臺灣博碩士論文加值系統

由於基因遺傳及飲食西化等因素，近年來罹患結腸直腸癌的病人日漸增加，其中腫瘤生長部位又以低位腸道之癌症（乙狀結腸與直腸交接處以及直腸部位）所佔比例最多。尤其針對低位直腸癌病人，除了需要面對罹癌本身的心理衝擊外，尚需面對因手術後所造成排便、排尿或性功能等之障礙而導致生活上的許多不便及衝擊，使得這類病人的生活品質受到嚴重影響。為降低手術後的衝擊，手術式經歷重大變化，從腹部會陰切除術切除直腸及肛門，留置永久性造口，改成肛門括約肌保留手術，但兩類手術對病人短期和長期的生活品質影響為何，未有定論。本研究目的是探討罹患低位直腸癌行肛門括約肌保留手術病人：（一）術後出院六個月內及術後出院日滿六個月以上之腸道功能障礙及健康相關生活品質之差異；（二）手術後腸道功能障礙嚴重度及家庭功能與整體生活品質之相關性；（三）與行腹部會陰切除術病人整體生活品質之比較。
本研究採立意取樣，以橫斷式及描述性相關性設計，使用結構式問卷於北部某醫學中心之門診進行收案，本研究共收案低位直腸癌行肛門括約肌保留手術之病人78位及腹部會陰切除術之病人10位。研究工具包含：個案人口學基本資料、EORTC QLQ-C30及EORTC QLQ-CR29、直腸癌低前位切除綜合症評分量表(LARS Score)及家庭關懷度指數(Family APGAR Index)。研究結果以T test、one-way ANOVA及複迴歸等統計方式進行資料分析。
本研究結果發現低位直腸癌行肛門括約肌保留手術之病人其術後腸道功能障礙嚴重度及家庭功能可預測整體生活品質。病人之家庭功能越好者，整體生活品質也越好；而病人術後腸道功能障礙越嚴重者，其整體生活品質則越差。另外，本研究也發現，比較術後出院日滿六個月以上之行肛門括約肌保留手術及行腹部會陰切除術的病人之整體生活品質，結果有顯著差異，行肛門括約肌保留手術之病人整體生活品質較差。但肛門括約肌保留手術者進一步依術式差異分為低前位切除及全直腸繫膜切除兩組，比較其生活品質，結果發現低位直腸癌行全直腸繫膜切除術者之整體生活品質皆比行低前位切除術者及行腹部會陰切除術者差，而行低前位切除術者與行腹部會陰切除者間無顯著差異。
根據本研究結果得到低位直腸癌經歷有或無肛門括約肌保留術式後生活品質差異，及術後腸道功能障礙嚴重度以及家庭功能程度與病人之生活品質關係的知識，可協助醫療專業人員視不同腸道功能障礙嚴重度及家庭功能之病人，計劃給予不一樣的介入及幫助，以及考量病人之家庭，並強化其功能，協助病人及家屬適應抗癌生活，提升整體生活品質。

Owing to hereditary factors and Westernized cuisine, the number of patients suffer from colorectal cancer has increased in recent years. Most tumors develop in the lower regions of the intestinal tract (in the junction between the sigmoid colon and the rectum and in the rectum). It is especially difficult for these patients with low rectal cancer to return to the same quality of life they had previously. Besides the psychological impact, the patients undergo the surgery may leave them with dysfunction of defecation, urination and sexual function. These problems cause them inconvenience and impact their quality of live significantly. To reduce this impact, the type of surgery has changed greatly. Abdominoperineal resection (APR) would leave a permanent stoma. This is changed to sphincter-preserving surgery (SPS) that would preserve sphincters. However, the short-term and the long-term impact of the above two surgeries on the patient’s quality of life have not come to a conclusion yet. The purposes of this study are 1) compare the bowel dysfunction and health-related quality of life between patients who have undergone SPS less than six months and more than six months; 2) examine the influence of the degree of bowel dysfunction after SPS and family function on the overall quality of life; and 3) compare the overall quality of life between patients who have undergone SPS and APR.
