住院费用及住院时间明显减少(P<0.05)。FTS对应激及免疫功能的改善作用优于传统方法。但两组并发症比较无明显差异(P>0.05)。
结论
结直肠癌患者行快速康复外科治疗是安全、有效的；结直肠癌患者快速康复外科治疗方案与传统治疗方案相比,减少住院时间及住院费用；快速康复外科减轻术后切口疼痛,并有利于患者术后应激及免疫功能的恢复。
Preface
Since the 90s of last century Danish Kehlet [1] first proposed a rapid recovery surgery (fast track surgery, FTS) concept, the concept of surgical treatment in progressive change. FTS measures to implement the concept of the purpose is to reduce perioperative surgical trauma patients, reducing the surgical stress response, accelerated postoperative recovery [2]. In this study from January 2009 to October 2009 period,86 cases of colorectal cancer treated patients, respectively, and traditional application of the control program FTS program, the two groups for the first exhaust defecation time, postoperative hospitalization costs, length of hospital stay, complications and postoperative stress and immune function recovery were studied as controls.
Objective
Fast-track surgery (FTS) treatments more traditional treatment of colorectal cancer patients scheme.
Methods
Comparative Study of 86 cases of colorectal cancer patients, fsts-track surgery were taken (n= 31) and traditional treatment programs (n= 55), postoperative hospital stay were compared, hospital charges, the first bowel movement and discharge patients The incidence of complications, stress and immune serum postoperatively.
Results
Two groups of patients were cured. Fsts-track surgery patients with the traditional group than the control group, after first bowel movement was significantly earlier discharge, hospital costs and length of stay decreased significantly (P<0.05). FTS on stress and improve immune function better than traditional methods. However, no significant difference between the two groups of complications (P> 0.05).
Conclusion
By fsts-track surgery of patients with colorectal cancer surgical treatment is safe and effective; fsts-track surgery in patients with colorectal cancer surgical treatment compared with conventional treatment to reduce the length of stay and hospital costs; fsts-track surgery to reduce postoperative pain, and facilitate Stress and immune function in patients with postoperative recovery.
自从上世纪90年代丹麦Kehlet最早提出了快速康复外科(fast track surgery,FTS)理念后,外科治疗理念就在逐步发生改变。FTS理念措施实施的目的是减轻围手术期病人的手术创伤,降低手术的应激反应,加快病人术后康复。本研究收集2009年1月至2009年10月期间收治的86例结直肠癌病人,分别应用FTS方案和传统对照方案,对两组病人的首次排气排便时间,术后住院费用,住院天数,术后并发症以及术后应激和免疫功能的恢复等进行对照研究。
目的
比较快速康复外科(FTS)治疗方案较传统方案治疗结直肠癌患者的优越性。
方法
对比研究86例结直肠肿瘤病人,分别采取快速康复外科治疗方案(n=31)和传统的治疗方案(n=55),比较两组病人术后住院时间、住院费用、首次排气排便时间和术后并发症的发生率,血清应激及免疫等临床指标。
结果
两组病人均痊愈出院。快速康复组病人与传统对照组相比,术后首次排气排便时间均明显提前,住院费用及住院时间明显减少(P<0.05)。FTS对应激及免疫功能的改善作用优于传统方法。但两组并发症比较无明显差异(P>0.05)。
结论
结直肠癌患者行快速康复外科治疗是安全、有效的；结直肠癌患者快速康复外科治疗方案与传统治疗方案相比,减少住院时间及住院费用；快速康复外科减轻术后切口疼痛,并有利于患者术后应激及免疫功能的恢复。
Preface
Since the 90s of last century Danish Kehlet [1] first proposed a rapid recovery surgery (fast track surgery, FTS) concept, the concept of surgical treatment in progressive change. FTS measures to implement the concept of the purpose is to reduce perioperative surgical trauma patients, reducing the surgical stress response, accelerated postoperative recovery [2]. In this study from January 2009 to October 2009 period,86 cases of colorectal cancer treated patients, respectively, and traditional application of the control program FTS program, the two groups for the first exhaust defecation time, postoperative hospitalization costs, length of hospital stay, complications and postoperative stress and immune function recovery were studied as controls.
