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武漢加油！ 白衣天使從來都是白衣天使，白衣天使從來也都不是白衣天使！ 在今天武漢封城的特殊日子，發(fā)布DCR小組的好兄弟、武漢同濟(jì)醫(yī)院王桂華教授翻譯的文章。 祝愿所有人平安，武漢加油?。。?/p> 
1.華中科技大學(xué)同濟(jì)醫(yī)學(xué)院附屬同濟(jì)醫(yī)院胃腸外科中心2.中國醫(yī)科大學(xué)附屬盛結(jié)直腸外科3.溫州醫(yī)科大學(xué)附屬第一醫(yī)院結(jié)直腸外科美國結(jié)直腸外科醫(yī)師協(xié)會致力于通過推進(jìn)結(jié)腸、直腸和肛門疾病的科學(xué)、預(yù)防和管理來確保高質(zhì)量的醫(yī)療。臨床實(shí)踐指南委員會負(fù)責(zé)引領(lǐng)國際力量，通過制定基于現(xiàn)有最佳證據(jù)的臨床實(shí)踐指南，定義結(jié)直腸肛門疾病的優(yōu)質(zhì)醫(yī)療。這份指南具有廣泛性而并非特定性，供所有需要了解如何應(yīng)對指南中提及的各種情況的人使用，包括臨床醫(yī)生、護(hù)理工作者和渴求相關(guān)疾病治療信息的患者。其旨在提供制訂臨床決策所參考的信息，而非確定特定的治療方案。我們需要認(rèn)識到這份指南不應(yīng)被視作包括所有合適的治療方法，也不能排除可以達(dá)到相同效果的合理治療方法。對于任何特定方案是否適當(dāng)?shù)淖罱K標(biāo)準(zhǔn)應(yīng)該由醫(yī)師根據(jù)患者各方面的個(gè)體情況來評判。美國每年約有100000人行結(jié)腸或小腸造口手術(shù)。結(jié)腸或小腸造口用于處理各種臨床情況，包括腫瘤、憩室和炎癥性腸病1。遺憾的是，與其他類型常規(guī)的外科手術(shù)相比，造口手術(shù)出現(xiàn)并發(fā)癥的比例更高。最近一項(xiàng)基于全國外科手術(shù)質(zhì)量改善計(jì)劃的人群研究數(shù)據(jù)顯示，平診造口術(shù)的未調(diào)整并發(fā)癥發(fā)生率為37%，急診手術(shù)的未調(diào)整并發(fā)癥發(fā)生率為55%2。此外，醫(yī)院之間風(fēng)險(xiǎn)調(diào)整后并發(fā)癥率差異顯著，這提示有必要進(jìn)一步改善臨床結(jié)果2。然而，造口術(shù)真正的病理狀態(tài)包括對患者生活質(zhì)量的嚴(yán)重影響及造口護(hù)理相關(guān)的遠(yuǎn)期并發(fā)癥3–10。多達(dá)一半的造口是“有問題的”，包括皮膚刺激和造口用品佩戴困難，這些均需要延長醫(yī)療服務(wù)時(shí)間并增加醫(yī)療費(fèi)用（延長住院日和/或增加門診患者就診需求）4,11,12。與傳統(tǒng)的并發(fā)癥發(fā)生率類似，造口并發(fā)癥在各大醫(yī)院之間仍有較大差別，表明造口手術(shù)的質(zhì)量仍有待提高4,11。造口或造口位置不佳、術(shù)后并發(fā)癥和圍術(shù)期護(hù)理不足將加重造口術(shù)后管理的問題。這份指南旨在為外科醫(yī)生和其他希望改善造口患者護(hù)理和結(jié)局的衛(wèi)生保健者提供指導(dǎo)。這份臨床實(shí)踐指南重點(diǎn)在于需要造口的患者的外科治療，包括造口類型的選擇、造口建立和還納的技術(shù)、造口手術(shù)相關(guān)并發(fā)癥的防治和圍術(shù)期處理。這份指南的編寫并不是為了確定特定臨床狀況下是否建立造口，因?yàn)檫@個(gè)問題已經(jīng)由特定疾病（例如憩室炎、直腸癌、潰瘍性結(jié)腸炎）的臨床指南所確定。此外，這份指南關(guān)注的是成人結(jié)腸和小腸造口，而非尿路造口、可控性回腸代膀胱術(shù)或兒童造口，也沒有廣泛回顧造口的護(hù)理學(xué)文獻(xiàn)，如皮膚護(hù)理或特定器具、管理系統(tǒng)的使用。這份系統(tǒng)評價(jià)始于2014年1月29日以“造口術(shù)”、“造口”、“結(jié)腸造口”、“小腸造口”和“造口旁”為關(guān)鍵詞的檢索，對國家指南交流中心和PubMed所有現(xiàn)存的臨床實(shí)踐指南的檢索。五份指南被確認(rèn)均與造口護(hù)理和/或患者教育相關(guān)。我們匯總了了這五份指南的全文13-17。我們也獲取了現(xiàn)有臨床指南中參考文獻(xiàn)的全文。接著我們以“造口術(shù)（加權(quán)）”、“結(jié)腸造口術(shù)（加權(quán)）”和 “小腸造口術(shù)（加權(quán)）”為主題詞系統(tǒng)檢索了Ovid Medline和Cochrane Database of Collected Reviews。這三項(xiàng)檢索限定為英文文獻(xiàn)、摘要可獲取、人類研究。我們通過這次初步檢索確定了2394篇參考文獻(xiàn)，并閱讀了這些文獻(xiàn)的標(biāo)題和摘要。經(jīng)過初步篩選，確定了幾個(gè)主題：1）造口建立；2）造口還納；3）造口并發(fā)癥（預(yù)防與治療）；4）造口護(hù)理師價(jià)值的證據(jù)。有關(guān)這四個(gè)主題的所有系統(tǒng)評價(jià)、實(shí)驗(yàn)和其他≥20例患者的比較研究、非比較研究（也包含一些更小規(guī)模的研究），和所選中的綜述文獻(xiàn)，我們均獲取了全文。對這些文章的參考文獻(xiàn)列表進(jìn)行選擇性搜索后我們發(fā)現(xiàn)了其他相關(guān)文章，特別是在造口護(hù)理學(xué)領(lǐng)域，這些文章也以全文形式獲取。