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《中华消化外科杂志》2019年10月第18卷第10期论著

预防性回肠造口Ⅰ期开放和Ⅱ期开放对低位直肠癌患者术后恢复影响的前瞻性研究

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引用本文:
刘兆礼1,王冬2,赵资文2,等.预防性回肠造口Ⅰ期开放和Ⅱ期开放对低位直肠癌患者术后恢复影响的前瞻性研究[J].中华消化外科杂志,2019,18(10):940-945.DOI:10.3760/cma.j.issn.1673-9752.2019.10.009.
【摘要】

目的:探讨预防性回肠造口Ⅰ期开放和Ⅱ期开放对低位直肠癌患者术后恢复的影响。
方法:采用前瞻性研究的方法。选取2016年9月至2017年5月青岛大学附属医院收治的88例行腹腔镜直肠癌根治性切除+预防性回肠造口术治疗低位直肠癌患者的临床病理资料,按随机数字表法将入组患者分为两组。患者行腹腔镜直肠癌根治性切除+预防性回肠造口术(Ⅰ期开放)设为试验组;患者行腹腔镜直肠癌根治性切除+预防性回肠造口术(Ⅱ期开放)设为对照组。观察指标:(1)术后临床终点指标比较。(2)术后并发症比较。(3)应激反应指标比较。采用门诊和电话方式进行随访,了解患者术后恢复情况。患者出院后24 h内进行首次术后电话随访,患者出院后1周内与主管医师随时保持联系;出院2周门诊随访,每周对患者进行1次电话随访,直至术后1个月结束。出院后一旦出现不适症状,随时回院就诊,必要时再次入院治疗。随访时间截至术后1个月。正态分布的计量资料以Mean±SD表示,组间比较采用独立样本t检验。重复测量数据采用重复测量方差分析。计数资料以绝对数或百分比表示,组间比较应用X2检验或Fisher确切概率法。
结果:筛选出符合研究条件的患者88例,男61例,女27例;平均年龄为61岁,年龄范围为44~74岁。 88例患者中,试验组45例,对照组43例。(1)术后临床终点指标比较:试验组患者手术时间、首次进食半流质食物时间、术后发热时间、术后生命质量评分、住院时间和总住院费用分别为(122±9)min、(5.1±1.6)d、(54±8)h、(18.6±1.5)分、(6.7±1.2)d、(53 269±2 888)元,对照组患者上述指标分别为(128±10)min、(6.4±2.4)d、(65±7)h、(17.1±1.3)分、(8.1±1.4)d、(59 419±1 921)元。两组患者手术时间、首次进食半流质食物时间比较,差异均无统计学意义(t=1.716,1.329,P>0.05);两组患者术后发热时间、术后生命质量评分、住院时间和总住院费用比较,差异均有统计学意义(t=8.688,5.850,3.897,11.707,P<0.05)。(2)术后并发症比较:试验组患者造口相关并发症发生率为22.2%(10/45),其中造口水肿5例,水电解质紊乱2例,粪水性皮炎2例,造口感染1例;对照组为34.9%(15/43),其中造口水肿4例,水电解质紊乱3例,粪水性皮炎4例,造口感染2例,造口黏膜分离1例,造口狭窄1例。两组患者造口相关并发症发生率比较,差异无统计学意义(X2=1.733,P>0.05)。试验组患者系统并发症发生率为17.8%(8/45),其中急性尿潴留2例,切口感染2例,腹腔感染1例,肺部感染1例,泌尿系感染1例,下肢深静脉血栓形成1例;对照组为20.9%(9/43),其中急性尿潴留1例,切口感染1例,肠梗阻1例,肺部感染2例,泌尿系感染2例,下肢深静脉血栓形成1例,吻合口瘘1例。两组患者系统并发症发生率比较,差异无统计学意义(X2=0.140,P>0.05)。两组患者均无死亡病例。对照组术后发生吻合口瘘的患者经再次手术探查、持续腹腔冲洗等治疗痊愈后出院;其余患者均给予积极的保守治疗后痊愈出院。(3)应激反应指标比较:试验组患者C反应蛋白术前到术后第5天从(2.2±0.7)ng/L变化为(43.9±12.0)ng/L,肿瘤坏死因子α(TNF-α)术前到术后第5天从(12.2±1.9)fmmol/L变化为(11.3±1.4)fmmol/L,白细胞介素6(IL-6)术前到术后第5天从(95±17)ng/L变化为(107±14)ng/L,对照组患者上述指标变化情况分别为(2.2±0.8)ng/L变化为(58.8±10.7)ng/L,(11.6±1.6)fmmol/L变化为(12.7±1.3)fmmol/L,(94±16)ng/L变化为(117±13)ng/L。两组患者C反应蛋白、TNF-α及IL-6变化趋势比较,差异均有统计学意义(F=260.042,55.428,120.337,P<0.05);但C反应蛋白、TNF-α、IL-6组内变化趋势与时间交互效应,差异均无统计学意义(F=3.514,2.366,1.864,P>0.05)。
结论:与Ⅱ期开放比较,低位直肠癌患者行腹腔镜直肠癌根治性切除术进行预防性回肠造口Ⅰ期开放安全、有效,可降低患者术后应激反应,促进患者康复。