Objective
Fast-track surgery (FTS) treatments more traditional treatment of colorectal cancer patients scheme.
Methods
Comparative Study of 86 cases of colorectal cancer patients, fsts-track surgery were taken (n= 31) and traditional treatment programs (n= 55), postoperative hospital stay were compared, hospital charges, the first bowel movement and discharge patients The incidence of complications, stress and immune serum postoperatively.
Results
Two groups of patients were cured. Fsts-track surgery patients with the traditional group than the control group, after first bowel movement was significantly earlier discharge, hospital costs and length of stay decreased significantly (P<0.05). FTS on stress and improve immune function better than traditional methods. However, no significant difference between the two groups of complications (P> 0.05).
Conclusion
By fsts-track surgery of patients with colorectal cancer surgical treatment is safe and effective; fsts-track surgery in patients with colorectal cancer surgical treatment compared with conventional treatment to reduce the length of stay and hospital costs; fsts-track surgery to reduce postoperative pain, and facilitate Stress and immune function in patients with postoperative recovery.
引文
1 Kehlet H,Wilmore DW. Multimodel strategies to improve surgical outcome[J].Am J Surg,2002,183(6):630-641.
2 Wilmore DW.From Cathbertson to Fast-Track Surgery:70 years of progression in reducing stress in surgical patients [J].Ann Surg,2002,236(5):643-648.
3 Jakobsen DH,Sonne E.Convalescence after colonic surgery with fast-track vs conventional care[J].Colorectal Dis,2006,8(8):683-687.
4 Basse L,Jakobsen DH,et al.Functional recovery after open versus laparoscopic colonic resection:a randomized,blinded study[J].Ann Surg,2005 Mar;241(3):416-423.
5 黎介寿,对Fast-track Surgeryi(快通道外科)内涵的认识[J].中华医学杂志,2007,87(8)：515-517.
6 Slim K,Vicaut E,PanisY et al.Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation[J].Br J Surg,2004,91(9):1125-1130.
7 Urbach DR, Kennedy ED,Cohen MM.Colon and rectal anastomoses do not require routine drainage:a systematic review and meta-analysis[J].Ann Surg,1999,229(2):174-180.
8 Lewis SJ,Egger M,Sylvester PA,et al.Early enteral feeding versus"nil by mouth"after gastrointestinal surgery:systematic review and meta-analysis of controlled trials [J].BMJ,2001,323(7316):773-776.
9 Sagar PM,Kruegener G,Macfie J.Nasogastric intubation and elective abdominal Surgery[J].Br J Sury,1992,79(11):1127-1131.
10 Luckey A,Livingston E, Tache Y. Mechanisms and treatment of postoperative ileus[J]. Arch Surg,2003,138(2):206-214.
11 Correia M ITD,da Silva RG.The impact of early nutrition on metabolic response and postoperative ileus[J].Curr Opin Clin Nutr Metab Care,2004,7(5):577-583.
12. De Aguilar-Nascimento JE,Goelzer J.Early feeding after intestinal anastomoses:risks or benefits?[J].Rev Assoc Med Bras,2002,48(4):348-352.
13 Watters JM,Kirkpatrick SM,Norris SB Shamji FM,et al.Immediate postoperative enteral feeding results in impaired respiratory mechanics and decreased Mobility [J].Ann Surg,1997,226(3):369-377.
14 Correia M ITD,Waitzberg DL.The impact of malnutrition on morbidity,mortality, length of hospital stay and costs evaluated through a multivariate model analysis[J].Clin Nutr,2003,22(3):235-239.
15 Kaboli P,Henderson MC,White RH.DVT prophylaxis and anticoagulation in the surgical patient[J].Med Clin North Am,2003,87(1):77-110.
