大腸癌術(shù)后早期胃管拔出對患者血漿降鈣素原變化及對胃腸功能恢復(fù)的影響

牟亞剛，王建軍，張洪偉

(1.西電集團(tuán)醫(yī)院普外科，西安 710077；2.第四軍醫(yī)大學(xué)附屬西京醫(yī)院消化外科，西安 710032)

?

·論 著·

大腸癌術(shù)后早期胃管拔出對患者血漿降鈣素原變化及對胃腸功能恢復(fù)的影響

牟亞剛1，王建軍1，張洪偉2

(1.西電集團(tuán)醫(yī)院普外科，西安 710077；2.第四軍醫(yī)大學(xué)附屬西京醫(yī)院消化外科，西安 710032)

目的 探討大腸癌術(shù)后早期胃管拔出對患者血漿降鈣素原變化及對胃腸功能恢復(fù)的影響。方法 選取2010年2月至2014年8月西電集團(tuán)醫(yī)院普外科腫瘤科收治的大腸癌術(shù)后患者110例，采用隨機(jī)數(shù)表法分為2組，其中研究組55例，予術(shù)后早期胃管拔出治療，術(shù)后6 h開始飲水，12 h進(jìn)流食，3 d過渡到普通飲食；對照組55例，采取常規(guī)胃管拔出治療，術(shù)后排氣排便后拔出胃管，開始進(jìn)食。比較術(shù)后及干預(yù)前后治療前血漿降鈣素原水平及術(shù)后并發(fā)癥情況、術(shù)后排氣排便時間、住院時間、住院費用等觀察指標(biāo)。結(jié)果 (1)治療后2組血漿降鈣素原均明顯下降，但二者相比差異無統(tǒng)計學(xué)意義(P>0.05)；(2)治療后，研究組排氣時間(50.71±6.25)h、排便時間(66.43±5.87)h、住院時間(7.17±2.31)d及住院費用(41 562.87±274.36)元低于對照組(65.24±6.58)h、(74.56±5.69)h、(10.24±3.15)d、(47 893.57±314.82)元，差異有統(tǒng)計學(xué)意義(P<0.05)；(3)治療后，研究組并發(fā)癥發(fā)生率(9.09%)與對照組(7.27%)相近，差異無統(tǒng)計學(xué)意義(P>0.05)。結(jié)論 大腸癌術(shù)后早期胃管拔出有利于患者促進(jìn)胃腸功能恢復(fù)，縮短住院時間，同時不影響降鈣素原水平，不增加并發(fā)癥發(fā)生風(fēng)險，值得臨床推廣。

大腸癌； 早期胃管拔出； 降鈣素原； 胃腸功能

大腸癌(CRC)指內(nèi)在環(huán)境或遺傳等多種因素導(dǎo)致大腸黏膜上皮發(fā)生癌變的一種疾病。發(fā)達(dá)國家大腸癌已經(jīng)成為第三大腫瘤疾病[1]。我國雖然為大腸癌低發(fā)地區(qū)，但隨著生活方式的西化，其發(fā)病率明顯上升，目前已經(jīng)位于惡性腫瘤發(fā)病率的第五位。據(jù)調(diào)查統(tǒng)計，大腸癌的發(fā)病特點為經(jīng)濟(jì)發(fā)達(dá)地區(qū)的發(fā)病率較高；年齡越大，發(fā)病率越高；男性發(fā)病率高于女性[2-4]。手術(shù)為治療大腸癌的首選方式，術(shù)后容易發(fā)生胃腸功能紊亂，嚴(yán)重降低臨床治療。研究發(fā)現(xiàn)，早期胃管拔出能夠促進(jìn)胃腸蠕動，降低胃腸功能紊亂發(fā)生率，緩解痛苦，提高療效[5-7]?，F(xiàn)將研究結(jié)果報道如下。

1 資料與方法

1.1 一般資料 選取2010年12月至2014年8月西電集團(tuán)醫(yī)院診斷為大腸癌而收治入院，擬采取手術(shù)治療的患者110例為研究對象，采用隨機(jī)對照表法將患者分為研究組與對照組。研究組55例，其中男34例，女21例，平均(61.3±7.4)歲，Ⅰ期42例，Ⅱ期13例；對照組55例，其中男35例，女20例，平均(61.5±7.2)歲，Ⅰ期40例，Ⅱ期15例。2組患者的一般資料以及大腸癌分期差異無統(tǒng)計學(xué)意義(P>0.05)，具有可比性。

