Application effect of different incision surgeries combined with respiratory function exercise under the guidance of enhanced recovery after surgery concept in patients with lung cancer
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摘要:目的
探讨不同切口手术联合加速康复外科（enhanced recovery after surgery，ERAS）理念指导下的呼吸功能训练在肺癌患者中的应用效果。
方法选择2020年1月至2022年12月在苏州大学附属太仓医院择期行肺癌根治术的患者200例，随机分为4组，每组50例。A组接受单孔胸腔镜手术，术前ERAS宣教，呼吸训练器和常规呼吸功能训练；B组接受腋下肌肉非损伤性小切口手术，术前ERAS宣教，呼吸训练器和常规呼吸功能训练；C组接受腋下肌肉非损伤性小切口手术，术前常规宣教和常规呼吸功能训练；D组接受单孔胸腔镜手术，术前常规宣教和常规呼吸功能训练。比较4组患者术后恢复情况及术后疼痛评分。
结果与其他3组相比，A组患者肺部并发症发生率降低，下床时间更早，置管时间、住院时间均缩短（P＜0.05）；与B组、C组相比，A组患者术后疼痛显著减轻（P＜0.05）。与C组相比，B组患者肺部并发症发生率降低，下床时间、置管时间、住院时间缩短（P＜0.05）。手术切口相同组间的术后疼痛差异无统计学意义。
结论单孔胸腔镜肺癌手术联合ERAS理念指导下的呼吸功能训练可明显降低患者术后肺部并发症发生率，减轻术后疼痛，加速康复。
Abstract:ObjectiveTo explore the efficacy of different incision surgeries combined with respiratory function exercise under the guidance of enhanced recovery after surgery (ERAS) in lung cancer patients.
MethodsFrom January 2020 to December 2022, a total of 200 patients in Taicang Affiliated Hospital of Soochow University were collected and randomly divided into 4 groups, with 50 patients in each group. Patients in group A received single-hole thoracoscopic surgery, preoperative ERAS concept education and respiratory trainer combined with routine respiratory function exercise; patients in group B received subaxillary non-invasive small incision surgery, preoperative ERAS concept education and respiratory trainer combined with routine respiratory function exercise; patients in group C received subaxillary non-invasive small incision surgery, preoperative routine hospitalization education and respiratory function exercise; patients in group D received single-hole thoracoscopic surgery, preoperative routine hospitalization education and respiratory function exercise. The postoperative recovery indicators and postoperative pain score were compared among the four groups.
ResultsCompared with the other three groups, patients in group A had reduced incidence of pulmonary complications, earlier mobilization, earlier removal of the chest tube and shorter length of hospital stay (P＜0.05); compared with group B and group C, patients in group A had reduced postoperative pain score (P＜0.05). Compared with group C, patients in group B had reduced incidence of pulmonary complications, earlier mobilization, earlier removal of the chest tube and shorter length of hospital stay (P＜0.05). There was no significant difference in postoperative pain score between patients in group A and group D, and patients in group B and group C.
ConclusionsFor lung cancer patients, single-hole thoracoscopic surgery combined with respiratory function exercise under the guidance of ERAS concept can effectively reduce the incidence of pulmonary complications and postoperative pain, and promote postoperative recovery.