因?yàn)闆]有可選的MeSH主題詞（限定于英語、摘要可獲取、人類），2014年1月29日我們以“造口旁疝”為關(guān)鍵詞對Ovid Medline上關(guān)于造口旁疝的研究單獨(dú)進(jìn)行了檢索。在確定的228篇參考文獻(xiàn)中，進(jìn)行了標(biāo)題和摘要審閱，并獲得了具有主要患者數(shù)據(jù)的報(bào)告的全文，但病例報(bào)告和非常小的病例系列除外。我們還檢索了這些文章的參考文獻(xiàn)，以尋找其他的研究，并獲得了這些文獻(xiàn)。檢索截止時(shí)，共有263篇文獻(xiàn)以全文形式被查到。文中每個(gè)主題相關(guān)的這些證據(jù)被以證據(jù)列表的形式匯總。雖然這一指南的總體證據(jù)質(zhì)量較差，但所包含的陳述得到了高質(zhì)量的觀察性研究和一定的實(shí)驗(yàn)研究的支持。根據(jù)推薦等級Grades of Recommendation）、評價(jià)(Assessment)、發(fā)展（Development）、評效(Evaluation)(GRADE)體系選擇每一項(xiàng)陳述的最終推薦等級18。Table 1. The GRADE system-grading recommendations
| | 獲益vs風(fēng)險(xiǎn)與負(fù)擔(dān) | | | | | 獲益明顯大于風(fēng)險(xiǎn)和負(fù)擔(dān)，反之亦然 | 沒有重要限制或來自觀察性研究的壓倒性證據(jù)的隨機(jī)對照試驗(yàn) | 強(qiáng)推薦，可無保留地在多數(shù)情況下用于大部分患者 | | | 獲益明顯大于風(fēng)險(xiǎn)和負(fù)擔(dān)，反之亦然 | 有重要限制（不一致結(jié)論、方法學(xué)缺陷、間接或不精確）或來自觀察性研究的很強(qiáng)的證據(jù)的隨機(jī)對照試驗(yàn) | 強(qiáng)推薦，可無保留地在多數(shù)情況下用于大部分患者 | | | 獲益明顯大于風(fēng)險(xiǎn)和負(fù)擔(dān)，反之亦然 | | 強(qiáng)推薦，但可能因更高質(zhì)量證據(jù)可行而改變 | | | 獲益和風(fēng)險(xiǎn)及負(fù)擔(dān)平衡 | 沒有重要限制或來自觀察性研究的壓倒性證據(jù)的隨機(jī)對照試驗(yàn) | 弱推薦，最佳決策可能因?qū)嶋H情況或患者社會價(jià)值觀變化 | | | 獲益和風(fēng)險(xiǎn)及負(fù)擔(dān)平衡 | 有重要限制（不一致結(jié)論、方法學(xué)缺陷、間接或不精確）或來自觀察性研究的很強(qiáng)的證據(jù)的隨機(jī)對照試驗(yàn) | 弱推薦，最佳決策可能因?qū)嶋H情況或患者社會價(jià)值觀變化 | | | 獲益、風(fēng)險(xiǎn)和負(fù)擔(dān)的評估不確定；獲益和風(fēng)險(xiǎn)及負(fù)擔(dān)平衡 | | |
造口手術(shù)一般用于良性或者惡性疾病，在擇期或緊急情況下進(jìn)行，小腸或結(jié)腸造口，臨時(shí)性或永久性造口，在根治性手術(shù)時(shí)造口或姑息性手術(shù)時(shí)造口。盡管造口多種多樣，但造口手術(shù)時(shí)原則卻是普一致的的：造口的腸管必須血運(yùn)良好，并且經(jīng)過充分松解使得張力最小。在本節(jié)中，我們提出了基于證據(jù)的造口手術(shù)建議。造口部位選擇的技巧我們將在這份指南中一個(gè)單獨(dú)的部分討論。1. 如果條件允許，腹腔鏡輔助下造口優(yōu)于開腹手術(shù)造口手術(shù)。推薦等級：基于低質(zhì)量證據(jù)的強(qiáng)推薦，1C。尚無隨機(jī)對照試驗(yàn)比較通過傳統(tǒng)開放手術(shù)和微創(chuàng)手術(shù)造口的差異。然而，多個(gè)觀察性研究證實(shí)，與開腹手術(shù)相比，腹腔鏡造口術(shù)在短期內(nèi)安全且效果良好。腹腔鏡手術(shù)的優(yōu)點(diǎn)包括減少疼痛和麻醉需求，縮短住院時(shí)間，早日恢復(fù)腸道功能，減少總體并發(fā)癥19-22。并且腹腔鏡輔助下造口可能更易于還納23。多數(shù)腹腔鏡操作需要2-3個(gè)戳卡，其中一個(gè)置于預(yù)定的造口位置處4,25。中轉(zhuǎn)開腹不常發(fā)生，概率在0%-16%，并且更多近期的報(bào)道中概率則為個(gè)位數(shù)19–22,26–29。腹腔鏡輔助造口時(shí)，術(shù)者須特別注意避免拖出的腸管（雙腔造口）及系膜（單腔造口）的扭轉(zhuǎn)30。標(biāo)記近端和遠(yuǎn)端腸管，在腸管穿過筋膜后，再次建立氣腹，確定其方向是否正確26,28,30。在合適的病例，一種微創(chuàng)操作可代替腹腔鏡手術(shù)，即環(huán)切皮膚造口術(shù)（trephine ostomy creation）。這種手術(shù)方式通過擬行造口處的一個(gè)小切口做造口。在多數(shù)病例中這種手術(shù)方式可以在區(qū)域麻醉下進(jìn)行，據(jù)報(bào)道89%-94%可免于開腹手術(shù)31,32。一個(gè)對比環(huán)切皮膚造口術(shù)和腹腔鏡輔助下造口的前瞻性研究表明兩種方式的短期結(jié)果均可接受32。2. 在大多數(shù)情況下，回腸袢式造口優(yōu)于橫結(jié)腸袢式造口。推薦等級：基于中等質(zhì)量證據(jù)的弱推薦，2B。至少5個(gè)小型隨機(jī)對照實(shí)驗(yàn)和許多觀察性研究用于研究回腸袢式造口和橫結(jié)腸袢式哪一個(gè)是糞便轉(zhuǎn)流的更優(yōu)選擇（通常認(rèn)為是橫結(jié)腸袢式造口）33-44?；趥€(gè)證據(jù)，也進(jìn)行了幾項(xiàng)Meta分析，并且結(jié)論具有爭議，某種程度上由于研究之間存在異質(zhì)性45-48?？