1.2 方法 納入標(biāo)準(zhǔn)：(1)經(jīng)影像學(xué)檢查及病理檢查確診為大腸癌[8]；(2)術(shù)前未采取放療、化療術(shù)前等輔助治療；(3)年齡小于80歲；(4)腫瘤無轉(zhuǎn)移；(5)自愿參與本研究，并簽署知情同意書；(6)獲得本院倫理委員會認(rèn)可并全程跟蹤。排除標(biāo)準(zhǔn)：(1)心臟、肝臟、腎臟患有嚴(yán)重疾?。?2)近期發(fā)生胃腸功能器質(zhì)性病變；(3)3個月內(nèi)使用過影響胃腸蠕動的藥物；(4)合并全身各系統(tǒng)功能障礙者；(5)神志異常患者[9]。研究組：術(shù)后不采取胃腸減壓治療，在術(shù)后6 h拔出胃管，開始飲水，少量進(jìn)食藕粉等完全流質(zhì)食物，依據(jù)全流食→半流食→普通飲食的順序逐步過渡，在術(shù)后3 d時采取普通飲食，同時根據(jù)患者的進(jìn)食量，酌情輔以靜脈營養(yǎng)治療。對照組：術(shù)后采取胃腸減壓治療，常規(guī)留置胃管，待患者排氣后開始飲水，在排便后可以拔出胃管，開始逐步進(jìn)食流質(zhì)食物，并逐步過渡到普通飲食。在禁止進(jìn)食的期間采取完全靜脈營養(yǎng)治療保障身體所需，在進(jìn)食后則根據(jù)患者進(jìn)食量適度采取部分靜脈營養(yǎng)進(jìn)行輔助治療。2組患者均鼓勵在術(shù)后12 h開始早期離床活動，并且采取統(tǒng)一出院標(biāo)準(zhǔn)，即經(jīng)口進(jìn)食完全恢復(fù)正常，無需靜脈補液輔助，無發(fā)熱、感染等并發(fā)癥，各種引流管成功拔出，能夠自行活動。所有患者出院后均采取1個月門診復(fù)查及定期電話跟蹤隨訪。

1.3 觀察指標(biāo) 2組患者均在治療前24 h及術(shù)后1 d時，清晨空腹時抽取外周靜脈血2 mL，應(yīng)用肝素抗凝處理后，馬上置于離心機(jī)中以3 000 r/min離心15 min，留取上層清液，將其放置在-80 ℃冰箱內(nèi)進(jìn)行保存?zhèn)溆?。血漿降鈣素原定量檢測采用酶聯(lián)免疫熒光分析技術(shù)，使用儀器為mini-VIDAS全自動熒光免疫分析儀。術(shù)后詳細(xì)記錄患者的排氣時間、排便時間、住院時間以及住院費用，同時觀察記錄并發(fā)癥情況，本研究中主要并發(fā)癥為吻合口瘺、切口感染、胃腸功能紊亂以及腸梗阻。

2 結(jié) 果

2.1 2組患者血漿降鈣素原比較 治療前2組患者血漿降鈣素原比較差異無統(tǒng)計學(xué)意義(P>0.05)；手術(shù)后，2組患者血漿降鈣素原有所下降，研究組血漿降鈣素原水平與對照組比較，差異無統(tǒng)計學(xué)意義(P>0.05)。見表1。

表1 治療前后2組患者血漿降鈣素原比較

注：與治療前比較，△P>0.05；與治療后比較，*P>0.05。

2.2 術(shù)后恢復(fù)情況比較 與對照組比較，研究組排氣時間、排便時間及住院明顯縮短，住院費用明顯減少，差異有統(tǒng)計學(xué)意義(P<0.05)。見表2。

2.3 2組術(shù)后并發(fā)癥情況比較 手術(shù)后2組均未見腸梗阻等嚴(yán)重不良反應(yīng)，2組并發(fā)癥總發(fā)生率相比較，差異無統(tǒng)計學(xué)意義(P>0.05)。見表3。

