加速康复外科理念下胸段硬膜外镇痛与腹横筋膜阻滞对腹腔镜肝癌根治术患者术后综合效果的影响

Study on the comprehensive effects of thoracic epidural analgesia and transversus abdominis plane block after laparoscopic radical surgery of liver cancer with enhanced recovery after surgery

目的探讨加速康复外科理念下胸段硬膜外镇痛与腹横筋膜阻滞在腹腔镜肝癌根治术患者术后综合效果.方法选择采用腹腔镜肝癌根治术治疗的74例患者,其中男41例,女33例,年龄(58.4±9.8)岁,肝功能分级Child A级58例,B级16例;随机分为TEA组(n=38)和TAP组(n=36).TEA组患者在T8-9间隙行硬膜外穿刺置管.TAP组手术结束后,在超声引导下,胸腰筋膜处注射0.37%罗哌卡因;所有患者术毕均给予舒芬太尼150μg+氟比洛芬酯400 mg+托烷司琼40 mg静脉智能化自控镇痛(Ai-PCA,人先云平台),持续输注剂量为2 mL/h、锁定时间15 min、追加1.5 mL/次、极量8 mL/h.观察两组患者血流动力学指标、静息和运动状态下VAS评分,记录患者首次排气时间、拔尿管时间、首次下床活动时间和住院时间、90 d死亡时间、30 d再入院次数;检测两组患者手术当天和术后1、3、7 d,外周血白蛋白(Alb)、血红蛋白(Hb)、总蛋白(TP)含量和不良反应事件(恶心呕吐、低血压、感觉异常和少尿),手术并发症(肠梗阻、吻合口漏、伤口感染、肺炎).结果两组患者各个时间点的SBP、DBP和HR波动差异无统计学意义(P>0.05);两组静息和运动状态下TEA组各个时间点的VAS评分均较TAP组低(P<0.05),TEA组的首次按压时间明显晚于TAP组,同时按压次数、追加非甾体类药物例数和剂量也明显少于TAP组(P<0.05);TEA组首次下床时间和住院时间明显短于TAP组(P<0.05),首次排气时间和拔尿管时间、90 d死亡时间和30 d再入院次数差异无统计学意义(P>0.05);术后3 d和7 d,TEA组的Alb、Hb和TP明显高于TAP组(P<0.05),TEA组术后出现并发症14例(36.8%),TAP组13例(35.1%),两组差异无统计学意义(P>0.05).结论胸段硬膜外镇痛+Ai-PCA管理在促进腹腔镜肝癌根治患者术后快速康复优势明显,提升镇痛效果,能促进患者早期下床等,有利于患者胃肠道功能恢复,减少呼吸道并发症和手术切口感染等相关术后并发症,并显著提升患者的满意程度,可在临床选用.

Objective To investigate the comprehensive effects of thoracic epidural analgesia and transversus abdominis plane block after laparoscopic radical surgery of liver cancer with enhanced recovery alter surgery.Methods There were 41 males and 33 females,with an average age of(58.4±9.8)years,included into the study.According to hepatic function,there were 58 cases of Child Grade A and 16 cases of Grade B.They were randomly divided into TEA group(n=38)and TAP group(n=36).Patients in TEA group received epidural anesthesia at T8-9 level.After the operation,the patients in the TAP group received injection of 0.37%ropivacaine at the thoracolumbar fascia under the guidance of ultrasound.All patients were given with sufentanil 150μg,flurbiprofen axetil 400 mg and tropisetron 40 mg via intravenous analgesia pump,with a speed of 2 m L/h,the locking time of 15 min,an additional 1.5 m L/tim e,and an extreme volume of 8 mL/h.The hemodynamic parameters,VAS scores at rest and exercise status,first exhaust time,urine extubation time,first ambulatory time,hospital stay,90-day death time,and 30-day readmission count were recorded and compared.Peripheral albumin(Alb),hemoglobin(H b),total protein(T P),adverse events(nau sea,vomiting,hypotension,paresthesia,and oliguria),and surgical complications(intestinal obstruction,anastomotic leak,wound in-fection,pneumonia)were also comapred.Results There were no significant differences in SBP,DBP,and HR fluctuations at each time point of the two groups(P>0.05).The VAS scores of the TEA group at each time point were significantly lower than those of the TAP group at both resting and exercise states(P<0.05).The first anesthesia pump compression time of the TEA group was significantly later than that of the TAP group.The simultaneous compressions,and the additional nonsteroidal drug requirement and the dose,were also significantly less in the TEA group than those in the TAP group(P<0.05).The first ambulatory time and hospital stay of the TEA group were significantly shorter(P<0.05).There was no significant difference in the time of first exhaust,the time of urinary extubation,the 90—day death time or the number of 30-day readm ission,between the two groups(P>0.05).The levels of A lb,Hb,and TF of TEA group 3 and 7 days after surgery were significantly higher than the TAP group(P<0.05).The num ber of postoperative complications in the TEA group was 14(36.8%)and 13 in the TAP group(35.1%).There was no significant difference between the two groups(P>0.05).Conclusion The thoracic epidural analgesia has obvious advantages in promoting rapid recovery after laparoscopic liver cancer radical surgery.It can improve the analgesic effects and promote early ambulation;also reduce incisional infections and other related postoperative complications,and improve patients,satisfaction.