大肠癌术后早期胃管拔出对患者血浆降钙素原变化及对胃肠功能恢复的影响

牟亚刚，王建军，张洪伟

(1.西电集团医院普外科，西安 710077；2.第四军医大学附属西京医院消化外科，西安 710032)



·论 著·

大肠癌术后早期胃管拔出对患者血浆降钙素原变化及对胃肠功能恢复的影响

牟亚刚1，王建军1，张洪伟2

(1.西电集团医院普外科，西安 710077；2.第四军医大学附属西京医院消化外科，西安 710032)

目的 探讨大肠癌术后早期胃管拔出对患者血浆降钙素原变化及对胃肠功能恢复的影响。方法 选取2010年2月至2014年8月西电集团医院普外科肿瘤科收治的大肠癌术后患者110例，采用随机数表法分为2组，其中研究组55例，予术后早期胃管拔出治疗，术后6 h开始饮水，12 h进流食，3 d过渡到普通饮食；对照组55例，采取常规胃管拔出治疗，术后排气排便后拔出胃管，开始进食。比较术后及干预前后治疗前血浆降钙素原水平及术后并发症情况、术后排气排便时间、住院时间、住院费用等观察指标。结果 (1)治疗后2组血浆降钙素原均明显下降，但二者相比差异无统计学意义(P>0.05)；(2)治疗后，研究组排气时间(50.71±6.25)h、排便时间(66.43±5.87)h、住院时间(7.17±2.31)d及住院费用(41 562.87±274.36)元低于对照组(65.24±6.58)h、(74.56±5.69)h、(10.24±3.15)d、(47 893.57±314.82)元，差异有统计学意义(P<0.05)；(3)治疗后，研究组并发症发生率(9.09%)与对照组(7.27%)相近，差异无统计学意义(P>0.05)。结论 大肠癌术后早期胃管拔出有利于患者促进胃肠功能恢复，缩短住院时间，同时不影响降钙素原水平，不增加并发症发生风险，值得临床推广。

大肠癌； 早期胃管拔出； 降钙素原； 胃肠功能

大肠癌(CRC)指内在环境或遗传等多种因素导致大肠黏膜上皮发生癌变的一种疾病。发达国家大肠癌已经成为第三大肿瘤疾病[1]。我国虽然为大肠癌低发地区，但随着生活方式的西化，其发病率明显上升，目前已经位于恶性肿瘤发病率的第五位。据调查统计，大肠癌的发病特点为经济发达地区的发病率较高；年龄越大，发病率越高；男性发病率高于女性[2-4]。手术为治疗大肠癌的首选方式，术后容易发生胃肠功能紊乱，严重降低临床治疗。研究发现，早期胃管拔出能够促进胃肠蠕动，降低胃肠功能紊乱发生率，缓解痛苦，提高疗效[5-7]。现将研究结果报道如下。

1 资料与方法

1.1 一般资料 选取2010年12月至2014年8月西电集团医院诊断为大肠癌而收治入院，拟采取手术治疗的患者110例为研究对象，采用随机对照表法将患者分为研究组与对照组。研究组55例，其中男34例，女21例，平均(61.3±7.4)岁，Ⅰ期42例，Ⅱ期13例；对照组55例，其中男35例，女20例，平均(61.5±7.2)岁，Ⅰ期40例，Ⅱ期15例。2组患者的一般资料以及大肠癌分期差异无统计学意义(P>0.05)，具有可比性。

1.2 方法 纳入标准：(1)经影像学检查及病理检查确诊为大肠癌[8]；(2)术前未采取放疗、化疗术前等辅助治疗；(3)年龄小于80岁；(4)肿瘤无转移；(5)自愿参与本研究，并签署知情同意书；(6)获得本院伦理委员会认可并全程跟踪。排除标准：(1)心脏、肝脏、肾脏患有严重疾病；(2)近期发生胃肠功能器质性病变；(3)3个月内使用过影响胃肠蠕动的药物；(4)合并全身各系统功能障碍者；(5)神志异常患者[9]。研究组：术后不采取胃肠减压治疗，在术后6 h拔出胃管，开始饮水，少量进食藕粉等完全流质食物，依据全流食→半流食→普通饮食的顺序逐步过渡，在术后3 d时采取普通饮食，同时根据患者的进食量，酌情辅以静脉营养治疗。对照组：术后采取胃肠减压治疗，常规留置胃管，待患者排气后开始饮水，在排便后可以拔出胃管，开始逐步进食流质食物，并逐步过渡到普通饮食。在禁止进食的期间采取完全静脉营养治疗保障身体所需，在进食后则根据患者进食量适度采取部分静脉营养进行辅助治疗。2组患者均鼓励在术后12 h开始早期离床活动，并且采取统一出院标准，即经口进食完全恢复正常，无需静脉补液辅助，无发热、感染等并发症，各种引流管成功拔出，能够自行活动。所有患者出院后均采取1个月门诊复查及定期电话跟踪随访。