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肺癌是发病率和致死率最高的恶性肿瘤之一，治疗手段多样，包括手术、化疗、免疫治疗、靶向治疗、中药治疗等[1]。手术是肺癌最重要的治疗方式，其中胸腔镜手术是主要手术方式，以单孔胸腔镜手术为主。对于部分病情复杂或术中出现突发情况的患者，开放手术或胸腔镜手术转为开放手术的情况仍然常见。腋下肌肉非损伤性小切口手术是开放手术中创伤最小的手术方式。加速康复外科（enhanced recovery after surgery, ERAS）通过改善围手术期干预措施来降低患者的应激反应和创伤反应，从而加速患者机体恢复，实现快速康复的目的[2]。本研究对肺癌患者分别采用单孔胸腔镜手术和腋下肌肉非损伤性小切口手术，并应用ERAS理念指导患者进行呼吸功能训练，比较两种不同切口手术联合呼吸功能训练的应用效果。
1. 资料与方法
1.1 一般资料
选取2020年1月至2022年12月在苏州大学附属太仓医院择期行肺癌根治术的患者200例。纳入标准：（1）术前影像检查和术后病理诊断为肺癌；（2）心、肺、肝、肾等脏器功能及凝血功能可耐受手术；（3）术前检查未发现远处转移；（4）手术方式为肺叶切除术及淋巴结清扫术。排除标准：（1）肿瘤侵犯重要脏器或远处转移，不能行根治术；（2）术后出现严重并发症；（3）术后病理诊断为良性肿瘤；（4）有其他严重呼吸系统疾病史；（5）依从性差。
1.2 患者分组
根据区组随机化设计，将患者分配至A组、B组、C组和D组，每组各50例。研究人员及负责医师对分组情况不知晓。A组接受单孔胸腔镜手术，术前ERAS宣教，呼吸训练器和常规呼吸功能训练；B组接受腋下肌肉非损伤性小切口手术，术前ERAS宣教，呼吸训练器和常规呼吸功能训练；C组接受腋下肌肉非损伤性小切口手术，常规入院宣教和常规呼吸功能训练；D组接受单孔胸腔镜手术，常规入院宣教和常规呼吸功能训练。
1.3 ERAS宣教
A组和B组患者接受ERAS宣教，包括术前咨询和ERAS计划教育，嘱咐患者不吸烟、不饮酒，不做肠道准备，术前禁食6 h、禁水2 h，术后6 h恢复正常饮食。手术前1天晚上22：00口服100 g葡萄糖/1 000 mL水，术前2～3 h口服50 g葡萄糖/500 mL水。术中采用全身麻醉复合肋间神经阻滞，使用毛毯加热系统和静脉输液加热装置以防止术中低体温。术后2 d给予持续静脉镇痛。患者术后1～4 d开始进食和目标定向行走，并向研究护士报告行走距离（病房内有标记器）。完成膀胱训练后取出导尿管。鼓励患者继续行走并延长下床活动时间。
1.4 呼吸功能训练及手术方法
A组和B组进行呼吸训练器及爬楼梯呼吸训练；C组和D组进行爬楼梯呼吸训练。（1）呼吸训练器：患者处于站位或半卧位，闭口用鼻子尽力吸气，根据具体情况憋气30～60 s，而后缩唇轻闭慢慢呼气，吸气和呼气的时间比为1∶2或1∶3，缩唇程度以不感觉费力为适度。呼吸功能训练需达到设定目标，如不能达到目标则以吹不动或吸不动为止。每日训练3次，共训练1周。（2）爬楼梯训练：患者爬楼时采用缩唇呼吸，至轻度气喘时停止，每日2次，每次15～30 min。非损伤性小切口位于腋下第4肋间，长约12 cm；该切口不损伤胸大肌、背阔肌及胸背神经。单孔胸腔镜手术切口位于腋前线第4～5肋间，长约3 cm。
1.5 观察指标
收集患者的年龄、性别、手术部位、病理类型、病理分期。观察患者术后肺部并发症（包括肺部感染、肺不张、呼吸衰竭），术后下床时间、置管时间、住院时间、疼痛评分。拔管指征为胸管引流量少于150 mL，无气泡引出，影像检查见两肺复张，无液气胸。术后1、2、3 d采用数字评定量表（numeric rating scale, NRS）进行疼痛情况评估：0分为无痛，＜3分为镇痛效果良好，3～6分为基本满意，≥7分镇痛效果差，10分为无法忍受的疼痛。
1.6 统计学处理
采用SPSS 25.0软件进行统计分析，计量资料以$ \bar{x}\pm s $表示，4组比较采用单因素方差分析，两两比较采用t检验；计数资料以n（%）表示，采用χ2检验。检验水准（α）为0.05。
2. 结 果
2.1 4组患者临床资料比较
结果（表1）显示：4组患者的年龄、性别、手术部位、病理类型、病理分期差异均无统计学意义。
表 1 4组患者临床资料比较Table 1. Comparison of clinical data of patients among four groupsIndex Group A
(n＝50)Group B
(n＝50)Group C
(n＝50)Group D
(n＝50)F/χ2 P Age/year 59.81±10.43 60.59±10.54 61.57±10.61 60.49±10.45 0.340 0.525 Male n(%) 27(54) 29(58) 31(62) 30(60) 3.030 0.078 Left lesion n(%) 22(44) 20(40) 24(48) 18(36) 3.430 0.487 Pathological stage n(%) 0.380 0.773 Ⅰ 29(58) 31(62) 32(64) 33(66) Ⅱ 17(34) 15(30) 13(26) 15(30) Ⅲa 4(8) 4(8) 5(10) 2(4) Pathological type n(%) 1.058 0.245 Adenocarcinoma 24(48) 25(50) 25(50) 26(52) Squamous carcinoma 21(42) 21(42) 18(36) 18(36) Other 5(10) 4(8) 7(14) 6(12) Group A: patients received single-hole thoracoscopic surgery, ERAS education, respiratory trainer and routine respiratory function exercise; group B: patients received subaxillary non-invasive small incision surgery, ERAS education, respiratory trainer and routine respiratory function exercise; group C: patients received subaxillary non-invasive small incision surgery, routine education and routine respiratory function exercise; group D: patients received single-hole thoracoscopic surgery, routine education and routine respiratory function exercise. 2.2 4组患者术后肺部并发症和疼痛比较