16 Kehlet H.Multimodal approach to control postoperative pathophysiology and Rehabilitation[J].Br J Anaesth,1997,78(5):606-617.
17 Danic B.[How human sciences can help to understand blood donation[J]?Transfus Clin Bi ol,2003,10(3):146-150.
18 Pramanik T,Adhikary P,Roychowdhury P,et al.Alteration of blood p ressure among the donors in a blood donation camp[J].MymensinghMed J,2005,14(2):189-190.
19 Kalinski P,Nakamura Y,Watchmaker P,et al.Helper r oles of NK and CD8+T cells in the induction of tumor immunity. Polarized dendritic cells as cancer vaccines[J]. I mmunol Res,2006,36(1-3):137-146.
20 KappesDJ,He X,He X.Role of the transcription factor Th-POK in CD4:CD8 lineage commitment[J].I mmunol Rev,2006,209:237-252.
21 Ott L,McClian CJ,Gillesp ie M,et al.Cytokines and metabolic dysfunction after sever head injury.J Neurotrauma,1994,11(3):447.
22 Rahra HB,Bendlx J,Ahlbrgh P,et al.Coagulation, inflammatory, and stress responsea in randomized comparison of open and laparoscopic repair of recurrent inguinal hernia [J].Surg Endosc,2006.20(3):468-472.
23 Suter M,M artinet O,Spertini F.Reduced acute phase response after laparoscopic total extraperitoneal bilateral hernia repair compared to open repair with the Stoppa procedure [J].Surg Endosc,2002,16(8):1214-1219.
24 Ogawa K, Hirai M, Katsube T, et al.Suppression of cellular immunityby surgical stress [J].Surgery,2000,127:329-336.
25郑树忠,关于卫生事业发展与费用控制的探讨[J].中国卫生资源,2000,3(5)：203-205.
1 Basse L, Jakobsen DH,Bardram L,et al.Functional recovery after open versus laparoscopic colonic resection [J].Ann Surg,2005,241:416-423.
2 Zhou T,Ting WX,Jiang Y, et al.Early removing gast rointestinal decompression and early oral feeding improve patient s'rehabilitation after colorectostomy[J]. World J Gast roenterol,2006,12(15):2459-2463.
3 Basse L,Hjort JD,Billesbolle P,et al.A clinical pathway to accelerate recovery after colonic resection[J].Annals of Surgery,2000,232(1):51-57.
4 Kehlet H,Wilmore DW.Multimodel strategies to imp rove surgical outcome[J].Am J Surg, 2002,183(6):630-641.
5 Basse L,Raskov HH,Jacobsen DH,et al.Accelerated postoperative recovery program after colonic resection improves physical performance,pulmonary function and body composition[J].Br J Surg,2002,89(4):446-453.
6 Jakobsen D H, onne E.Convalescence after colonic surgery with fast-track vs conventional care[J].Golorectal Dis,2006,8:683.
7 Wind J.Elective colon surgery according to a'fasttrack'programme. Ned Tijdschr Geneeskd 2006; 150:299-304.
8 W.Schwenk & N.Giinther & P.Wendling et al."Fast-track"rehabilitation for elective colonic surgery in Germany-prospective observational data from a multi-centre quality assurance programme.Int J Colorectal Dis (2008)23:93-99.
9 Kehlet H,Wilmore DW.Multimodal strategies to improve surgical outcome[J].Am J Surg. 2002,183(6):630-641.
10 Slim K,Vicaut E,Panis Y,et al.Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel p reparation[J].Br J Surg,2004,91(9):1125-1130.
11 Bucher P,Mermillod B,Gervaz P,et al.Mechanical bowel preparation for elective colorectal surgery.Arch Surg,2004,139:1359-1364.
12 Bucher P,Gervaz P,Egger JF,et al.Morphologic alterations associated with mechanical bowel preparation before elective colorectal surgery:a randomized trial[J].Dis Colon Rectum,2006,49 (1):109-112.