1.3 观察指标 2组患者均在治疗前24 h及术后1 d时，清晨空腹时抽取外周静脉血2 mL，应用肝素抗凝处理后，马上置于离心机中以3 000 r/min离心15 min，留取上层清液，将其放置在-80 ℃冰箱内进行保存备用。血浆降钙素原定量检测采用酶联免疫荧光分析技术，使用仪器为mini-VIDAS全自动荧光免疫分析仪。术后详细记录患者的排气时间、排便时间、住院时间以及住院费用，同时观察记录并发症情况，本研究中主要并发症为吻合口瘘、切口感染、胃肠功能紊乱以及肠梗阻。

2 结 果

2.1 2组患者血浆降钙素原比较 治疗前2组患者血浆降钙素原比较差异无统计学意义(P>0.05)；手术后，2组患者血浆降钙素原有所下降，研究组血浆降钙素原水平与对照组比较，差异无统计学意义(P>0.05)。见表1。

表1 治疗前后2组患者血浆降钙素原比较

注：与治疗前比较，△P>0.05；与治疗后比较，*P>0.05。

2.2 术后恢复情况比较 与对照组比较，研究组排气时间、排便时间及住院明显缩短，住院费用明显减少，差异有统计学意义(P<0.05)。见表2。

2.3 2组术后并发症情况比较 手术后2组均未见肠梗阻等严重不良反应，2组并发症总发生率相比较，差异无统计学意义(P>0.05)。见表3。

表2 手术后2组患者恢复情况比较

注：与对照组比较，△P<0.05。

表3 治疗前后2组患者临床疗效情况

注：与对照组比较，△P>0.05。

3 讨 论

CRC作为临床常见恶性肿瘤，临床首选方法为手术切除术，但由于手术中牵拉、麻醉影响以及手术创伤等因素，CRC患者术后胃肠功能会出现暂时性麻痹，从而出现腹胀、肛门无法排气排便等情况[10-12]。术后胃肠功能紊乱能够降低患者抵抗力，延迟患者恢复，严重者发生肠梗阻、肠粘连等并发症[13-14]。随着快速康复理论广泛认可，传统治疗中，为了避免肠梗阻等并发症，术后患者需留置胃管至术后排气排便才可拔出，近年来相关研究表明术后早期进食并不增加并发症风险，利于胃肠道功能恢复[15-16]。研究证实发生肠梗阻时,巨噬细胞被激活，引发炎性反应，阻碍肠括约肌收缩导致肠梗阻,同时白细胞表达增加，导致肠壁产生粘连，降钙素原作为降钙素前体，是重要的炎性反应标志物，不仅对于感染性疾病诊疗具有重要意义，而且对CRC术后肠梗阻具有预测作用[17-18]。通过检测血浆降钙素原、观察胃肠功能变化以及并发症情况，来早期胃管拔出对大肠癌术后患者的影响。

本研究中，治疗后2组患者的血浆降钙素原均有所回降，但是无论治疗前后，2组的血浆降钙素原水平比较，差异无统计学意义(P>0.05)，提示早期胃管拔出并不影响患者的血浆降钙素原，不增加术后发生肠梗阻的风险性；治疗后，研究组患者在排气时间、排便时间、住院时间以及住院费用上具有明显优势，与对照组比较，差异有统计学意义(P<0.05)，提示早期胃管拔出能够加快胃肠功能恢复，缩短治疗时间，减少住院费用。且2组患者均未见肠梗阻的发生，研究组总发生率与对照组相近，提示早期胃管拔出不影响术后并发症的发生，具有高安全性。有研究显示CRC术后早期拔出胃管不仅使患者更为舒适，而且促进患者行下床活动，促进胃肠功能恢复[19-20]。

综上所述，早期胃管拔出作为快速康复外科的重要组成部分，逐渐开始受到广泛认可，在CRC术后采取早期胃管拔出不仅促进胃肠功能恢复，而且降低住院费用，对降钙素原无影响，是改善CRC术后患者一种安全有效的干预措施。

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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

牟亚刚，男，主治医师，硕士，主要从事胃肠外科临床工作。

10.3969/j.issn.1672-9455.2015.15.017

A

1672-9455(2015)15-2182-03

2015-02-16

2015-04-15)