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腹腔鏡術(shù)后口服膳食纖維促進(jìn)腸功能恢復(fù)的效果研究

白潤(rùn)芳，楊曉梅，施多芹，張帥，張玉蓮，姚晚俠，何宏靈

[目的]觀察腹腔鏡手術(shù)后口服膳食纖維(DF)對(duì)促進(jìn)術(shù)后排氣排便及防止腹脹發(fā)生等腸功能恢復(fù)方面的效果。[方法]選取2016年9月—12月在陜西省人民醫(yī)院婦科住院行腹腔鏡手術(shù)病人78例,按照手術(shù)名稱分層隨機(jī)抽樣分為兩組各39例,兩組均在術(shù)后6 h開(kāi)始少量飲水,肛門排氣后進(jìn)流食,排便后逐漸進(jìn)普食;DF組術(shù)后次日09:00用200 mL溫水溶解維樂(lè)夫DF 7.5 g(1袋15 g)10 min～20 min內(nèi)逐漸喝完,首次服用后12 h內(nèi)仍未排氣者再同法服用7.5 g;兩組其他醫(yī)療護(hù)理措施均相同,比較兩組術(shù)后首次肛門排氣時(shí)間、排便時(shí)間、術(shù)后住院時(shí)間以及腹脹等的發(fā)生率,觀察口服DF者有無(wú)不良反應(yīng)。[結(jié)果]DF組和對(duì)照組術(shù)后首次肛門排氣時(shí)間在24 h內(nèi)25例(64.1%)、4例(10.3%)；24 h～48 h內(nèi)排氣12例(30.8%)、20例(51.2%)，超過(guò)48 h 2例 (5.1%)、15例(38.5%),兩組比較差異有統(tǒng)計(jì)學(xué)意義(P<0.01);首次排便在48 h內(nèi)20例(51.2%)、7例( 17.9%)、48 h～72 h之內(nèi)13例(33.3%)、17例(43.6%)，超過(guò)72 h 6例(15.4%)、15例(38.5%),兩組比較差異有統(tǒng)計(jì)學(xué)意義(P<0.01);術(shù)后住院時(shí)間DF組為(4.64±1.40)d，對(duì)照組為(4.38±1.07)d,兩組比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05);DF組無(wú)腹脹、惡心、嘔吐等發(fā)生,對(duì)照組有8例(20.5%),兩組比較差異有統(tǒng)計(jì)學(xué)意義(P<0.01)。[結(jié)論]腹腔鏡術(shù)后口服DF可以明顯縮短術(shù)后排氣排便時(shí)間,降低術(shù)后腹脹的發(fā)生率,較快恢復(fù)術(shù)后胃腸功能,無(wú)腹瀉、腹痛、惡心、嘔吐等不良反應(yīng)發(fā)生。

膳食纖維;口服;婦科;腹腔鏡手術(shù);肛門排氣；胃腸功能

AbstractObjective: To observe the effect of orally-administered dietary fiber (DF) on anal aerofluxus,defecation and abdominal distension prevention after laparoscopic surgery,and to collect data on relevant side effects.Methods: A total of 78 patients with laparoscopic surgery from gynecology department of Shaanxi Provincial People’s hospital (2016-09 to 2016-12) were recruited in this study.Patients were evenly divided into two groups by stratified random sampling,39 cases in each.Patients of the two groups started to drink water at 6 h after surgery,liquid diet after anal aerofluxus and common food after defecation.DF group took half package of vilof (7.5 g,dissolved in 200ml warm water,9 o’clock on the next day after surgery) in 10 to 20 minutes,and another half package was given to the patients with no anal aerofluxus more than 12 h;DF group and control group shared the same medical treatment;the first anal aerofluxus time,defecation time,postoperative hospitalization date and incident rate of abdominal distension were compared,meanwhile,close observation was conducted among DF patients to discover side effects.Results:There were 25 cases (64.1%) who took first anal aerofluxus within 24 h after surgery in DF group and 4 cases (10.3%) in control group.12 cases (30.8%) in DF group and 20 cases (51.2%) in control group between 24-48 h.2 cases (5.1%) in DF group and 20 cases (51.2%) in control group over 48 h.The differences were statistically significant (P<0.01).There were 20 cases (51.2%) in DF group and 7 cases (17.9%) in control group took the first defecation within 48 h;13 cases (33.3%) in DF group and 17 cases (43.6%) in control group between 48-72 h;6 cases (15.4%) in DF group and 15 cases (38.5%) in control group over 72 h;the differences were statistically significant(P<0.01).The postoperative hospitalization stay of DF group was (4.64±1.40) days,and (4.38±1.07) days in the control group;there was no significant difference between the two groups (P>0.05).There were no patients with abdominal distension,nausea,and vomiting discovered in DF group,while 8 cases were reported in control group,and the difference was statistically significant (P<0.01).Conclusions: Orally- taken DF after laparoscopic surgery could remarkably shorten the time of anal aerofluxus and defecation,lower the incidence of abdominal distension and recover the postoperative gastrointestinal function.It was safe and no side effects as diarrhea,abdominal pain,nausea or vomiting were observed.