【Abstract】

Objective:To investigate the effects of stage Ⅰ opening and stage Ⅱ opening of prophylactic ileostomy on postoperative recovery in low rectal cancer.
Methods:The prospective study was conducted. The clinical data of 88 patients with low rectal cancer who underwent laparoscopic rectal resection and prophylactic terminal ileostomy in the Affiliated Hospital of Qingdao University from September 2016 to May 2017 were collected. According to random number table, patients undergoing laparoscopic rectal resection combined with prophylactic ileostomy with stage I opening were allocated into experimental group, and patients undergoing laparoscopic rectal resection combined with prophylactic ileostomy with stage Ⅱ opening were allocated into control group. Observation indicators: (1) comparison of postoperative clinical endpoints indices; (2) comparison of postoperative complications; (3) comparison of stress response indices. Follow-up was performed using outpatient examination and telephone interview to detect recovery of patients. The patients were followed up for the first time within 24 hours after discharge and kept in contact with the doctor at any time within 1 week after discharge. The patients were followed up at 2 weeks after discharge in outpatient department and then were followed up by telephone interview once a week within 1 month after operation. Patients returned to hospital if there was any discomfort after discharge, and were re-admitted if necessary. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the independent sample t test. Repeated measurement data were analyzed using repeated ANOVA. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact propability.
Results:Eighty-eight patients were screened for eligibility, including 61 males and 27 females, aged from 44 to 74 years, with an average age of 61 years. There were 45 patients in the experimental group and 40 in the control group, respectively. (1) Comparison of postoperative clinical endpoints indices: the operation time, time to first semiliquid diet, postoperative fever time, quality of life score, duration of hospital stay, and total hospitalization expenses were (122±9)minutes, (5.1±1.6)days, (54±8)hours, 18.6±1.5, (6.7±1.2)days, (53 269±2 888)yuan in the experimental group, and (128±10)minutes, (6.4±2.4)days, (65±7)hours, 17.1±1.3, (8.1±1.4)days, (59 419±1 921)yuan in the control group, respectively. There was no significant difference in operation time or time to first semiliquid diet between the two groups (t=1.716, 1.329, P>0.05). There were significant differences in the postoperative fever time, quality of life score, duration of hospital stay, and total hospitalization expenses between the two groups (t=8.688, 5.850, 3.897, 11.707, P<0.05). (2) Comparison of postoperative complications: the incidence of ileostomy-related complications was 22.2%(10/45) in the experimental group, including 5 cases of ileostomy edema, 2 of fluid and electrolyte imbalance, 2 of fecal dermatitis, 1 of ileostomy infection; the incidence of ileostomy-related complications was 34.9%(15/43) in the control group, including 4 cases of ileostomy edema, 3 of fluid and electrolyte imbalance, 4 of fecal dermatitis, 2 of ileostomy infection, 1 of ileostomy membrane separation, and 1 of ileostomy stenosis; there was no significant difference in the incidence of ileostomy-related complications between the two groups (χ2=1.733, P>0.05). The incidence of system complications was 17.8%(8/45) in the experimental group, including 2 case of acute urinary retention, 2 of incisional infection, 1 of abdominal infection, 1 of pulmonary infection, 1 of urinary infection, 1 of deep venous thrombosis of the lower extremities; the incidence of system complications was 20.9%(9/43) in the control group, including 1 case of acute urinary retention, 1 of incisional infection, 1 of intestinal obstruction, 1 of pulmonary infection, 1 of urinary infection, 1 of deep venous thrombosis of the lower extremities, 1 of anastomotic fistula; there was no significant difference in the incidence of system complications between the two groups (χ2=0.140, P>0.05). There was no death in the two groups. Patients with postoperative anastomotic leakage in the experimental group were recovered and discharged after re-surgical exploration and continuous abdominal irrigation, and the remaining patients were discharged after active conservative treatment. (3) Comparison of stress response indices: from preoperation to postoperative 5 days, the C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) were changed from (2.2±0.7)ng/L to (43.9±12.0)ng/L,from (12.2±1.9)fmmol/L to (11.3±1.4)fmmol/L, from (95±17)ng/L to (107±14)ng/L in the experimental group, and from (2.2±0.8)ng/L to (58.8±10.7)ng/L,from (11.6±1.6)fmmol/L to (12.7±1.3)fmmol/L,from (94±16)ng/L to (117±13)ng/L in the control group, respectively, showing significant differences in the changing trends of CRP, TNF-α, IL-6 between the two groups (F=260.042, 55.428, 120.337, P<0.05). However, the changing trend within groups had interactive effects with time, showing no significant difference (F=3.514, 2.366, 1.864, P>0.05).
Conclusion
:Compared with stage Ⅱ opening, stage Ⅰ opening of prophylactic ileostomy in laparoscopic rectal resection for low rectal cancer is safe and effective, which can reduce postoperative stress response and promote patients′ rehabilitation.

DOI:10.3760/cma.j.issn.1673-9752.2019.10.009
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