This study adopts purposive sampling and uses cross-sectional, descriptive and correlational study design examining cases from outpatients at a Medical Center in Northern Taiwan with data collection by using structured questionnaires. Participants are patients with lower rectal cancer. 78 of them had undergone sphincter-preserving surgery, and 10 of them had undergone abdominoperineal resection. The measurement tools include the basic case demographic information, EORTC QLQ-C30 and EORTC QLQ-CR29, the low anterior resection syndrome score (LARS score), and the family APGAR index. The results were analyzed by t-tests, one-way analysis of variance (ANOVA), multiple regression, and other methods.
The results show that the overall quality of life of patients who have undergone sphincter-preserving surgery can be predicated by family function and the degree of bowel dysfunction after surgery. The patient’s quality of life increased along with the better family function, and decreased along with the higher degree of bowel dysfunction. Moreover, this study also found a significant difference between the quality of life in patients who have undergone SPS and APR over six months. The patients who have undergone SPS have the lower quality of life. We further divided patients who underwent SPS into two groups according to their type of surgery: total mesorectal excision (TME) and low anterior resection (LAR) and analyze the difference between TME, LAR, and abdominoperineal resection (APR). The results show that the overall quality of life of patients who have undergone TME have the lower quality of life than that of LAR and APR. There is no significant difference between LAR and APR.
The results of this study provide insight into the quality of life of patients who have undergone sphincter-preserving surgery or not for lower rectal cancer, as well as drawing a relationship between the quality of life, the degree of bowel dysfunction and family function. It would help healthcare professionals to plan the unique interventions according to the different degree of bowel dysfunction and family function, and strengthen family function to help patients and their family to adapt to their new way of life and raise their quality of life.

目錄
口試委員審定書 i
致謝 ii
中文摘要 iii
Abstract v
目錄 vii
圖目錄 x
表目錄 x
第一章 緒論 1
第一節 研究動機及重要性 1
第二節 研究目的 3
第三節 名詞定義 4