13 Zmora O,Mahajna A,Bar2Zakai B,et al.Is mechanical bowel p reparation mandatory for left-sided colonic anastomosis?Results of a p rospective randomized trial[J].Tech Coloproctol, 2006,10(2):131-135.
14 Bucher P,Gervaz P,Soravia C,et al.Randomized clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery[J].Br J Surg,2005,92(4): 409-414.
15贺冠海,贾忠,方欣,封光华.成人先天性巨结肠症肠道准备和手术方法探讨.[J]Med Res.2006,35(9)：98-100.
16江志伟,李宁,黎介寿.加速康复外科理念在结肠切除病人中应用进展.[J].中国实用外科杂志,2007,27,(10)：836-838.
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25 Mattei P,Rombeau JL.Review of the pathophysiology and management of postoperative ileus[J].World J Surg,2006;30(8):1382.
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27 Nelson R,Tse B,Edwards S.Systematic review of prophylactic nasogastric decompression after abdominal operations[J]Br J Surg,2005,92(6):673-680.
28 Zhou T,Wu XT,Zhou YJ,et al.Early removing gastrointestinal decompression and early oral feed ing improve pa tients rehab ilitation after colorectostomy[J].world J Gastr-oenterol,2006,12(15):2459-2463.
29 Brandstrup B, Tonnesen H, Beier2Holgersen R,et al.Effects of intravenous fluid restriction on postoperative comp lications:comparison of two perioperative fluid regimens:a randomized assessor2blinded multicenter trial[J].Ann Surg,2003,238(5):641-648.
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assessorblinded multi. center trial[J] Ann Surg,2003,238(5):641-648.
31 Brandstrup B.Fluid therapy for the surgical patient[J].Best Pract Res Clin Anaes-thesiol,2006,20(2):265-283.
32 Wilmore DW,Kehlet H.Management of patient s in fast t rack surgery [J].BMJ, 2001;322(7284):473.
33 Mattei P,Rombeau JL.Review of the pathophysiology and management of postoperative ileus[J].World J Surg,2006;30(8):1382.
34 Basse L,Jakobsen DH,Bardram L,et al.Functional recovery after open versus laparoscopic colonic resection:a randomized,blinded study [J].Ann Surg,2005;241(3):416
35 Mattei P,Rombeau JL.Review of the pathophysiology and management of postoperative ileus [J].World J Surg,2006;30(8):1382.
36 Schuster TG, Montie J E.Postoperative ileus after abdominal surgery [J].Urology, 2002;59(4):465.
37 Jesus EC,Karliczek A,Matos D,et al.Prophylactic anastomotic drainage for colorectal surgery[J].Cochrane Database Syst Rev,2004,18(4):CD002100.
38 Basse L,WernerM,Kehlet H.Is urinary drainage necessary during continuous ep idural analgesia after colonic resection?[J].Reg Anesth PainMed,2000,25(5):498-501.
39 Mattei P,Rombeau JL.Review of the pathophysiology and management of postoperative ileus[J].World J Surg,2006;30(8):1382.
40 Livingston EH,Passaro EP J r.Postoperative ileus[J].Dig Dis Sci,1990;35(1):121.
41 Luckey A,Livingston E,Tache Y.Mechanisms and treatment of postoperative ileus[J].Arch Surg,2003,138(2):206-214.
42 Johnson Casto C,Krammer J,Drake J.Postoperative feeding:a clinical review[J].Obstet Gynecol Surv,2000,55(9):571-573.
43 Kehlet H,Wilmore DW. Multimodal strategies to imp rove surgical outcome[J].Am J Surg,2002,183(6):630-661.
44 Delaney CP, Zutshi M, Senagore AJ,et al. Prospective, randomized,controlled trial between a pathway of controlled rehab ilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection[J]Dis Colon Rec-tum,2003,46(7):851-859.