Keywordsdietary fiber;oral;gynecological;laparoscopic surgery;anal exhaust；intestinal function

腹腔鏡手術(shù)是一種微創(chuàng)手術(shù),它具有創(chuàng)傷小、免疫干擾輕、出血少、術(shù)后恢復(fù)快等優(yōu)點(diǎn)[1],在外科和婦科應(yīng)用廣泛。手術(shù)創(chuàng)傷、麻醉、人工氣腹、疼痛等易造成不同程度腸麻痹,嚴(yán)重者可并發(fā)腸梗阻,其發(fā)生率約為1%[2]。 臨床上為了避免或減少術(shù)后腸梗阻等并發(fā)癥的發(fā)生,術(shù)后常規(guī)予病人禁食、流食,視病人胃腸道功能恢復(fù)情況逐步給予半流質(zhì)、軟食等過(guò)渡飲食[3]。除了早下床活動(dòng)、刺激穴位等,研究證明口服清澈液體[4]、喝咖啡[5-6]、口服中藥[7]可促進(jìn)術(shù)后排氣、排便時(shí)間提前,早日恢復(fù)胃腸功能。有研究發(fā)現(xiàn)攝入膳食纖維(dietary fiber，DF)可促進(jìn)腸蠕動(dòng),防治便秘效果良好[8-10]。本研究采用口服維樂(lè)夫DF來(lái)促進(jìn)術(shù)后肛門排氣、排便,防治腹脹,取得良好效果?，F(xiàn)報(bào)告如下。

1 對(duì)象與方法

1.1 對(duì)象 選擇2016年9月—12月在陜西省人民醫(yī)院婦科住院行腹腔鏡手術(shù)病人78例,按照手術(shù)方式分層隨機(jī)抽樣分為兩組,DF組和對(duì)照組各39例。兩組入組標(biāo)準(zhǔn)相同。納入標(biāo)準(zhǔn):全身麻醉,婦科良性疾患,腹腔鏡手術(shù),充分了解研究目的和方法、利弊等。排除標(biāo)準(zhǔn):腹腔鏡術(shù)后次日09:00前已經(jīng)肛門排氣、排便者,孕婦、惡性腫瘤、術(shù)后化療、有腸道手術(shù)史,合并肝、腎、心臟等其他全身重大疾病病人,所有病人均簽知情同意書,研究方案經(jīng)醫(yī)院倫理委員會(huì)批準(zhǔn)。

1.2 飲食方法 兩組常規(guī)飲食指導(dǎo)相同,均在術(shù)后6 h開(kāi)始飲水,少量分次逐漸進(jìn)無(wú)渣流食如清粥、果汁等,肛門排氣后進(jìn)半流食如普通粥類、湯面條等,排便后進(jìn)普通飲食;DF組在此基礎(chǔ)上術(shù)后次日09:00用200 mL溫水溶解維樂(lè)夫DF 7.5 g(1袋15 g)10 min～20 min內(nèi)逐漸喝完,首次服用后12 h內(nèi)仍未排氣者再同法服用7.5 g;對(duì)照組不服用膳食纖維,用無(wú)渣流食替代。維樂(lè)夫DF每100 g含能量831 kJ,蛋白質(zhì)0,脂肪0,糖類5.3 g,DF 91 g,鈉28 mg。兩組的其他護(hù)理與治療均相同,均在術(shù)后12 h指導(dǎo)和鼓勵(lì)病人下床活動(dòng)。