结果（表2）显示：A组患者肺部并发症（肺部感染、肺不张、呼吸衰竭）发生率明显低于其他3组（P＜0.05）；B组患者肺部并发症发生率低于C组（P＜0.05）。术后1、2、3 d，A组患者NRS评分低于B组、C组（P＜0.05）。
表 2 4组患者的术后指标比较Table 2. Comparison of postoperative indicators in patients among four groupsIndex Group A
(n＝50)Group B
(n＝50)Group C
(n＝50)Group D
(n＝50)F/χ2 P Pulmonary complications n(%) Lung infections 3(6) 8(16)* 15(30)*△ 13(26)* 9.506 0.024 Atelectasis 3(6) 6(12)* 12(24)*△ 13(26)* 10.128 0.016 Respiratory failure 1(2) 3(6)* 6(12)*△ 8(16)* 11.754 0.027 Postoperative pain/score 1 d 6.31±1.38 7.35±1.41* 7.43±1.35* 6.38±1.44 0.824 0.537 2 d 5.95±1.51 6.73±1.60* 6.68±1.59* 5.85±1.45 0.385 0.107 3 d 3.32±1.58 4.99±1.72* 4.76±1.76* 4.02±1.59 0.228 0.072 Time to get out of bed/h 20.73±7.58 28.67±7.98* 34.32±8.61*△ 21.06±7.67* 10.851 0.034 Time to remove chest tube/h 86.85±13.02 123.83±12.39* 153.34±12.79*△ 88.59±10.18* 7.319 0.019 Length of hospital stay/h 118.93±12.61 164.65±13.75* 178.51±13.02*△ 132.44±13.20* 17.847 0.041 Group A: patients received single-hole thoracoscopic surgery, ERAS education, respiratory trainer and routine respiratory function exercise; group B: patients received subaxillary non-invasive small incision surgery, ERAS education, respiratory trainer and routine respiratory function exercise; group C: patients received subaxillary non-invasive small incision surgery, routine education and routine respiratory function exercise; group D: patients received single-hole thoracoscopic surgery, routine education and routine respiratory function exercise. *P＜0.05 vs group A; △P＜0.05 vs group B. 2.3 4组患者术后下床时间、置管时间、术后住院时间比较
结果（表2）显示：A组患者术后下床时间早于其他3组，置管时间、术后住院时间短于其他3组（P＜0.05）；B组患者术后下床时间早于C组，置管时间、术后住院时间短于C组（P＜0.05）。
3. 讨 论
肺癌是全球最常见的恶性肿瘤之一，发病率及致死率逐年升高。单孔胸腔镜肺部手术已成为胸外科重要的微创术式[3]。多项研究[4-6]表明，单孔胸腔镜手术较开放手术术后疼痛程度轻、胸管引流时间短、术后住院时间短、术后并发症少。但是，肿瘤侵犯重要脏器、血管、气管，或胸腔镜手术中出现大出血时，腋下肌肉非损伤性小切口为适宜的手术方式或中转术式。单孔胸腔镜手术与腋下肌肉非损伤性小切口手术均符合ERAS理念。本研究无腔镜中转开放手术病例。
ERAS将微创理念延续到术前、术中和术后[7]，除减小手术切口外，降低患者术后并发症发生率、缩短患者住院时间及减少住院费用等也是其目标。呼吸功能训练是肺癌术前重要的准备事项，为术后快速康复奠定基础[8]。ERAS理念指导的呼吸功能训练可以更有效地增强呼吸肌力量，提高协调性，促进患者术后咳嗽咳痰，进而减少肺部并发症，缩短术后卧床时间[6,9]。本研究中，ERAS组（A组和B组）患者术前除爬楼梯训练外，使用呼吸训练器进行呼吸功能训练，提高训练效果的同时，增强结果的可观察性。结果显示，ERAS组患者术后肺部并发症减少、恢复加快，支持既往研究结果，其中单孔胸腔镜手术联合ERAS理念患者（A组）术后疼痛更轻。
本研究存在一定局限性：病例数较少，虽然对结果进行多重比较，但并未校正两两比较的P值，存在一类错误膨胀，需谨慎解释并推广结果。未来，将增加样本量或进行多中心研究以验证本研究结果。综上所述，对于接受单孔胸腔镜手术或腋下肌肉非损伤性小切口手术的患者，联合ERAS均有助于加速恢复，其中单孔胸腔镜手术联合ERAS理念指导下的呼吸功能训练更能使肺癌患者获益。
伦理声明 本研究获得苏州大学附属太仓医院伦理委员会批准(2023-ky-035)，患者签署知情同意书。
利益冲突 所有作者声明不存在利益冲突。
作者贡献 张法旺：数据收集、处理和撰稿；李森、于新辉：研究设计、修改稿件；舒健：论文审核。