第二章 文獻查證 5
第一節 直腸癌之概論 5
第二節 低位直腸癌之治療 9
第三節 癌症病人之生活品質及相關影響因素 12
第四節 家庭功能的測量 16
第五節 肛門括約肌保留手術後之生活品質及相關影響因素 18
第六節 肛門括約肌保留手術後之功能障礙嚴重度的測量 22
第七節 肛門括約肌保留手術後之生活品質的測量 24
第三章 研究方法 26
第一節 研究架構 26
第二節 研究假設 27
第三節 研究設計 27
第四節 研究對象與研究場所 28
第五節 研究工具 30
第六節 研究步驟 39
第七節 資料處理與統計分析方法 41
第八節 研究對象權益之維護與倫理考量 42
第四章 研究結果 43
第一節 低位直腸癌病人社會人口學特質與疾病治療狀況分析 43
第二節 低位直腸癌行肛門括約肌保留手術病人健康相關生活品質問卷評分結果分析 51
第三節 低位直腸癌行肛門括約肌保留手術病人健康相關生活品質與各自變項之相關檢定 60
第四節 時間因素對低位直腸癌行肛門括約肌保留手術病人術後腸道症狀及健康相關生活品質之影響 79
第五節 直腸癌低前位切除綜合症嚴重度與健康相關生活品質之相關分析 85
第六節 低位直腸癌行肛門括約肌保留手術病人之家庭功能與健康相關生活品質之相關分析 85
第七節 低位直腸癌行肛門括約肌保留手術病人健康相關生活品質之預測因子多變項分析 87
第八節 低位直腸癌行肛門括約肌保留手術病人與行腹部會陰切除術病人健康相關生活品質之比較 89
第五章 討論 96
第一節 低位直腸癌病人社會人口學特質與疾病治療狀況 96
第二節 低位直腸癌行肛門括約肌保留手術病人健康相關生活品質之概況 97
第三節 低位直腸癌行肛門括約肌保留手術病人社會人口學特質及疾病治療狀況與健康相關生活品質之相關性 100
第四節 時間因素對低位直腸癌行肛門括約肌保留手術病人術後腸道症狀及健康相關生活品質之影響 102
第五節 直腸癌低前位切除綜合症嚴重度與健康相關生活品質之相關分析 105
第六節 低位直腸癌行肛門括約肌保留手術病人之家庭功能與健康相關生活品質之相關分析 107
第七節 低位直腸癌行肛門括約肌保留手術病人健康相關生活品質之預測因子多變項分析 108
第八節 低位直腸癌行肛門括約肌保留手術病人與行腹部會陰切除術病人健康相關生活品質之差異 109
第六章 結論與建議 112
第一節 結論 112
第二節 護理臨床實務運用 114
第三節 研究限制及建議 116
參考資料 117
中文參考資料 117
英文參考資料 118
附錄一 研究工具同意書1 126
附錄二 研究工具同意書2 127
附錄三 研究工具同意書3 128
附錄四 研究倫理委員會同意書 129
附錄五 研究問卷 132
附錄六 研究問卷 133
附錄七 研究問卷 135
附錄八 研究問卷 137
附錄九 研究問卷 138

圖目錄
圖3-1-1 研究架構 26
圖3-6-1 研究步驟 40

表目錄
表2-1-1 直腸癌的分期 8
表3-5-1 EORTC QLQ-C30問卷內容 31
表3-5-2 EORTC QLQ-CR29問卷內容 34
表4-1-1-1 直腸癌病人之基本人口學資料與疾病特性 (N=88) 47
表4-1-1-2 直腸癌病人之基本人口學資料與疾病特性（續） (N=88) 48
表4-1-2-1 LARS Score直腸癌低前位切除綜合症評分量表之各題選項頻率與計分統計(SPS group N=78) 49
表4-1-2-2 個案依LARS Score直腸癌低前位切除綜合症量表評分之嚴重度分布 (SPS group N=78) 49
表4-1-3-1 Family APGAR Index家庭關懷度指數之各題選項頻率與計分統計 (SPS group N=78) 50
表4-1-3-2 個案依Family APGAR Index家庭關懷度指數得分之等級分佈 (SPS group N=78) 50
表4-2-1-1 低位直腸癌病人生活品質核心問卷(EORTC QLQ-C30)各題項之描述性統計分析 (SPS group N=78) 54
表4-2-1-2 低位直腸癌病人生活品質核心問卷(EORTC QLQ-C30)各題項之描述性統計分析（續） (SPS group N=78) 55
表4-2-2 低位直腸癌病人生活品質核心問卷(EORTC QLQ-C30)各題組/單題之計分以百分換算的結果 (SPS group N=78) 56
表4-2-3-1 低位直腸癌病人結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)各題項之描述性統計分析 (SPS group N=78) 57
表4-2-3-2 低位直腸癌病人結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)各題項之描述性統計分析（續）(SPS group N=78) 58
表4-2-4 低位直腸癌病人結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)各題組/單題之計分以百分換算的結果 (SPS group N=78) 59
表4-3-1-1 低位直腸癌病人各項社會人口學及疾病治療特性變項與生活品質核心問卷(EORTC QLQ-C30)計分的關係分析 (SPS group N=78) 63
表4-3-1-2 低位直腸癌病人各項社會人口學及疾病治療特性變項與生活品質核心問卷(EORTC QLQ-C30)計分的關係分析（續）(SPS group N=78) 64