傊?，現(xiàn)有的證據(jù)表明回腸袢式造口和橫結(jié)腸袢式造口均能有效轉(zhuǎn)流糞便48，減輕吻合口漏的后果46。此外，回腸雙腔袢式和結(jié)腸袢式造口有相近的并發(fā)癥發(fā)生率，但并發(fā)癥的形式卻不同。下文即是對這些不同形式并發(fā)癥的總結(jié)。關(guān)于感染性并發(fā)癥發(fā)生小腸袢式造口相對占優(yōu)勢。結(jié)腸造口還納后切口感染率顯著高于回腸造口，范圍在5%-20%，相比之下回腸造口約為3%33,34,39–41,44,45,47。橫結(jié)腸袢式造口術(shù)后膿毒血癥略為常見（OR, 0.54; 95% CI, 0.30–0.99）48，還有造口脫垂，在42%橫結(jié)腸袢式造口的患者中發(fā)生38,46,48。最后，由于更小的氣味、較少因造口脫垂而調(diào)整穿衣以及更便利的造口護(hù)理，回腸袢式造口的患者可能比橫結(jié)腸雙腔造口患者有更好的生活質(zhì)量33,38,49,50。但是，一項(xiàng)小規(guī)模的隨機(jī)對照實(shí)驗(yàn)表明“社交限制”在回腸和結(jié)腸造口患者之間并無差異。相反，造口還納后梗阻性并發(fā)癥發(fā)生則結(jié)腸造口占優(yōu)勢。還納后腸梗阻更常出現(xiàn)于回腸造口(OR=2.13)39,41,45,47,48，盡管這并沒有得到一致證明46。在已發(fā)表的臨床試驗(yàn)表明回腸造口更多的排泄量也與更高比例的脫水、更加需要飲食調(diào)整和更高的再入院率相關(guān)38,44,47,48。總之，現(xiàn)有證據(jù)表明小腸袢式造口和橫結(jié)腸袢式造口均能有效轉(zhuǎn)流糞便，減輕吻合口漏的后果。但回腸袢式造口脫垂的風(fēng)險(xiǎn)更低，也更少出現(xiàn)感染性并發(fā)癥，并且可能改善患者體驗(yàn)。出于這些原因，當(dāng)代結(jié)直腸外科實(shí)踐中通常傾向于支持回腸造口。然而，所有轉(zhuǎn)流性造口均有很高并發(fā)癥，而且對一些特殊的臨床情況，進(jìn)行特定的造口方式轉(zhuǎn)流可能更有利。比如，有些作者提出對于過度肥胖的患者，可能更容易做橫結(jié)腸袢式造口35,39。同時(shí)，對于有盲腸穿孔風(fēng)險(xiǎn)的惡性結(jié)腸梗阻患者，一些外科醫(yī)生主張?jiān)诨孛ぐ赀h(yuǎn)端做造口進(jìn)行轉(zhuǎn)流。3. 只要有可能，回腸造口和結(jié)腸造口都應(yīng)高于皮膚表面。推薦等級：基于低質(zhì)量證據(jù)的強(qiáng)推薦，1C。一些前瞻性觀察研究報(bào)道在各醫(yī)療中心之間“有問題的”造口比例差異很大，這表明手術(shù)技術(shù)對造口并發(fā)癥的發(fā)生有很大影響4,11,43。盡管許多因素導(dǎo)致造口功能或造口設(shè)備佩戴不適，但在外科醫(yī)生可以控制的因素是造口突出皮膚上方的高度。一項(xiàng)高質(zhì)量多中心的造口功能的觀察性研究（其中仔細(xì)測量了造口突出表面的高度）發(fā)現(xiàn)造口突出皮膚表面高度與患者護(hù)理造口的好壞之間有很強(qiáng)的相關(guān)關(guān)系4。在一定范圍內(nèi)，造口的突出皮膚表面的高度與造口并發(fā)癥之間存在線性逆相關(guān)11。其他觀察性研究和外科專家的意見證實(shí)了這些發(fā)現(xiàn)52-55。一般來說，回腸造口時(shí)造口高度要超過皮膚表面2cm，結(jié)腸造口時(shí)造口高度要超過皮膚表面1cm。然而，并不是在所有臨床情況中，這個(gè)標(biāo)準(zhǔn)都可以達(dá)到，比如那些腹壁比較厚和系膜攣縮的患者，例如肥胖、克羅恩病、類癌及硬纖維瘤病患者。然而，如果技術(shù)可行，外科醫(yī)生應(yīng)該避免做與皮膚齊平的造口?？墒褂靡恍┘夹g(shù)來增加造口腸管長度包括選擇性腸系膜血管結(jié)扎、“盲端造口”造術(shù)和選擇肥胖患者的上腹部造口。4. 當(dāng)使用支撐桿進(jìn)行袢式造口時(shí)，可使用軟的或硬的造口支撐棒。推薦等級:基于低質(zhì)量證據(jù)的弱推薦，2C。幾乎沒有證據(jù)支持或在反對在進(jìn)行袢式造口時(shí)使用支撐棒，有些外科醫(yī)生對所有的袢式造口手術(shù)都使用，有些是選擇性的，有些則完全不使用。一項(xiàng)單獨(dú)的、小型隨機(jī)對照試驗(yàn)比較了回腸造口術(shù)中使用支撐棒與完全不使用棒，結(jié)果顯示早期造口回縮率沒有顯著差異56。關(guān)于所使用的支撐棒的類型，已經(jīng)有了一些研究。雖然目前還沒有比較硬造口支撐棒和軟的造口支撐棒的隨機(jī)試驗(yàn)，但已經(jīng)有一些小型的觀察性研究證明了各種軟造口支撐棒的優(yōu)點(diǎn)，比如紅色橡膠導(dǎo)管57-59。與硬支撐棒相比，軟的支撐棒可以更容易地安置和更換造口器具。當(dāng)造口存在明顯的張力時(shí)，硬支撐棒可能會發(fā)揮作用，但這是有爭議的。5. 可以考慮使用防粘連材料來減少臨時(shí)性造口部位的粘連。等級的推薦:基于中等質(zhì)量證據(jù)的弱推薦，2B雖然只有4%的轉(zhuǎn)流的回腸造口患者需要開腹還納，但腹腔粘連常常使這些手術(shù)復(fù)雜化或延長手術(shù)時(shí)間60。三項(xiàng)隨機(jī)試驗(yàn)研究了防粘連材料在臨時(shí)造口術(shù)中的使用及其對隨后還納的影響61-63。在研究羥甲基纖維素與透明質(zhì)酸鹽（Seprafilm, Genzyme, Cambridge, MA）的兩項(xiàng)試驗(yàn)中，在首次手術(shù)中使用透明質(zhì)酸鹽時(shí)，回腸造口腸管周圍的粘連明顯減少，但兩組的還納手術(shù)時(shí)間無差異61,62。