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表 1 4组患者临床资料比较
Table 1 Comparison of clinical data of patients among four groups
Index Group A
(n＝50)Group B
(n＝50)Group C
(n＝50)Group D
(n＝50)F/χ2 P Age/year 59.81±10.43 60.59±10.54 61.57±10.61 60.49±10.45 0.340 0.525 Male n(%) 27(54) 29(58) 31(62) 30(60) 3.030 0.078 Left lesion n(%) 22(44) 20(40) 24(48) 18(36) 3.430 0.487 Pathological stage n(%) 0.380 0.773 Ⅰ 29(58) 31(62) 32(64) 33(66) Ⅱ 17(34) 15(30) 13(26) 15(30) Ⅲa 4(8) 4(8) 5(10) 2(4) Pathological type n(%) 1.058 0.245 Adenocarcinoma 24(48) 25(50) 25(50) 26(52) Squamous carcinoma 21(42) 21(42) 18(36) 18(36) Other 5(10) 4(8) 7(14) 6(12) Group A: patients received single-hole thoracoscopic surgery, ERAS education, respiratory trainer and routine respiratory function exercise; group B: patients received subaxillary non-invasive small incision surgery, ERAS education, respiratory trainer and routine respiratory function exercise; group C: patients received subaxillary non-invasive small incision surgery, routine education and routine respiratory function exercise; group D: patients received single-hole thoracoscopic surgery, routine education and routine respiratory function exercise. 
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表 2 4组患者的术后指标比较
Table 2 Comparison of postoperative indicators in patients among four groups
Index Group A
(n＝50)Group B
(n＝50)Group C
(n＝50)Group D
(n＝50)F/χ2 P Pulmonary complications n(%) Lung infections 3(6) 8(16)* 15(30)*△ 13(26)* 9.506 0.024 Atelectasis 3(6) 6(12)* 12(24)*△ 13(26)* 10.128 0.016 Respiratory failure 1(2) 3(6)* 6(12)*△ 8(16)* 11.754 0.027 Postoperative pain/score 1 d 6.31±1.38 7.35±1.41* 7.43±1.35* 6.38±1.44 0.824 0.537 2 d 5.95±1.51 6.73±1.60* 6.68±1.59* 5.85±1.45 0.385 0.107 3 d 3.32±1.58 4.99±1.72* 4.76±1.76* 4.02±1.59 0.228 0.072 Time to get out of bed/h 20.73±7.58 28.67±7.98* 34.32±8.61*△ 21.06±7.67* 10.851 0.034 Time to remove chest tube/h 86.85±13.02 123.83±12.39* 153.34±12.79*△ 88.59±10.18* 7.319 0.019 Length of hospital stay/h 118.93±12.61 164.65±13.75* 178.51±13.02*△ 132.44±13.20* 17.847 0.041 Group A: patients received single-hole thoracoscopic surgery, ERAS education, respiratory trainer and routine respiratory function exercise; group B: patients received subaxillary non-invasive small incision surgery, ERAS education, respiratory trainer and routine respiratory function exercise; group C: patients received subaxillary non-invasive small incision surgery, routine education and routine respiratory function exercise; group D: patients received single-hole thoracoscopic surgery, routine education and routine respiratory function exercise. *P＜0.05 vs group A; △P＜0.05 vs group B.
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