快速康复外科理念在肝癌肝切除术围手术期管理中的临床价值

目的 探讨快速康复外科（FTS）理念应用于肝癌肝切除围手术期管理的价值.方法 前瞻性分析2011年9月至2013年7月广西钦州市第一人民医院收治的40例肝癌患者的临床资料.患者均行肝切除术,按照随机数字表法将患者分为FTS组（20例）和对照组（20例）.FTS组采用FTS理念指导下的围手术期处理措施.对照组采用传统围手术期处理措施,比较两组患者术中情况、肝门阻断时间、手术时间、术中出血量、术中输血量、腹腔引流管拔除时间、术后肛门排气和排便时间、术后住院时间、住院费用、术后1、3、6dC反应蛋白变化情况、肝功能恢复情况、术后并发症发生情况等.所有患者采用电话及门诊随访,随访时间截至2013年9月.计量资料比较采用t检验,计数资料比较采用x2检验.非正态分布数据采用秩和检验.结果 两组患者均治愈出院,无围手术期死亡.FTS组和对照组患者术后腹腔引流管拔除时间分别为（2.3±1.0）d和（4.6±0.7）d,两组比较,差异有统计学意义（t=0.74,P＜0.05）.FTS组患者术后肛门排气时间和排便时间分别为（2.5±0.5）d和（3.1±0.7）d,对照组分别为（4.3±0.7）d和（4.8±0.4）d,两组比较,差异有统计学意义（f=0.34,1.70,P＜0.05）.FTS组患者术后住院时间和住院费用分别为（7.0±0.8）d和（3.6±0 3）万元,对照组分别为（8.5±0.9）d和（4.1±0.3）万元,两组比较,差异有统计学意义（=0.23,0.57,P＜0.05）.FTS组患者术后1、3、6dC反应蛋白水平分别为（56±7） mg/L、（122±7） mg/L、（35 ±7） mg/L,对照组分别为（198±24） mg/L、（137±5）mg/L、（49±8） mg/L,两组比较,差异有统计学意义（F=64.91,P＜0.05）;FFS组患者术后1、3、6d前白蛋白水平分别为（196±14） mg/L、（243±17）mg/L、（260±10） mg/L,对照组分别为（198±24）mg/L、（199±16） mg/L、（245±7）mg/L,两组比较,差异有统计学意义（F =22.69,P ＜0.05）;FTS组术后1、3、6dALT水平分别为（379±34） U/L、（166±12） U/L、（49±14）U/L,对照组分别为（367±75） U/L、（210±28） U/L、（197 ±22） U/L,两组比较,差异有统计学意义（F =4.51,P＜0.05）.FTS组患者术后并发腹腔积液1例、胸腔积液1例,无肺部感染及切口感染的患者;对照组术后并发腹腔积液4例、胸腔积液3例、肺部感染4例、切口感染2例,两组患者术后并发症发生情况比较,差异无统计学意义（x2=0.78,1.11,4.44,2.11,P＞0.05）.所有患者随访2～24个月,无因术后并发症再次手术或住院患者.结论 FTS理念应用于肝癌患者肝切除术围手术期的管理安全有效,能降低患者术后应激反应,加快患者肝功能恢复,加速患者的康复进程.

Value of fast track surgery principles in the perioperative management of liver cancer patients after hepatectomy

Objective To investigate the value of fast track surgery （FTS） principles in the perioperative management of liver cancer patients after hepatectomy. Methods Forty patients with primary liver cancer who were admitted to the First People＇s Hospital of Qinzhou from September 2011 to July 2013 were enrolled in this prospective study. All the patients were randomly divided into the FTS group （20 patients） and the control group （20 patients） according to the random number table. The perioperative management of patients in the FTS group was guided by the FTS principles, patients in the control group were managed with traditional methods. The intraoperative condition, time for portal occlusion, operation time, volume of intraoperative blood loss and blood transfusion, time to drainage tube removal, time to flatus and defecation, duration of postoperative hospital stay, expenses, changes of C-reactive protein on postoperative day 1,3, 6, recovery of hepatic function and incidence of postoperative complications. All patients were followed up via phone call and out-patient examination till September2013. All data were analyzed using the t test or chi-square test. The non-normal distribution paramenters were analyzed using the rank sum test. Results All patients were cured with no perioperative death. The time for postoperative drainage tube removal, time to flatus and defecation, duration of postoperative hospital stay and expenses were （2.3±1.0）days, （2.5±0.5）days, （3.1±0.7）days, （7.0±0.8）daysand （3.6±0.3） ×10^4yuanin the FTS group, and （4.6 ±0.7）days, （4.3±0.7）days, （4.8±0.4）days, （8.5 ±0.9）days and （4.1 ±0.3） × 10^4 yuan, with significant differences between the 2 groups （ t = 0. 74, 0. 34, 1.70, 0. 23,0. 57, P 〈 0.05 ）. The levels of C-reactive proteins at postoperative day 1, 3, 6 were （56 ± 7）mg/L, （122 ± 7）mg/L and （35 ± 7）mg/L in the FTS group, and （ 198 ± 24 ） mg/L, （ 137± 5 ） mg/L and （ 49 ±8 ） mg/L, with significant differences between the 2 groups （ F = 64.91, P 〈 0.05 ）. The levels of prealbumin at postoperative day 1,3, 6 were （ 196 ±14） mg/L, （243 ± 17） mg/L, （260± 10） mg/L in the FTS group, and （ 198 ± 24） mg/L, （ 199 ± 16） mg/L and （ 245 ± 7 ） mg/L in the control group, with significant differences between the 2 groups （ F = 22. 69, P 〈 0.05 ）. The levels of alanine transaminase at postoperative day 1, 3, 6 were （379 ± 34）U/L, （166 ± 12）U/L, （49 ± 14） U/L in the FTS group, and （367 ± 75 ）U/L, （210 ± 28）U/L, （197 ±22）U/L in the control group, with significant differences between the 2 groups （F =4. 51, P 〈 0.05 ）. One patient was complicated with peritoneal effusion and 1 with thoracic effusion in the FTS group; 4 patients was complicated with peritoneal effusion, 3 with thoracic effusion, 4 with pulmonary infection and 2 with incisional infection in the control group, with no significant difference in the complication between the 2 groups （X2=0. 78, 1. 11, 4. 44, 2. 11, P 〉0.05）. All the patients were followed up for 2-24 months, no patients received reoperation or re-admitted to the hospital due to complications. Conclusion The application of FTS principle in the perioperative management of liver cancer patients after hepatectomy is safe and effective, it could alleviate the post-operative stress reaction and accelerate the recovery of liver function and patients＇ condition.