1.3 觀察指標(biāo) 比較兩組病人首次肛門排氣時(shí)間、排便時(shí)間、術(shù)后住院時(shí)間以及腹脹等的發(fā)生率,觀察服用DF的不良反應(yīng)如腹瀉、腹痛等。所有指標(biāo)時(shí)間都從手術(shù)結(jié)束開(kāi)始計(jì)算。

1.4 預(yù)實(shí)驗(yàn)計(jì)算樣本量 本研究中的主要指標(biāo)有2個(gè),術(shù)后首次肛門排氣時(shí)間與排便時(shí)間,見(jiàn)表1。

表1 預(yù)實(shí)驗(yàn)兩組首次肛門排氣時(shí)間與排便時(shí)間 例(%)

β=0.10,k=1,查表得μ為0.05(雙側(cè))=1.96,μ為0.1=1.28,代入公式,根據(jù)術(shù)后24 h內(nèi)首次排氣例數(shù)得出的n為32例;根據(jù)術(shù)后48 h內(nèi)首次排便例數(shù)得出的n為20例,取最大值32例,設(shè)最大丟失率20%,得最終兩組樣本人數(shù)為各39例。

1.5 統(tǒng)計(jì)學(xué)分析 采用SPSS 21.0進(jìn)行統(tǒng)計(jì)分析,計(jì)量資料用t檢驗(yàn),計(jì)數(shù)資料用χ2檢驗(yàn)(含校正檢驗(yàn)),P<0.05 為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 兩組病人一般資料比較(見(jiàn)表2)

表2 兩組病人一般資料比較

2.2 兩組病人術(shù)后首次排氣、排便情況比較 DF組首次排氣、排便時(shí)間均早于對(duì)照組,兩組比較差異有統(tǒng)計(jì)學(xué)意義(P<0.01)。見(jiàn)表3。

表3 兩組病人術(shù)后首次排氣、排便情況比較 例(%)

2.3 兩組病人術(shù)后住院時(shí)間比較(見(jiàn)表4)

表4 兩組病人術(shù)后住院時(shí)間比較d

2.4 DF服用與首次排氣、排便的關(guān)系 DF組最早肛門排氣時(shí)間為首次服用后0.5 h,最晚39.3 h;排便最早為首次服用后1.3 h,最晚93 h;31例(79.5%)病人只服用1次,8例(20.5%)服用2次。首次排氣、排便距離服用時(shí)間:12小時(shí)內(nèi)排氣31例(79.5%),24 h內(nèi)排便23例(60.0%)。

2.5 兩組不良反應(yīng)發(fā)生情況 DF組術(shù)后無(wú)腹脹及惡心、嘔吐癥狀發(fā)生,對(duì)照組有8例(20.5%),兩組比較差異有統(tǒng)計(jì)學(xué)意義(P<0.01)。DF組在使用DF過(guò)程中無(wú)腹瀉、腹痛等不良反應(yīng)發(fā)生。

3 討論

腹部手術(shù)病人由于手術(shù)的創(chuàng)傷及麻醉對(duì)神經(jīng)的阻滯,胃、小腸、結(jié)腸正?；倦娀顒?dòng)受到干擾而被減弱[1],術(shù)后胃、腸蠕動(dòng)受到一定的抑制,易致腹脹發(fā)生。腹脹可導(dǎo)致膈肌抬高,會(huì)影響肺臟呼吸過(guò)程中的活動(dòng)空間,容易引起肺不張、肺部感染[11]。 胃腸道功能的延遲恢復(fù)會(huì)影響整個(gè)機(jī)體功能,延長(zhǎng)住院時(shí)間,增加病人治療的總費(fèi)用[6]。