相反，一項(xiàng)使用可噴霧水凝膠屏障（SprayGel, Confluent Surgical Inc., Waltham,MA）的研究表明，粘連指數(shù)降低，總的手術(shù)時(shí)間減少約6分鐘63。這是否具有臨床意義是有爭議的，并且沒有成本效益研究支持（或反對）防粘連材料的常規(guī)使用。6. 行永久性造口時(shí)放置輕量型聚丙烯補(bǔ)片，以降低造口旁疝的發(fā)生率。推薦等級:基于中等質(zhì)量證據(jù)的強(qiáng)推薦，1B。四項(xiàng)隨機(jī)對照試驗(yàn)表明，造口時(shí)放置人工補(bǔ)片能顯著降低造口旁疝的發(fā)生率64-67。在這些研究中使用的補(bǔ)片是部分可吸收的，具有大孔徑的輕量型聚丙烯補(bǔ)片。大多數(shù)研究的隨訪時(shí)間相對較短（4項(xiàng)研究中有3項(xiàng)不足12個(gè)月），而一項(xiàng)研究報(bào)告了造口術(shù)后5年的長期結(jié)果。在本研究中，21例（81%）傳統(tǒng)造口手術(shù)中有17例診斷造口旁疝，15例（13%）聯(lián)合補(bǔ)片加固的造口手術(shù)中有2例診斷為造口旁疝。在更小的預(yù)防性補(bǔ)片加固的非隨機(jī)研究中也報(bào)道了一致的結(jié)果68,69。關(guān)于生物材料在預(yù)防性造口部位加固中的應(yīng)用，已發(fā)表的資料有限。一項(xiàng)非常小的隨機(jī)對照試驗(yàn)報(bào)告了在造口時(shí)使用豬脫細(xì)胞真皮(Permacol, Covidien, Norwalk, CT)的10例患者中0例發(fā)生了造口旁疝，而10例未加固的造口的患者中有3例發(fā)生了造口旁疝70。然而，由于平均隨訪時(shí)間只有6.5個(gè)月，這些結(jié)果很難詮釋。對16例應(yīng)用生物材料加固的造口手術(shù)的患者進(jìn)行回顧性研究，未發(fā)現(xiàn)疝復(fù)發(fā)或補(bǔ)片侵蝕的發(fā)生（中位隨訪38個(gè)月）71。最近發(fā)表的一項(xiàng)使用非交聯(lián)豬脫細(xì)胞真皮（Strattice, Lifecell, Bridgewater, NJ）進(jìn)行造口加固隨機(jī)、對照、多中心的試驗(yàn)，選擇113例患者，發(fā)現(xiàn)在隨后的24個(gè)月的隨訪中疝發(fā)生率無顯著差異（6/58 vs 7/55）72。7. 腹膜外隧道式造口可降低造口旁疝的發(fā)生率。推薦等級:基于低質(zhì)量證據(jù)的弱推薦，2C。腹膜外隧道式末端結(jié)腸造口是一種降低造口旁疝發(fā)生率的方法68。有幾項(xiàng)研究比較了腹膜外隧道式和腹膜內(nèi)末端結(jié)腸造口。一項(xiàng)隨訪至少6個(gè)月（最長5年）的試驗(yàn)顯示，傳統(tǒng)結(jié)腸造口手術(shù)造口旁疝的發(fā)生率為62例中的5例，而隧道式結(jié)腸造口手術(shù)造口旁疝的發(fā)生率為66例中的0例73。一個(gè)7項(xiàng)觀察性研究的Meta分析顯示，腹膜外隧道式造口造口旁疝的風(fēng)險(xiǎn)顯著降低（6.4% vs 13.3%）68。不幸的是，所有納入的研究并沒有報(bào)告隨訪時(shí)間。最近，2個(gè)小的觀察性研究比較了腹膜外隧道式結(jié)腸造口手術(shù)和傳統(tǒng)的腹腔鏡結(jié)腸造口手術(shù)69，70。在一項(xiàng)研究中，22例患者中只有1例在2年隨訪時(shí)間內(nèi)發(fā)生造口旁疝，而在另一項(xiàng)研究中，12例患者中0例在22個(gè)月隨訪時(shí)間內(nèi)發(fā)生造口旁疝。這些結(jié)果需要更長時(shí)間隨訪的隨機(jī)試驗(yàn)的證據(jù)，才能提出更有力的建議。8. 對于新的回腸造口的患者，術(shù)后護(hù)理路徑可以防止因脫水而再次入院。推薦等級:基于低質(zhì)量證據(jù)的強(qiáng)推薦，1C。脫水是回腸造口術(shù)后并發(fā)癥之一，影響多達(dá)30%的患者，是回腸造口術(shù)后再入院最常見的指征74-76。為了解決這個(gè)問題，一些中心已經(jīng)實(shí)施了術(shù)后護(hù)理路徑，包括患者教育、患者自我護(hù)理加強(qiáng)、標(biāo)準(zhǔn)化出院標(biāo)準(zhǔn)、出院后攝入和排泄量的跟蹤、訪視護(hù)士教育和早期隨訪。在已發(fā)表的報(bào)告中，這些項(xiàng)目與較低的脫水再入院率有關(guān)，表明了此類項(xiàng)目的應(yīng)用前景77-79。對于臨時(shí)回腸造口和結(jié)腸造口，需要二次手術(shù)以恢復(fù)腸道連續(xù)性。Hartmann還納手術(shù)歷來被認(rèn)為是一種復(fù)雜的手術(shù);然而，即使是相對簡單的回腸造口還納手術(shù)也有顯著的并發(fā)癥60,80–83。一項(xiàng)關(guān)于回腸造口還納術(shù)的并發(fā)癥的系統(tǒng)回顧研究，發(fā)現(xiàn)回腸造口還納的并發(fā)癥率為17%，死亡率為0.4%，4%的患者需要開腹手術(shù)，7%的患者出現(xiàn)腸梗阻60。本節(jié)的目的是為造口還納手術(shù)的技術(shù)方面提供循證指導(dǎo)。關(guān)于造口還納手術(shù)的時(shí)間循證學(xué)證據(jù)不足。然而，現(xiàn)有的研究表明，根據(jù)臨床情況，選擇早期（3周內(nèi)）或者晚期關(guān)閉造口是安全的84-88。1. 