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46 Bradshaw B QLiu S S,Thirlby R C.Standardized perioperative care protocols and reduced length of stay after colon surgery[J].J Am Coll Surg,1998,186(5):501-506.
47 Wind J,Polle SW,Fung Kon Jin PH,et al.Systematic review of enhanced recovery programmes in colonic surgery[J].Br J Surg,2006;93(7):800.
48 Basse L,Thorbol J E,Lossl K,et al.Colonic surgery with accelerated rehabilitation or conventional care[J].Dis Colon Rectum,2004;47(3):271.
49 Basse L,Thorbol J E,Lossl K,et al.Colonic surgery with accelerated rehabilitation or conventional care[J].Dis Colon Rectum,2004;47(3):271.
2 Wilmore DW.From Cathbertson to Fast-Track Surgery:70 years of progression in reducing stress in surgical patients [J].Ann Surg,2002,236(5):643-648.
3 Jakobsen DH,Sonne E.Convalescence after colonic surgery with fast-track vs conventional care[J].Colorectal Dis,2006,8(8):683-687.
4 Basse L,Jakobsen DH,et al.Functional recovery after open versus laparoscopic colonic resection:a randomized,blinded study[J].Ann Surg,2005 Mar;241(3):416-423.
5 黎介寿,对Fast-track Surgeryi(快通道外科)内涵的认识[J].中华医学杂志,2007,87(8)：515-517.
6 Slim K,Vicaut E,PanisY et al.Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation[J].Br J Surg,2004,91(9):1125-1130.
7 Urbach DR, Kennedy ED,Cohen MM.Colon and rectal anastomoses do not require routine drainage:a systematic review and meta-analysis[J].Ann Surg,1999,229(2):174-180.
8 Lewis SJ,Egger M,Sylvester PA,et al.Early enteral feeding versus"nil by mouth"after gastrointestinal surgery:systematic review and meta-analysis of controlled trials [J].BMJ,2001,323(7316):773-776.
9 Sagar PM,Kruegener G,Macfie J.Nasogastric intubation and elective abdominal Surgery[J].Br J Sury,1992,79(11):1127-1131.
10 Luckey A,Livingston E, Tache Y. Mechanisms and treatment of postoperative ileus[J]. Arch Surg,2003,138(2):206-214.
11 Correia M ITD,da Silva RG.The impact of early nutrition on metabolic response and postoperative ileus[J].Curr Opin Clin Nutr Metab Care,2004,7(5):577-583.
12. De Aguilar-Nascimento JE,Goelzer J.Early feeding after intestinal anastomoses:risks or benefits?[J].Rev Assoc Med Bras,2002,48(4):348-352.
13 Watters JM,Kirkpatrick SM,Norris SB Shamji FM,et al.Immediate postoperative enteral feeding results in impaired respiratory mechanics and decreased Mobility [J].Ann Surg,1997,226(3):369-377.
14 Correia M ITD,Waitzberg DL.The impact of malnutrition on morbidity,mortality, length of hospital stay and costs evaluated through a multivariate model analysis[J].Clin Nutr,2003,22(3):235-239.
15 Kaboli P,Henderson MC,White RH.DVT prophylaxis and anticoagulation in the surgical patient[J].Med Clin North Am,2003,87(1):77-110.
16 Kehlet H.Multimodal approach to control postoperative pathophysiology and Rehabilitation[J].Br J Anaesth,1997,78(5):606-617.
17 Danic B.[How human sciences can help to understand blood donation[J]?Transfus Clin Bi ol,2003,10(3):146-150.
18 Pramanik T,Adhikary P,Roychowdhury P,et al.Alteration of blood p ressure among the donors in a blood donation camp[J].MymensinghMed J,2005,14(2):189-190.
19 Kalinski P,Nakamura Y,Watchmaker P,et al.Helper r oles of NK and CD8+T cells in the induction of tumor immunity. Polarized dendritic cells as cancer vaccines[J]. I mmunol Res,2006,36(1-3):137-146.
