NOSESⅣ型改良手术联合加速康复理念在乙状结肠癌治疗中的应用1例

刘帅 江良县 毕铁男

[摘要] 探討通过改良结直肠癌经自然腔道取标本手术（natural orifice specimen extraction surgery，NOSES）无菌无瘤操作的技术要点，使之更能融合加速康复外科（enhanced recovery after surgery，ERAS）其主张术前不进行常规肠道准备等理念。入组2018年7月浙江省台州医院胃肠外科一例乙状结肠癌患者，采取NOSESⅣ型改良手术联合实施加速康复路径。该患者顺利完成手术，手术时间140 min，术中出血量20 mL。术后顺利按快速康复路径恢复饮食，胃肠功能恢复顺利，无相关并发症发生，于6 d内康复出院。从本案例来看，实施NOSES手术联合加速康复理念是可行的，只要在手术操作环节上作出改良，不仅能从根源上最大可能避免腹部切口感染，减小患者手术创伤，减轻患者术后切口疼痛，也让ERAS理念得以实施，并在术后恢复上体现出一定的优势：该患者术后直至出院未应用肠外营养，术后当天即进行全流质饮食，术后当天进行运动，术后出院时间6 d内，术后随访18个月余未见复发，整体上看近期疗效满意，为后续NOSES手术联合加速康复理念研究提供临床资料支持。

[关键词] 结直肠癌;经自然腔道取标本;加速康复;NOSESⅣ型改良手术;无菌无瘤

[中图分类号] R735.34          [文献标识码] C          [文章编号] 1673-9701（2020）15-0174-04

A case report of application of NOSES type Ⅳ modified surgery combined with enhanced recovery in the treatment of sigmoid cancer

LIU Shuai   JIANG Liangxian   BI Tienan   ZHOU Shenkang

Department of Gastrointestinal Surgery，Taizhou Hospital of Zhejiang Province， Taizhou   317000， China

[Abstract] To make natural orifice specimen extraction surgery（NOSES） more integrated with the concept of enhanced recovery after surgery（ERAS） that does not require routine bowel preparation before surgery by modifying the technical points of aseptic and tumor-free operation of NOSES. A patient with sigmoid cancer treated in gastrointestinal surgery of our hospital in July 2018 was treated with NOSES type Ⅳ modified surgery combined with ERAS. The patient completed the operation successfully，the operation duration was 140 minutes，and the intraoperative blood loss was 20 mL. After the operation，the diet was resumed smoothly following ERAS， the gastrointestinal function recovered smoothly， and no related complications occurred. The patient recovered and was discharged from hospital within 6 days. It is proved by this case that it is feasible to implement the concept of NOSES surgery combined with ERAS provided improvements are made in the operation procedure. It can not only ultimately avoid the abdominal incision infection，reduce the surgical trauma of the patient，relieve the pain of the incision，but also realize the ERAS concept. There are certain advantages demonstrated in postoperative recovery：the patient was not required parenteral nutrition after surgery till discharge; the patient was given a full-liquid diet and exercised on the day after operation;the patient was discharged within 6 days after surgery;there was no recurrence during the 18 months follow-up  after operation. Overall，the short-term efficacy was satisfactory. It provided clinical data support for the further study of the concept of NOSES surgery combined with ERAS.

[Key words] Colorectal cancer;Natural orifice specimen extraction surgery;Enhanced recovery; NOSES type Ⅳ modified surgery;Aseptic and tumor-free

结直肠癌NOSES手术与传统腹腔镜手术比较具有创伤更小、恢复快、无痕等优势。加速康复理念（ERAS）以追求患者达到快速康复为目的，通过优化围手术期的系列措施以降低患者心理和生理的创伤应激来降低手术并发症、住院时间及住院费用。理论上两者优势结合使结直肠癌的治疗更上1个台阶。……