對于回腸袢式造口還納，吻合器和手工縫合技術(shù)都是可接受的。推薦等級:基于中等質(zhì)量的證據(jù)的強(qiáng)推薦，1B。4個(gè)隨機(jī)對照試驗(yàn)比較了吻合器吻合和手工吻合在回腸袢式造口中的應(yīng)用89-92?？偟膩碚f，結(jié)果是相似的，手工吻合組術(shù)后腸梗阻的風(fēng)險(xiǎn)更高，手術(shù)時(shí)間更長93。最近，一項(xiàng)多中心隨機(jī)對照試驗(yàn)（HASTA試驗(yàn))登記了27個(gè)中心的337名患者。術(shù)后，13.4%的患者發(fā)生腸梗阻，而10.3%的吻合器吻合和16.6%的手工縫合的患者發(fā)生腸梗阻（p=不顯著），吻合器組吻合口漏發(fā)生率為3%，手工縫合吻合口漏發(fā)生率為1.8% （p =不顯著）89。吻合器組的手術(shù)時(shí)間明顯縮短約15分鐘（p < 0.001）89。幾項(xiàng)觀察性研究表明，使用吻合器吻合時(shí)，住院時(shí)間較短;但是，必須考慮到這些研究中存在偏見的可能性94-96。最近，一項(xiàng)74名患者的單中心隨機(jī)試驗(yàn)表明，在標(biāo)準(zhǔn)回腸造口術(shù)中加入腹腔鏡，腹腔鏡組中，并發(fā)癥發(fā)生率較低，住院時(shí)間較短（4天vs 5天）97，98。手術(shù)時(shí)間平均延長15分鐘。這項(xiàng)技術(shù)可以解決標(biāo)準(zhǔn)回腸造口閉合術(shù)造成腸梗阻的風(fēng)險(xiǎn)，但目前還沒有足夠的證據(jù)支持。2. 在可行的情況下，應(yīng)當(dāng)對造口部位皮膚進(jìn)行重塑，并且與其他方法相比，荷包縫合皮膚可能具有優(yōu)勢。等級的推薦：基于中等質(zhì)量證據(jù)的強(qiáng)推薦，1B。造口閉合的切口傳統(tǒng)上是保留開放的，愈合是次要目標(biāo)。然而，在現(xiàn)代實(shí)踐中，這些切口的皮膚通常是部分或完全關(guān)閉的。這種做法的優(yōu)點(diǎn)是避免開放性傷口，從而需要更長的傷口填塞時(shí)間。各種各樣的方法被用來切開皮膚，然后在造口還納時(shí)關(guān)閉皮膚切口。至少有9項(xiàng)研究，包括5項(xiàng)隨機(jī)試驗(yàn)，比較了各種方法。5項(xiàng)研究（2項(xiàng)隨機(jī)對照試驗(yàn)）比較了回腸造口和/或結(jié)腸造口還納后荷包縫合方法（在切口中心留一個(gè)小口）與傳統(tǒng)的線型縫合的差異，結(jié)果顯示前者的縫合方法顯著降低了切口感染率（兩項(xiàng)隨機(jī)對照試驗(yàn)的比例分別為0% vs 37%，7%vs 39%）99-103。此外，幾項(xiàng)研究表明，荷包縫合的病人舒適度提高99，100。其他研究（包括2項(xiàng)隨機(jī)對照試驗(yàn)）比較了造口（還納）切口一期縫合與一期延遲縫合、創(chuàng)面填塞和/或留置引流縫合104-106。這些研究發(fā)現(xiàn)，一期縫合切口感染率在0%至10%之間，二期縫合切口感染率為8%至20%之間104-106。一項(xiàng)隨機(jī)試驗(yàn)研究了一種抗生素植入物，但這對切口感染率沒有影響（兩組均為10%）107。3. 對于經(jīng)驗(yàn)豐富的醫(yī)生來說，腹腔鏡Hartmann造口還納相對于開放手術(shù)還納是一個(gè)安全選擇。等級的推薦：基于低質(zhì)量證據(jù)的強(qiáng)推薦，1C。雖然沒有隨機(jī)試驗(yàn)比較開放和腹腔鏡Hartmann造口還納術(shù)，許多觀察性研究證明了腹腔鏡手術(shù)的安全性80，108。一項(xiàng)非隨機(jī)對照研究的系統(tǒng)回顧匯集了450名接受腹腔鏡或開放性Hartmann造口還納的受試者的數(shù)據(jù)。80。腹腔鏡手術(shù)與較低的并發(fā)癥發(fā)生率、較低的出血量和較短的住院時(shí)間相關(guān)，而在吻合口漏和死亡率方面則無差異80。盡管這些數(shù)據(jù)表明，在有經(jīng)驗(yàn)豐富的外科醫(yī)生的醫(yī)學(xué)中心使用腹腔鏡手術(shù)的安全性和潛在的良好結(jié)果，但要注意在這些觀察性研究中選擇偏倚的可能性。造口手術(shù)可能造成各種短期和長期并發(fā)癥，包括造口旁疝、脫垂、狹窄、回縮、造口旁靜脈曲張109、皮膚問題和代謝紊亂。本節(jié)的最初目的是為處理這些情況提供基于循證醫(yī)學(xué)證據(jù)的指導(dǎo)，然而，只有造口旁疝的并發(fā)癥的處理建議有足夠的證據(jù)。1. 造口旁疝的修補(bǔ)一般采用補(bǔ)片或重新造口的方法。推薦等級:基于低質(zhì)量證據(jù)的強(qiáng)推薦，1C。目前還沒有比較不同方法修補(bǔ)造口旁疝的RCT試驗(yàn)。然而，多項(xiàng)回顧性觀察研究表明，在疝部位進(jìn)行一期縫合修補(bǔ)，復(fù)發(fā)率非常高（46%-78%）110-116。一項(xiàng)觀察性研究的系統(tǒng)回顧得出結(jié)論：一期縫合存在69.4%的疝復(fù)發(fā)的風(fēng)險(xiǎn)117。因此，對于適合進(jìn)行開腹手術(shù)或腹腔鏡手術(shù)的患者，補(bǔ)片修補(bǔ)或重新造口比一期縫合修補(bǔ)更適合。重新造口對于非常大的造口旁疝可能是必要的，因?yàn)槭中g(shù)疝復(fù)位后仍有明顯的軟組織缺損殘留，這可能影響造口用品的粘貼。當(dāng)然，對于造口可以還納的患者，有癥狀的造口旁疝可能是造口還納的指征。2. 人工補(bǔ)片可用于造口旁疝修補(bǔ)術(shù)，短期內(nèi)腸道侵蝕或補(bǔ)片感染的風(fēng)險(xiǎn)較低。