Bonventre等[4]報(bào)道,術(shù)后飲用清澈可溶性液體,可促進(jìn)排氣排便；Piric等[6,12]報(bào)道,術(shù)后飲用咖啡可促使病人腸蠕動(dòng)加強(qiáng),早排氣,減少術(shù)后并發(fā)癥。維樂(lè)夫DF為食品級(jí),提取自菊苣,屬于可溶性DF,能完全溶解于水中[8-9],其成分為低聚果糖+多聚果糖,在口、胃、小腸不被水解消化,在結(jié)腸發(fā)酵后增殖有益菌,如益生元[8-10],能刺激腸道有益菌群生長(zhǎng),如雙歧桿菌、乳酸菌等,抑制了有害菌群的活性及生長(zhǎng);其發(fā)酵產(chǎn)生的短鏈脂肪酸如乙酸、乳酸等,降低了腸道pH值,具有抑制促炎性細(xì)胞因子活性,激活淋巴細(xì)胞和抑制細(xì)胞增殖作用等[10];隨著產(chǎn)生的二氧化碳?xì)怏w(CO2)和氫氣(H2)作用,進(jìn)一步又促進(jìn)了腸道蠕動(dòng);多聚果糖的吸水性促進(jìn)糞便膨脹,增加了糞便重量。雙通道的作用既保護(hù)了腸道黏膜,又促進(jìn)糞便順利排出[13]。DF本身不被身體所吸收,也不增加肝臟以及腎臟等代謝負(fù)擔(dān),被稱為人體“第七大營(yíng)養(yǎng)素”[14],除了促進(jìn)排便,還在肥胖、結(jié)腸癌、心血管疾病、糖尿病等方面有很好的作用[14-16]。表3表明DF組術(shù)后首次排氣時(shí)間在術(shù)后24 h之內(nèi)占64.1%,首次排便時(shí)間在術(shù)后48 h之內(nèi)占51.2%,遠(yuǎn)高于對(duì)照組,說(shuō)明口服維樂(lè)夫DF的確可促進(jìn)術(shù)后病人排氣、排便提前,早日恢復(fù)胃腸道功能，與以往研究結(jié)論相同[14-16]。表4說(shuō)明兩組術(shù)后住院時(shí)間無(wú)差別,與Bonventre等[5-6]研究認(rèn)為住院時(shí)間縮短不同,與Dulskas等[12]研究結(jié)果一致,可能與本研究選樣排除惡性腫瘤及術(shù)后化療有關(guān),其他婦科良性腫瘤病人住院時(shí)間均較為短暫,本研究中兩組病人最短術(shù)后住院時(shí)間為2 d,最長(zhǎng)為8 d,平均3 d ～5 d;另外,術(shù)后胃腸功能恢復(fù)并不是出院的唯一指標(biāo),還有傷口愈合等身體其他指標(biāo)。正常人攝入的DF的指導(dǎo)值是每天至少30 g[10]，本研究79.5%的人僅服用維樂(lè)夫DF 7.5 kg即見(jiàn)效,術(shù)后最大總量為15 g,每次7.5 g,服用者無(wú)腹脹、惡心、嘔吐發(fā)生,并且無(wú)腹瀉、腹痛等不良反應(yīng),又不增加肝腎代謝風(fēng)險(xiǎn),應(yīng)用安全,效果可靠。

4 小結(jié)

本研究結(jié)果顯示,應(yīng)用維樂(lè)夫DF可以有效縮短術(shù)后首次排氣、排便時(shí)間,減少腹脹發(fā)生,效果安全、可靠,目前未見(jiàn)不良反應(yīng)。不足之處是有些病人未能在術(shù)后及時(shí)服用。

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Effectoforally-administereddietaryfiberonrecoveryofintestinalfunctionafterlaparoscopicsurgery

BaiRunfang,YangXiaomei,ShiDuoqin,etal

(Shaanxi Provincial People’s Hospital,Shaanxi 710068 China)

R473.6

A

10.3969/j.issn.1009-6493.2017.28.013

1009-6493(2017)28-3531-04

2017-04-08;

2017-07-25)

(本文編輯 孫玉梅)

陜西省自然科學(xué)基礎(chǔ)研究計(jì)劃資助項(xiàng)目,編號(hào):2015JM8485。

白潤(rùn)芳,主管護(hù)師,本科,單位:710068,陜西省人民醫(yī)院;楊曉梅、施多芹、張帥、張玉蓮單位:710068,陜西省人民醫(yī)院;姚晚俠(通訊作者)單位:710125,西安培華學(xué)院;何宏靈(通訊作者)單位：710061,西安交通大學(xué)第一附屬醫(yī)院。

信息白潤(rùn)芳，楊曉梅，施多芹，等.腹腔鏡術(shù)后口服膳食纖維促進(jìn)腸功能恢復(fù)的效果研究[J].護(hù)理研究，2017，31(28)：3531-3534.