表4-3-1-3 低位直腸癌病人各項社會人口學及疾病治療特性變項與生活品質核心問卷(EORTC QLQ-C30)計分的關係分析（續）(SPS group N=78) 65
表4-3-1-4 低位直腸癌病人各項社會人口學及疾病治療特性變項與生活品質核心問卷(EORTC QLQ-C30)計分的關係分析（續）(SPS group N=78) 66
表4-3-1-5 低位直腸癌病人各項社會人口學及疾病治療特性變項與生活品質核心問卷(EORTC QLQ-C30)計分的關係分析（續）(SPS group N=78) 67
表4-3-1-6 低位直腸癌病人各項社會人口學及疾病治療特性變項與生活品質核心問卷(EORTC QLQ-C30)計分的關係分析（續）(SPS group N=78) 68
表4-3-2-1 低位直腸癌病人各項社會人口學及疾病治療特性變項與結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)計分的關係分析 69
表4-3-2-2 低位直腸癌病人各項社會人口學及疾病治療特性變項與結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)計分的關係分析（續） 70
表4-3-2-3 低位直腸癌病人各項社會人口學及疾病治療特性變項與結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)計分的關係分析（續） 71
表4-3-2-4 低位直腸癌病人各項社會人口學及疾病治療特性變項與結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)計分的關係分析（續） 72
表4-3-2-5 低位直腸癌病人各項社會人口學及疾病治療特性變項與結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)計分的關係分析（續） 73
表4-3-2-6 低位直腸癌病人各項社會人口學及疾病治療特性變項與結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)計分的關係分析（續） 74
表4-3-2-7 低位直腸癌病人各項社會人口學及疾病治療特性變項與結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)計分的關係分析（續） 75
表4-3-2-8 低位直腸癌病人各項社會人口學及疾病治療特性變項與結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)計分的關係分析（續） 76
表4-3-2-9 低位直腸癌病人各項社會人口學及疾病治療特性變項與結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)計分的關係分析（續） 77
表4-3-2-10 低位直腸癌病人各項社會人口學及疾病治療特性變項與結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)計分的關係分析（續） 78
表4-4-1 肛門括約肌保留術後≦6M與術後>6M~48M在生活品質核心問卷(EORTC QLQ C30)差異之one-way ANOVA檢定 81
表4-4-2-1 肛門括約肌保留術後≦6M與術後>6M~48M在結腸直腸癌特殊性生活品質問卷(EORTC QLQ CR29)差異之one-way ANOVA檢定 82
表4-4-2-2 肛門括約肌保留術後≦6M與術後>6M~48M在結腸直腸癌特殊性生活品質問卷(EORTC QLQ CR29)差異之one-way ANOVA檢定（續） 83
表4-5-1 直腸癌低前位切除綜合症(LARS)及家庭功能與整體生活品質之相關分析 (SPS group N=78) 86
表4-5-2 不同腸道功能障礙等級與整體生活品質之one way ANOVA單變項檢定分析 (N=78) 86
表4-7-1 影響低位直腸癌行肛門括約肌保留手術後整體生活品質之變項複迴歸分析 (SPS group N=78) 88
表4-8-1 術後出院6個月以上至48個月之行肛門括約肌保留術跟行腹部會陰切除術在生活品質核心問卷(EORTC QLQ-C30)差異之T檢定 92
表4-8-2 術後出院6個月以上至48個月之行肛門括約肌保留術跟行腹部會陰切除術在結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)差異之T檢定 93
表4-8-3 術後出院6個月以上至48個月之肛門括約肌保留術依術式不同與腹部會陰切除術其術後在生活品質核心問卷(EORTC QLQ-C30)差異之One-way ANOVA分析 94
表4-8-4 術後出院6個月以上至48個月之肛門括約肌保留術依術式不同與腹部會陰切除術其術後在結腸直腸癌特殊性生活品質問卷(EORTC QLQ-CR29)差異之One-way ANOVA分析 95

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衛生福利部國民健康署（2017年5月4日）．103年癌症登記報告．取自
http://www.hpa.gov.tw/Pages/List.aspx?nodeid=119
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