推薦等級:基于低質(zhì)量證據(jù)的強(qiáng)推薦，1C。既往，由于害怕污染和隨之而來的補(bǔ)片感染，在腸道開放的情況下使用補(bǔ)片是不被鼓勵(lì)的。然而，在已發(fā)表的關(guān)于造口旁疝修補(bǔ)的研究中，補(bǔ)片感染的風(fēng)險(xiǎn)被證明較低，補(bǔ)片感染的合發(fā)生率率從2.2%到2.6%不等117。在包括16項(xiàng)關(guān)于開放補(bǔ)片造口旁疝修補(bǔ)術(shù)的系統(tǒng)綜述中，僅有1例補(bǔ)片侵蝕鄰近腸管的報(bào)道117。對于開放造口旁疝補(bǔ)片修補(bǔ)的各種術(shù)式的已被報(bào)道，包括onlay補(bǔ)片修補(bǔ)術(shù)、肌后間隙補(bǔ)片修補(bǔ)和Sugarbaker或slit techniques法腹腔內(nèi)修補(bǔ)術(shù)式117。目前還沒有對這些術(shù)式進(jìn)行比較的實(shí)驗(yàn)，但在2012年的一項(xiàng)系統(tǒng)綜述中，采用這4種技術(shù)的疝復(fù)發(fā)的總發(fā)生率為：Onlay補(bǔ)片修補(bǔ)后的復(fù)發(fā)率為17.2%（95% CI, 11.9%–23.4%），Sublay補(bǔ)片修補(bǔ)術(shù)后的復(fù)發(fā)率為6.9% （1.1%–17.2%），Keyhole法修補(bǔ)術(shù)后的復(fù)發(fā)率為7.2% (1.7%–16.0%)，Sugarbaker法修補(bǔ)術(shù)后的復(fù)發(fā)率為 15% (3.2%–37.9%)117。這些數(shù)據(jù)的局限性包括它們?yōu)榛仡櫺院驮S多研究的隨訪時(shí)間較短。3. 生物材料可代替人工補(bǔ)片用于造口旁疝修補(bǔ)。推薦等級：基于低質(zhì)量證據(jù)的弱推薦，2C。在嚴(yán)重污染的情況下， 以膠原基質(zhì)為基礎(chǔ)的生物補(bǔ)片通常用于代替補(bǔ)片進(jìn)行疝修補(bǔ)。使用生物材料進(jìn)行造口旁疝修補(bǔ)的一些小型回顧性回顧報(bào)道了疝復(fù)發(fā)率在7%到27%之間118-122。然而這些研究的隨訪時(shí)間很短（9-18個(gè)月）。在這種情況下，需要有更長的隨訪時(shí)間的進(jìn)一步的比較研究來確定生物修復(fù)材料的功效和成本效益。4. 腹腔鏡下造口旁疝修補(bǔ)術(shù)是一種安全的手術(shù)方式，可以代替開放法造口旁疝修補(bǔ)術(shù)。推薦等級：基于低質(zhì)量證據(jù)的強(qiáng)推薦，1C。盡管尚無隨機(jī)對照實(shí)驗(yàn)將腹腔鏡與開放造口旁疝修補(bǔ)術(shù)進(jìn)行比較，但許多觀察性研究已明確了腹腔鏡補(bǔ)片修補(bǔ)的可行性，其復(fù)發(fā)率與開放補(bǔ)片修補(bǔ)的復(fù)發(fā)率相似123-134。最常用的兩種腹腔鏡下造口旁疝修補(bǔ)術(shù)是Sugarbaker法補(bǔ)片修補(bǔ)術(shù)和Keyhole/slit法補(bǔ)片修補(bǔ)術(shù)。在Sugarbaker法補(bǔ)片修補(bǔ)術(shù)中，一個(gè)完整的補(bǔ)片放置在腹膜下方，造口腸袢從補(bǔ)片外側(cè)穿到腹壁缺損處。Keyhole/slit法補(bǔ)片修補(bǔ)術(shù)用1-2張帶有開孔的補(bǔ)片，造口腸袢從開孔處穿過，然后出腹壁。目前尚無比較這兩種修補(bǔ)手術(shù)的隨機(jī)對照研究，然而，幾項(xiàng)回顧性對照研究報(bào)道應(yīng)用Slit法補(bǔ)片修補(bǔ)術(shù)后的復(fù)發(fā)率(58%–72.7%) 顯著高于改良Sugarbaker法修補(bǔ)術(shù)（0%–15.4%）124，125。但是Slit修補(bǔ)術(shù)后的隨訪時(shí)間是改良Sugarbaker法修補(bǔ)術(shù)的2倍。一項(xiàng)Meta分析調(diào)查了11個(gè)回顧性研究的臨床數(shù)據(jù)，證明Keyhole/slit法造口旁疝修補(bǔ)術(shù)后的復(fù)發(fā)率為20.8% （160例）， 高于Sugarbaker 法修補(bǔ)術(shù)（11.6%， 110 例) 117。最近一項(xiàng)前瞻性、多中心的非對照試驗(yàn)，對61例造口旁疝患者實(shí)施了腹腔鏡下雙層合成補(bǔ)片Sugarbaker法修補(bǔ)術(shù)，隨訪26個(gè)月后的復(fù)發(fā)率為6.6%，揭示了此技術(shù)的應(yīng)用前景131。所有造口患者都需要接受教育、培訓(xùn)和社會心理支持，以很好的適應(yīng)造口相關(guān)的自我護(hù)理1，135。此外，如皮膚刺激癥狀和滲漏等造口相關(guān)的問題也比較常見，患者在醫(yī)院和家中都需要醫(yī)療幫助來解決這些問題3，53，136。缺乏足夠的造口護(hù)理可能會導(dǎo)致患者無法提高自我護(hù)理技能，進(jìn)而導(dǎo)致抑郁和/或社交孤立，以及增加醫(yī)療保健需求和費(fèi)用3，137-139。在一項(xiàng)針對接受造口手術(shù)的癌癥患者的大型研究中，有84％的患者表示他們在處理造口滲漏方面遇到過技術(shù)困難136。并且，患者認(rèn)為技術(shù)困難與自己沒有得到足夠的準(zhǔn)備信息有關(guān)，從而可能導(dǎo)致情感，社會和婚姻問題136。此外，有證據(jù)表明，衛(wèi)生保健提供者通常不擅長處理造口相關(guān)問題。全科醫(yī)生和腫瘤科護(hù)士的調(diào)查問卷證實(shí)，他們沒有接受過充分的培訓(xùn)，無法為造口手術(shù)患者提供全面的護(hù)理，他們依靠造口專科護(hù)士來共同管理患者140，141。