表2 手術(shù)后2組患者恢復(fù)情況比較

注：與對照組比較，△P<0.05。

表3 治療前后2組患者臨床療效情況

注：與對照組比較，△P>0.05。

3 討 論

CRC作為臨床常見惡性腫瘤，臨床首選方法為手術(shù)切除術(shù)，但由于手術(shù)中牽拉、麻醉影響以及手術(shù)創(chuàng)傷等因素，CRC患者術(shù)后胃腸功能會出現(xiàn)暫時性麻痹，從而出現(xiàn)腹脹、肛門無法排氣排便等情況[10-12]。術(shù)后胃腸功能紊亂能夠降低患者抵抗力，延遲患者恢復(fù)，嚴(yán)重者發(fā)生腸梗阻、腸粘連等并發(fā)癥[13-14]。隨著快速康復(fù)理論廣泛認(rèn)可，傳統(tǒng)治療中，為了避免腸梗阻等并發(fā)癥，術(shù)后患者需留置胃管至術(shù)后排氣排便才可拔出，近年來相關(guān)研究表明術(shù)后早期進(jìn)食并不增加并發(fā)癥風(fēng)險，利于胃腸道功能恢復(fù)[15-16]。研究證實發(fā)生腸梗阻時,巨噬細(xì)胞被激活，引發(fā)炎性反應(yīng)，阻礙腸括約肌收縮導(dǎo)致腸梗阻,同時白細(xì)胞表達(dá)增加，導(dǎo)致腸壁產(chǎn)生粘連，降鈣素原作為降鈣素前體，是重要的炎性反應(yīng)標(biāo)志物，不僅對于感染性疾病診療具有重要意義，而且對CRC術(shù)后腸梗阻具有預(yù)測作用[17-18]。通過檢測血漿降鈣素原、觀察胃腸功能變化以及并發(fā)癥情況，來早期胃管拔出對大腸癌術(shù)后患者的影響。

本研究中，治療后2組患者的血漿降鈣素原均有所回降，但是無論治療前后，2組的血漿降鈣素原水平比較，差異無統(tǒng)計學(xué)意義(P>0.05)，提示早期胃管拔出并不影響患者的血漿降鈣素原，不增加術(shù)后發(fā)生腸梗阻的風(fēng)險性；治療后，研究組患者在排氣時間、排便時間、住院時間以及住院費用上具有明顯優(yōu)勢，與對照組比較，差異有統(tǒng)計學(xué)意義(P<0.05)，提示早期胃管拔出能夠加快胃腸功能恢復(fù)，縮短治療時間，減少住院費用。且2組患者均未見腸梗阻的發(fā)生，研究組總發(fā)生率與對照組相近，提示早期胃管拔出不影響術(shù)后并發(fā)癥的發(fā)生，具有高安全性。有研究顯示CRC術(shù)后早期拔出胃管不僅使患者更為舒適，而且促進(jìn)患者行下床活動，促進(jìn)胃腸功能恢復(fù)[19-20]。

綜上所述，早期胃管拔出作為快速康復(fù)外科的重要組成部分，逐漸開始受到廣泛認(rèn)可，在CRC術(shù)后采取早期胃管拔出不僅促進(jìn)胃腸功能恢復(fù)，而且降低住院費用，對降鈣素原無影響，是改善CRC術(shù)后患者一種安全有效的干預(yù)措施。

[1]Jakovljevic M,Gutzwiller F.Costs differences among monoclonal antibodies-based first-line oncology cancer protocols for breast cancer,colorectal carcinoma and non-Hodgkin′s lymphoma[J].J Buon,2014,19(4):1111-1120.

[2]Chen C,Sun P,Ye S.Hypertension as a predictive biomarker for efficacy of bevacizumab treatment in metastatic colorectal cancer:a meta-analysis[J].J Buon,2014,19(4):917-924.

[3]Fan F,Bellister S,Lu J.The requirement for freshly isolated human colorectal cancer(CRC) cells in isolating CRC stem cells[J].Br J Cancer,2015,112(3):539-546.

[4]Waller J,Osborne K.Enthusiasm for cancer screening in Great Britain:a general population survey[J].Br J Cancer,2015,112(3):562-566.

[5]Pereira AA,Rego JF.Association between KRAS mutation and lung metastasis in advanced colorectal cancer[J].Br J Cancer,2015,112(3):424-428.

[6]Repetto O,Paoli P.Levels of soluble E-cadherin in breast,gastric,and colorectal cancers[J].Biomed Res Int,2014,2014:408047.

[7]Ahmadi A,Mobasheri M.Prevalence of hypertension and type 2 diabetes mellitus in patients with colorectal cancer and their median survival time:a cohort study[J].J Res Med Sci,2014,19(9):850-854.

[8]Cata JP,Gottumukkala V.Blood transfusion practices in cancer surgery[J].Indian J Anaesth,2014,58(5):637-642.

[9]Dotse E,Bian Y.Isolation of colorectal cancer stem-like cells[J].Cytotechnology,2014,23(2):79-82.

[10]Bassuk SS,Manson JE.Oral contraceptives and menopausal hormone therapy:relative and attributable risks of cardiovascular disease,cancer,and other health outcomes[J].Ann Epidemiol,2014,25(13):193-200.

[11]Jenkins MA,Dowty JG,Ouakrim D.Short-term risk of colorectal cancer in individuals with Lynch syndrome:a meta-analysis[J].J Clin Oncol,2015,33(4)：326-331.

