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Feasibility of Non-conventional Indwelling Catheter in Enhanced Recovery after Surgery of Gastric Cancer
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摘要:
目的 探讨加速康复外科胃癌患者术后不常规留置导尿管的可行性。 方法 回顾性分析2016年6月至2017年3月, 南京总医院普通外科采用加速康复外科理念择期行胃癌根治术患者的临床资料。入选患者麻醉诱导期插入导尿管, 手术结束时即刻拔除导尿管并以此时间为观察起始点, 记录患者术后首次排尿时间、首次排尿量、重插尿管的比例, 分析首次排尿延迟及重插尿管的危险因素。 结果 137例患者纳入本研究, 其中男性90例(65.7%), 女性47例(34.3%), 平均年龄(58.9±10.1)岁, 术后首次排尿时间为(5.3±2.1)h, 首次自解尿量(298.9±101.3)ml, 重置尿管比例为11.7%(16/137);相比开腹组, 机器人组自主排尿率高, 诱导排尿率、重置导尿管及尿路刺激征发生率均较低(P均 < 0.05);以术后6 h首次排尿时间作为分界, 与≤ 6 h组相比, >6 h组术中输液量、尿量及术后首次自解尿量均较多, 首次下床活动时间延迟(P均 < 0.01)。 结论 加速康复外科胃癌患者术后即刻拔除尿管是可行的, 术中控制性输液、多模式镇痛是不常规留置导尿管的基础条件, 机器人手术有利于患者术后早期恢复自主排尿。 Abstract:Objective This study aimed to explore the feasibility of non-conventional indwelling catheter in enhanced recovery after surgery(ERAS) for postoperative patients with gastric cancer. Methods The clinical data of patients undergoing gastric cancer radical surgery with ERAS were analyzed retrospectively in the Department of General Surgery, Nanjing General Hospital of Nanjing Military Region from June 2016 to March 2017. All catheters were inserted in the patients during the anesthesia induction period and removed immediately after surgery. The first time of urination after surgery, the volume, and the proportion of re-catheterization were recordedat the observing start point. The risk factors of the delay of the first urination and the reset of catheters were analy-zed. Results In all 137 patients, there were 90 male (65.7%) and 47 female cases (34.3%) with an average age of (58.9±10.1)years. The first time of urination was (5.3±2.1) hours; the volume of the first urination was (298.9±101.3)ml; the incidence of resetting catheters was 11.7%(16/137). Subgroup analysis showed that the automatic urination rate was higher in the robotic surgery group. The induced urination rate, the incidence of resetting the urinary catheter, and the urinary tract irritation of the robotic surgery group were all lower compared with the open surgery group(all P < 0.05). 6-hour was used as the cutting line of the first postoperative urination time. Compared with the ≤ 6 h group, the >6 h group had more intraoperative infusion, urinary volume, and the first time of postoperative urine volume that delayed the first time of mobilization(all P < 0.01). Conclusion sIt is feasible for patients with gastric cancer in ERAS to remove the urinary catheter immediately after surgery. Intraoperative control of infusion and multimodal analgesia are the basic conditions for non-conventional indwelling catheters. Robotic surgery is favorable for early postoperative recovery of automatic urination. 利益冲突 无 -
表 1 加速康复外科胃癌患者围手术期处理
项目 具体措施 术前 健康教育 多模式健康教育：口头、视频、彩色宣教手册、加速康复外科APP 禁食 术前1 d 8:00 p.m.口服麦芽糊精果糖饮品(素乾)800 ml, 术前2 h(6:00 a.m.)口服400 ml 肠道准备 不常规进行 鼻胃管 不放置 术中 用药 麻醉诱导：咪唑安定0.03 mg/kg，舒芬太尼0.03 μg/kg，丙泊酚2 mg/kg，罗库溴胺0.6 mg/kg，同时开始泵注右美托咪定0.6 μg/kg 麻醉维持：丙泊酚4~6 mg/(kg·h)，右美托咪定0.2~0.4 μg/(kg·h)，顺式阿曲库胺0.05~0.1 mg/(kg·h)，间歇给予舒芬太尼10 μg 止痛 麻醉诱导后，手术开始前给予帕瑞昔布40 mg；术前30 min静脉滴注生理盐水100 ml +氟比洛芬100 mg；切口罗哌卡因浸润止痛 腹腔引流 不常规放置 保温 术中进行 限制性补液 有 麻醉方式 全麻 术后 抗生素使用 术后1~2 d 镇痛 多模式镇痛技术：静脉(生理盐水100 ml+氟比洛芬50 mg静脉滴注×2次/d；每8小时静脉推注派瑞昔布钠40 mg)+口服非甾体类抗炎药(氨酚羟考酮200 mg/次×2次/d) 早期进水、进食 24 h内开始咀嚼口香糖×2次/d，每次2粒 早期下床活动 术后24 h内下床活动；机体条件较好者，手术当天即下床活动 出院标准 能自由行走，能经口进食、通气，停止静脉输液 
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表 2 机器人组与开腹组患者术后排尿情况比较[n(%)]
项目 自主排尿 诱导排尿 排尿失败重置导尿管 尿路刺激征 机器人组(n=101) 83(82.2) 9(8.9) 6(5.6) 3(3.0) 开腹组(n=36) 10(27.8) 11(30.6) 10(27.8) 5(13.9) P值 0.000 0.002 0.001 0.029
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表 3 不同首次排尿时间组术中及术后情况比较(x±s)
项目 术中输液量(ml) 术中尿量(ml) 首次自解尿量(ml) 首次下床活动时间(h) 首次排尿时疼痛VAS评分(分) 首次排尿≤6 h组(n=85) 1268.3±183.2 442.3±61.2 223.3±43.6 3.2±1.1 2.5±0.7 首次排尿＞6 h组(n=52) 1787.6±154.5 614.2±101.6 322.6±63.2 7.0±1.6 2.9±0.9 P值 0.000 0.000 0.001 0.000 0.056 VAS:视觉模拟评分
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