此外，非專業(yè)醫(yī)生和專科醫(yī)生的造口手術(shù)部位選擇質(zhì)量也有所不同，而標(biāo)準(zhǔn)是由造口?？谱o(hù)士確立的142。由于以上所有原因，美國結(jié)直腸外科醫(yī)生協(xié)會認(rèn)為，造口手術(shù)患者的包括術(shù)前、圍手術(shù)期和術(shù)后護(hù)理由造口專科護(hù)士來完成是最佳的，例如經(jīng)傷口造口失禁護(hù)士協(xié)會（WoCn）認(rèn)證委員會認(rèn)證的護(hù)士143。但是，不是所有的臨床情況都能提供這種最佳護(hù)理，尤其是在偏遠(yuǎn)地區(qū)和緊急情況下。但是，只要有可能，行造口的患者都應(yīng)尋求造口專科護(hù)士的幫助。本章節(jié)的目的是概述支持造口護(hù)士在造口患者護(hù)理中的價(jià)值的證據(jù)。本文的局限性包括數(shù)據(jù)來源于極少的基于人群的研究和/或隨機(jī)試驗(yàn)，以及許多研究中包括了尿路造口的患者。1. 造口患者宣教應(yīng)包括術(shù)前和術(shù)后部分，并盡可能包含一個(gè)專業(yè)人員，例如WoCn護(hù)士。推薦等級：基于中等質(zhì)量證據(jù)的強(qiáng)推薦，1B。多項(xiàng)觀察研究和橫向研究以及1個(gè)小型RCT研究支持造口護(hù)士進(jìn)行圍手術(shù)期教育138，139，144-147。Chaudhri及其同事將造口手術(shù)前的42位患者隨機(jī)分配到術(shù)前強(qiáng)化教育計(jì)劃中，發(fā)現(xiàn)這種干預(yù)措施可縮短住院時(shí)間（8天 vs 10天），減少出院后非計(jì)劃醫(yī)療干預(yù)措施的需要，縮短熟練造口護(hù)理的時(shí)間（5.5天 vs 9天），以及節(jié)省成本139。幾項(xiàng)大型回顧性研究表明，造口護(hù)士的術(shù)前教育與減少造口相關(guān)的并發(fā)癥相關(guān)（23％比32％），并且顯著減少了術(shù)后皮膚問題和滲漏問題144，147。基于造口患者調(diào)查表的大量研究結(jié)果表明，造口護(hù)士的宣教受到患者的高度重視，并且與更好的心理社會適應(yīng)能力相關(guān)136，146，148。Follick等人發(fā)現(xiàn)，不充分的造口健康教育是患者者經(jīng)常擔(dān)心的問題。84％的患者（接受調(diào)查的患者術(shù)后平均時(shí)間為4.5年）報(bào)告說，他們在處理自身造口方面遇到了技術(shù)上困難。并且患者認(rèn)為自己沒有受過足夠的健康教育與這些技術(shù)困難有關(guān)，而這些技術(shù)困難又與情感，社交和婚姻問題有關(guān)136。相反，由WoCn認(rèn)證的護(hù)士進(jìn)行術(shù)前教育能改善對造口的長期適應(yīng)調(diào)整146。盡管以上研究集中在術(shù)前教育，但術(shù)后、院內(nèi)教育對患者也很重要149。Hedrick150使用造口調(diào)整量表評分系統(tǒng)研究了醫(yī)院造口護(hù)士護(hù)理與術(shù)后適應(yīng)之間的關(guān)系。他們發(fā)現(xiàn)，在醫(yī)院看過造口護(hù)士的患者具有更高的適應(yīng)分?jǐn)?shù)，并且而造口護(hù)士被認(rèn)為是讓他們適應(yīng)的最重要因素。幾部已發(fā)布的指南為有關(guān)造口患者的術(shù)前和術(shù)后教育提供了指導(dǎo)1，16。WoCn出版的《臨床醫(yī)生最佳實(shí)踐指南》概述了術(shù)前和術(shù)后的教育主題1。推薦的術(shù)前教育主題包括消化道解剖學(xué)和生理學(xué)，擬定的手術(shù)方式，造口用品的演示，描述造口術(shù)后對生活方式的調(diào)整以及心理準(zhǔn)備。推薦的術(shù)后主題包括造口的解剖學(xué)和功能、造口袋程序操作培訓(xùn)、營養(yǎng)攝入、穿衣、藥物、身體形象、心理問題（例如悲傷，沮喪和焦慮）、社會和娛樂問題、人際關(guān)系、性和親密問題、常見的并發(fā)癥，如滲漏和皮炎以及可獲取的資源，包括支持小組和在線資源1。盡管這些指南基于專家意見而不是證據(jù)，但它們?yōu)榭赡鼙灰鬄樾率中g(shù)患者提供教育的非WoCn從業(yè)人員提供了有用的指導(dǎo)。2. 術(shù)前造口部位標(biāo)記應(yīng)盡可能由受過訓(xùn)練的人員進(jìn)行。推薦等級：基于低質(zhì)量證據(jù)的強(qiáng)推薦，1C。造口部位標(biāo)記可能會影響一些結(jié)局，包括造口相關(guān)的并發(fā)癥，例如滲漏和皮炎，患者適應(yīng)造口和獨(dú)立照顧自己的能力以及醫(yī)療服務(wù)和費(fèi)用。就造口相關(guān)并發(fā)癥而言，多項(xiàng)觀察性研究表明，術(shù)前部位標(biāo)記與術(shù)后問題減少相關(guān)4,144,145,147,151-153。研究表明，缺少造口部位標(biāo)記是發(fā)生“問題造口”的危險(xiǎn)因素，有時(shí)將其認(rèn)為是需要額外護(hù)理和用品以保證24小時(shí)佩戴住造口袋4,144,151,152。幾項(xiàng)研究還表明，造口部位標(biāo)記與減少患者無法有效護(hù)理的造口有關(guān)，并且使患者更好地適應(yīng)了造口12,147,153。盡管專家認(rèn)為缺少術(shù)前標(biāo)記會導(dǎo)致醫(yī)療保健成本增加，但缺乏證據(jù)證明這種關(guān)聯(lián)，這是一個(gè)需要進(jìn)一步研究的主題。