[12]Ding H,Wu W,Jiang T.Meta-analysis comparing the safety and efficacy of metastatic colorectal cancer treatment regimens,capecitabine plus irinotecan(CAPIRI) and 5-fluorouracil/leucovorin plus irinotecan(FOLFIRI)[J].Tumour Biol,2014,23(7):1-9.

[13]Shi Y,Han Y,Xie F.ASPP2 enhances Oxaliplatin(L-OHP)-induced colorectal cancer cell apoptosis in a p53-independent manner by inhibiting cell autophagy[J].J Cell Mol Med,2014,19(3):535-543.

[14]Alford SH,Rattan R.Protective effect of bisphosphonates on endometrial cancer incidence in data from the Prostate,Lung,Colorectal and Ovarian(PLCO) Cancer Screening Trial[J].Cancer,2015,121(3):441-447.

[15]Mohr SB.Meta-analysis of vitamin D sufficiency for improving survival of patients with breast cancer[J].Anticancer Res,2014,34(3):1163-1166.

[16]Maus MK,Hanna DL,Stephens CL.Distinct gene expression profiles of proximal and distal colorectal cancer:implications for cytotoxic and targeted therapy[J].Pharmacogenomics J,2014,23(2):48-51.

[17]Castells A,Andreu M,Binefa G.Ostpolypectomy surveillance in patients with adenomas and serrated lesions:a proposal for risk stratification in the context of organized colorectal cancer-screening programs[J].Endoscopy,2015,47(1):86-87.

[18]Ionescu C,Braicu C,Chiorean R.TIMP-1 expression in human colorectal cancer is associated with SMAD3 gene expression levels:a pilot study[J].J Gastrointestin Liver Dis,2014,23(4):413-418.

[19]Resch A,Langner C.Risk assessment in early colorectal cancer:histological and molecular markers[J].Dig Dis,2015,33(1):77-85.

[20]Colangelo T,Fucci A,Votino C,et al.MicroRNA-130b promotes tumor development and is associated with poor prognosis in colorectal cancer[J].Neoplasia,2013,15(9):1086-1099.

Research on influence of early gastric tube extubation on plasma procalcitonin change and gastrointestinal function recovery after colorectal cancer operation

MOUYa-gang1,WANGJian-jun1,ZHANGHong-wei2

(1.DepartmentofGeneralSurgery,XidianGroupHospital,Xi′an,Shaanxi710077,China;2.DepartmentofDigestiveSurgery,AffiliatedXijingHospital,FourthMilitaryMedicalUniversity,Xi′an,Shaanxi710032,China)

Objective To investigate the curative effect of early gastric tube extubation by observing the changes the plasma procalcitonin and gastrointestinal function in the colorectal cancer patients with early postoperative gastric tube extubation.Methods 110 postoperative patients with colorectal cancer admitted in the general department of Xidian Group Hospital from February 2009 to August 2014 were selected and divided into 2 groups according to the random number table.The observation group(55 cases) was performed the early postoperative gastric tube extubation,started to drink water at postoperative 6 h,eat fluid diet at 12 h and transfered to the common diet on 3 d;The control group(55 cases) adopted the conventional gastric tube extubation therapy,pulled out the gastric tube extubation after postoperative exhaustion and defecation and then started to eat food.The plasma procalcitonin levels after operation,before and after intervention were recorded,meanwhile postoperative complications situation,postoperative exhaustion and defecation time,hospital stay and hospital cost were recorded.Results (1)The plasma procalcitonin level after treatment in the two groups were significantly declined,but the plasma procalcitonin level in the observation group was similar to that in the control group,there was no statistically significant difference(P>0.05);(2)After treatment,the exhaust time in the observation group was(50.71±6.25)h,defecation time was(66.43±5.87) h,length of hospital stay was(7.17±2.31)d and hospitalization expenses were(41 562.87±274.36)Yuan,which were significantly lower than(65.24±6.58 )h,(74.56±5.69)h,(10.24±3.15)d and(47 893.57±314.82)Yuan in the control group,the differences were statistically significant(P<0.05);(3)After treatment,the occurrence rate of complications in the observation group was 9.09%,which was near 7.27% in the control group,showing no statistically significant difference(P>0.05).Conclusion Early gastric tube extubation in the postoperative patients with colorectal cancer is conducive to promote the gastrointestinal function recovery and shorten the hospital stay without affecting the procalcitonin level and increasing the risk of complications occurrence,which is worthy of clinical promotion.

colorectal cancer; early gastric tube extubation; procalcitonin; gastrointestinal function

牟亞剛，男，主治醫(yī)師，碩士，主要從事胃腸外科臨床工作。

10.3969/j.issn.1672-9455.2015.15.017

A

1672-9455(2015)15-2182-03

2015-02-16

2015-04-15)