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摘要:
目的 探讨快速康复外科(FTS)治疗对肝移植患者预后的影响。 方法 病例纳入标准:(1)病因为肝硬化或符合米兰标准的原发性肝癌;(2)手术方式为改良背驮式肝移植;(3)首次接受肝移植。排除标准:(1)年龄≤16岁;(2)多次肝移植手术;(3)术前或术中行肝动脉插管化疗栓塞或射频消融等治疗手段。本前瞻性随机单盲研究选取2011年1月至2013年12月在南京医科大学第一附属医院由同一医疗小组行肝移植手术且符合上述标准的52例患者。根据围手术期处理的不同分为FTS组(21例)和传统治疗(NFTS)组(31例)。FTS治疗包括完善的术前教育、术前不行肠道准备、术前不放置鼻胃管、术后不放置引流管、术中预防低体温、微创切口、早期运动并加强营养等。比较两组患者术中和术后情况。采用逐步Logistic回归模型评估FTS治疗和临床观察指标之间的关系, 以分析FTS治疗对肝移植预后的影响。 结果 与NFTS组比较, FTS组手术时间和无肝期时间均明显缩短, 同时FTS组术中出血量和输血率亦明显减少(均为P<0.05)。此外, FTS组患者恢复较好, 术后重症监护室(ICU)住院时间和总住院时间均较NFTS组明显缩短(均为P<0.05)。Logistic回归分析结果显示, FTS治疗是缩短术后ICU住院时间(比值比为0.301, 95%可信区间为0.184~0.494, P=0.000)和总住院时间(比值比为0.148, 95%可信区间为0.085~0.257, P=0.000)的有利因素。 结论 FTS治疗应用于肝移植围手术期患者, 可以有效改善其预后。 Abstract:Objective To explore the impact of fast-track surgery (FTS) on prognosis of liver transplant patients. Methods Inclusion criterias: (1) primary disease was cirrhosis or primary liver cancer meeting Milan criteria; (2) surgical method was modified piggyback orthotopic liver transplantation (OLT); (3) no liver transplantation operation was performed before. Exclusion criterias: (1) age≤16 years old; (2) receiving OLT more than 1 time; (3) transcatheter hepatic arterial chemoembolization or radiofrequency ablation was performed before or during operation. From January 2011 to December 2013 in First Affiliated Hospital of Nanjing Medical University, 52 patients meeting the criteria above were enrolled into this prospective random single-blinded study(all operations were performed by same team). According to different peri-operative managements, they were divided into FTS group (n=21) and non-FTS (NFTS) group (n=31). Protocol of FTS included comprehensive pre-operative education, no bowel preparation, no usage of nasogastric tube pre-operation and surgical drainage post-operation, prevention of hypothermic during operation, smaller incision, early exercise and enhanced oral nutrition. Intra-and post-operative parameters were compared between 2 groups. Step-by-step Logistic regression was used to evaluate relationship between FTS and clinical parameters, in order to analyze the impact of FTS on the prognosis of liver transplantation. Results Compared with NFTS group, operation time and anhepatic phase time decreased significantly in FTS group, as well as intra-operative bleeding and transfusion (all in P<0.05). Besides, intensive care unit(ICU) days and total length of stay in FTS group were shorter than those in NFTS group, which indicated a better prognosis of patients in FTS group(both in P<0.05). Logistic regression suggested that FTS management was a favorable factor of shortening ICU days (odds ratio: 0.301, 95% confidence interval: 0.184-0.494, P=0.000) and total length of stay (odds ratio: 0.148, 95% confidence interval: 0.085-0.257, P=0.000). Conclusions Application of FTS in perioperative period can improve the prognosis of liver transplant patients. -
Key words:
- Fast-track surgery /
- Liver transplantation /
- Surgical drainage /
- Length of stay
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表 1 两组肝移植患者的围手术期处理措施
Table 1. Peri-operative management of liver transplant patients in 2 groups
时间 FTS组(n=21) NFTS组(n=31) 术前 (1) 详细全面的术前咨询教育(2) 不进行肠道准备和预防性应用抗生素(3) 术前6 h禁食,术前2 h禁水(4) 术前2 h静脉输注葡萄糖溶液补充能量(5) 不放置鼻胃管 术中 (1) 麻醉:缩短麻醉时间,控制性降压(中心静脉压 < 5 cm H2O,1 cm H2O =0.098 kPa);加强保暖;限制输液量;合理镇痛(2) 手术方法:控制手术时间;必要时以牺牲肝功能为代价来减少出血(3) 不放置引流管 (1) 麻醉:无特殊要求(2) 手术方法:常规手术方法(3) 常规放置引流管 术后 (1) ICU治疗:患者完全苏醒后早期拔除气管插管;早期回普通病房继续治疗(2) 心电监护:返回普通病房后第1日早上取消(3) 早期运动:术后第1日不多于2 h的床旁运动;之后逐渐增加,直至第5日恢复正常运动(4) 肠内营养:回普通病房后6 h内口服肠内营养剂;第5日为流质无渣饮食;减少静脉输液量(5) 尿管拔除:返回普通病房后第1日早上拔除 (1) ICU治疗:麻醉完全苏醒后常规观察3~5 d才拔除气管插管;之后回普通病房继续治疗(2) 心电监护:回普通病房后常规放置2~3 d(3) 早期运动:无(4) 肠内营养:无(5) 尿管拔除:回普通病房后常规放置2~3 d 表 2 两组肝移植患者术中和术后情况的比较
Table 2. Comparison of operative and post-operative parameters of liver transplant patients between 2 groups
时间 观察指标 FTS组(n=21) NFTS组(n=31) P值 术中 手术时间[min,M(Q1~Q3)] 260(220~370) 340(280~460) 0.012 无肝期时间[min,M(Q1~Q3)] 50(45~68) 60(55~73) 0.006 术中出血量[ml,M(Q1~Q3)] 1 200(1 000~4 000) 2 800(1 600~7 000) 0.023 输血≥1 000 ml[n(%)] 12(57) 28(90) 0.035 术后 ICU住院时间[d,M(Q1~Q3)] 2(1~7) 6(4~12) 0.000 总住院时间[d,M(Q1~Q3)] 20(16~32) 26(21~35) 0.000 术后并发症发生率[n(%)] 4(19) 7(23) 0.626 腹腔积液 3 6 胸腔积液 0 2 肝肾功能不良 1 0 切口愈合延迟 0 1 出血 1 1 再次入院(n) 0 0 — 死亡(n) 0 0 — 注:M(Q1~Q3)为中位数(四分位间距) -
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