盡管由經(jīng)認(rèn)證的造口護(hù)士進(jìn)行造口部位標(biāo)記是最理想的（結(jié)合到術(shù)前教育課程中），但通常都是訓(xùn)練有素的外科醫(yī)生進(jìn)行術(shù)前的造口定位，尤其是在急診情況下。Macdonald及其同事研究了外科醫(yī)生和外科學(xué)員選擇合適的造口部位的能力，發(fā)現(xiàn)外科醫(yī)生選擇的部位與造口護(hù)士（標(biāo)準(zhǔn)的）不同，大多數(shù)“位置較差”的造口在腹壁很低的位置142。結(jié)果發(fā)現(xiàn)，結(jié)直腸外科醫(yī)生被選擇的造口部位與造口?？谱o(hù)士更為一致。一項(xiàng)對外科學(xué)員的調(diào)查顯示，他們在造口部位選擇方面的培訓(xùn)是偶然的，造口?？谱o(hù)士很少提供這種培訓(xùn)142。2007年，美國結(jié)腸和直腸外科醫(yī)師協(xié)會與WOCN聯(lián)合發(fā)表了一份關(guān)于接受糞便造口手術(shù)患者術(shù)前造口標(biāo)記價(jià)值的聲明（可從以下網(wǎng)站獲得：http://www./physicians/position_statements/stoma_siting/）154。被要求進(jìn)行造口定位的外科醫(yī)生應(yīng)熟悉正確選擇造口位置的原則。WoCn建議的位置選擇步驟包括使用多個(gè)位置來確定適當(dāng)?shù)奈恢茫ㄓ绕涫亲耍苊獬霈F(xiàn)褶皺和疤痕，考慮穿著衣服/皮帶，并經(jīng)腹直肌造口。盡管最后的建議（經(jīng)腹直肌造口）是常見的做法，但它是基于專家意見的，因?yàn)闆]有證據(jù)支持或反對它。盡管協(xié)會強(qiáng)烈支持術(shù)前定位，但大家公認(rèn)術(shù)中情況可能不允許在所有情況下都使用最佳的皮膚部位造口。3. 所有患者都應(yīng)獲得造口教育、護(hù)理和支持的后續(xù)護(hù)理。推薦等級：基于低質(zhì)量證據(jù)的強(qiáng)推薦，1C。有大量證據(jù)表明，造口護(hù)理相關(guān)的技術(shù)問題以及造口對生活質(zhì)量的負(fù)面影響較為常見3-12，155。此外，由于加速康復(fù)理念目前造口手術(shù)后的住院時(shí)間縮短了，從而醫(yī)院內(nèi)造口教育和培訓(xùn)的機(jī)會減少了。這提示造口護(hù)士的隨訪和長期護(hù)理很重要。兩項(xiàng)隨機(jī)試驗(yàn)和多項(xiàng)觀察性研究支持出院后造口護(hù)士護(hù)理的價(jià)值，其可以以家庭，門診或電話的形式提供155-159。這種后續(xù)護(hù)理與患者獨(dú)立自我護(hù)理的能力增強(qiáng)、造口相關(guān)問題減少、造口術(shù)后適應(yīng)改善、對護(hù)理的滿意度提高以及生活質(zhì)量提高相關(guān)156-158。長時(shí)間之后，永久性造口患者可能持續(xù)出現(xiàn)未經(jīng)處理的造口相關(guān)并發(fā)癥和技術(shù)難題160-163。一項(xiàng)743例長期造口術(shù)患者的近期研究表明，有61％的患者有客觀證據(jù)表明出現(xiàn)了造口周圍皮膚問題，28％的患者經(jīng)常出現(xiàn)滲漏，87％的患者使用各種配件工具幫助佩戴造口袋160。經(jīng)過造口護(hù)士的護(hù)理后，滲漏、皮膚問題和配件的使用顯著減少，生活質(zhì)量得分提高160。這項(xiàng)研究受到所有患者均已改用新造口袋的限制，因此，造口護(hù)士的護(hù)理并不是唯一的干預(yù)措施。但是這些數(shù)據(jù)表明，即使是長期造口術(shù)的患者也存在與造口相關(guān)的重大技術(shù)問題并且需要護(hù)理。由于非專業(yè)的醫(yī)療保健提供者不擅長處理造口問題140，141，造口護(hù)士需要在圍手術(shù)期之外為造口患者提供必要的服務(wù)。因此，所有有造口的患者均應(yīng)在需要時(shí)并盡可能請一名造口護(hù)士進(jìn)行后續(xù)護(hù)理。ASCRS臨床實(shí)踐指導(dǎo)委員會成員Scott 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王桂華 教授，副主任醫(yī)師，博士生導(dǎo)師 華中科技大學(xué)同濟(jì)醫(yī)學(xué)院附屬同濟(jì)醫(yī)院胃腸外科中心，醫(yī)學(xué)博士，美國Wake Forest 大學(xué)博士后，國家自然科學(xué)基金優(yōu)秀青年基金獲得者。近年，先后承擔(dān)國家自然科學(xué)基金項(xiàng)目5項(xiàng)，發(fā)表SCI第一作者及通訊作者論文16篇，累計(jì)影響因子140，包括 “Cell”, “Nature Cell Biology”等雜志。作為共同發(fā)明人獲得已授權(quán)專利3項(xiàng)(中國2項(xiàng)，美國1項(xiàng))，作為共同研發(fā)人獲得國家I類新藥臨床批文1項(xiàng)。 學(xué)術(shù)任職：中國抗癌協(xié)會腫瘤代謝專業(yè)委員會“細(xì)胞代謝與炎癌轉(zhuǎn)化”學(xué)組副組長；湖北省臨床腫瘤協(xié)會青年專家委員會常委。 研究方向：細(xì)胞代謝與腫瘤，細(xì)胞衰老與腫瘤，腫瘤耐藥。 臨床擅長：胃腸道腫瘤的微創(chuàng)手術(shù)治療，腫瘤靶向治療，晚期胃腸道腫瘤的綜合治療和個(gè)體化治療，胃腸道間質(zhì)瘤的手術(shù)治療和術(shù)后綜合治療，腫瘤復(fù)發(fā)與耐藥后的個(gè)體化治療。
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