20 KappesDJ,He X,He X.Role of the transcription factor Th-POK in CD4:CD8 lineage commitment[J].I mmunol Rev,2006,209:237-252.
21 Ott L,McClian CJ,Gillesp ie M,et al.Cytokines and metabolic dysfunction after sever head injury.J Neurotrauma,1994,11(3):447.
22 Rahra HB,Bendlx J,Ahlbrgh P,et al.Coagulation, inflammatory, and stress responsea in randomized comparison of open and laparoscopic repair of recurrent inguinal hernia [J].Surg Endosc,2006.20(3):468-472.
23 Suter M,M artinet O,Spertini F.Reduced acute phase response after laparoscopic total extraperitoneal bilateral hernia repair compared to open repair with the Stoppa procedure [J].Surg Endosc,2002,16(8):1214-1219.
24 Ogawa K, Hirai M, Katsube T, et al.Suppression of cellular immunityby surgical stress [J].Surgery,2000,127:329-336.
25郑树忠,关于卫生事业发展与费用控制的探讨[J].中国卫生资源,2000,3(5)：203-205.
1 Basse L, Jakobsen DH,Bardram L,et al.Functional recovery after open versus laparoscopic colonic resection [J].Ann Surg,2005,241:416-423.
2 Zhou T,Ting WX,Jiang Y, et al.Early removing gast rointestinal decompression and early oral feeding improve patient s'rehabilitation after colorectostomy[J]. World J Gast roenterol,2006,12(15):2459-2463.
3 Basse L,Hjort JD,Billesbolle P,et al.A clinical pathway to accelerate recovery after colonic resection[J].Annals of Surgery,2000,232(1):51-57.
4 Kehlet H,Wilmore DW.Multimodel strategies to imp rove surgical outcome[J].Am J Surg, 2002,183(6):630-641.
5 Basse L,Raskov HH,Jacobsen DH,et al.Accelerated postoperative recovery program after colonic resection improves physical performance,pulmonary function and body composition[J].Br J Surg,2002,89(4):446-453.
6 Jakobsen D H, onne E.Convalescence after colonic surgery with fast-track vs conventional care[J].Golorectal Dis,2006,8:683.
7 Wind J.Elective colon surgery according to a'fasttrack'programme. Ned Tijdschr Geneeskd 2006; 150:299-304.
8 W.Schwenk & N.Giinther & P.Wendling et al."Fast-track"rehabilitation for elective colonic surgery in Germany-prospective observational data from a multi-centre quality assurance programme.Int J Colorectal Dis (2008)23:93-99.
9 Kehlet H,Wilmore DW.Multimodal strategies to improve surgical outcome[J].Am J Surg. 2002,183(6):630-641.
10 Slim K,Vicaut E,Panis Y,et al.Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel p reparation[J].Br J Surg,2004,91(9):1125-1130.
11 Bucher P,Mermillod B,Gervaz P,et al.Mechanical bowel preparation for elective colorectal surgery.Arch Surg,2004,139:1359-1364.
12 Bucher P,Gervaz P,Egger JF,et al.Morphologic alterations associated with mechanical bowel preparation before elective colorectal surgery:a randomized trial[J].Dis Colon Rectum,2006,49 (1):109-112.
13 Zmora O,Mahajna A,Bar2Zakai B,et al.Is mechanical bowel p reparation mandatory for left-sided colonic anastomosis?Results of a p rospective randomized trial[J].Tech Coloproctol, 2006,10(2):131-135.
14 Bucher P,Gervaz P,Soravia C,et al.Randomized clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery[J].Br J Surg,2005,92(4): 409-414.
15贺冠海,贾忠,方欣,封光华.成人先天性巨结肠症肠道准备和手术方法探讨.[J]Med Res.2006,35(9)：98-100.
16江志伟,李宁,黎介寿.加速康复外科理念在结肠切除病人中应用进展.[J].中国实用外科杂志,2007,27,(10)：836-838.
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