臺灣博碩士論文加值系統

手術後腸阻塞（Postoperative ileus，PI）是手術後引發的腸道功能暫時性損傷。手術後腸阻塞不但會造成病人噁心、嘔吐及腹脹等不舒服的感覺，更會增加術後之罹病率、延長住院天數及增加醫療支出等。
鴉片類藥物長久以來一直是重症腹部手術後疼痛控制之首選藥物。二十一世紀的今日，手術後病人對於疼痛控制的需求愈來愈高，經靜脈自控式止痛裝置可提供術後病人高度的止痛效果及滿意度。由於類鴉片藥物有抑制腸胃道蠕動功能之副作用，故外科醫師總會盡量限制病人類鴉片藥物的使用量，使病人陷入術後疼痛的困擾中。
以往對於術後腸胃道功能與病人自控式止痛裝置的研究多半集中於非重症腹部手術之病人，或者是經硬脊膜外給藥的病人。本研究分為兩部分：第一部分針對重症大腸直腸手術後病人使用經靜脈注射嗎啡自控式止痛裝置加入ketorolac對於嗎啡用量減少及腸道功能影響之研究；第二部份探討加入ketorolac對於影響腸胃道功能恢復之預測因子的相關性分析。
第一部分的研究一共納入74位病人，隨機分成兩組:M組只於靜脈自控式止痛裝置加入嗎啡，M+K組則除嗎啡外另加入了ketorolac。術後我們紀錄病人腸道功能恢復的時間（包括第一次腸道蠕動、排氣及進食時間）、第一次下床時間，疼痛分數及嗎啡相關副作用。
研究結果顯示加了ketorolac以後可減少嗎啡消耗量約29%，同時M+K組病人術後恢復第一次腸道蠕動及下床時間有顯著的縮短。對於第一次排氣及進食時間甚或住院天數，則兩組病人並無顯著差異。嗎啡相關副作用與疼痛分數在兩組病人之間亦無明顯不同。
本研究的結論是：雖然在靜脈自控式止痛裝置中添加ketorolac有顯著的降低嗎啡使用量的效應(morphine-sparing effect)，然而嗎啡使用量的減少並不能確實地加速腸道功能的回復，所以術後發生腸阻塞的原因，除了嗎啡之外，尚有多重影響的因素存在。因此，針對重症大腸直腸外科術後病人給予多方位照護（multimodal postoperative rehabilitation program）是必要的。
在第二部份的研究，我們一共收入102位大腸直腸手術病人，同樣地隨機分成M組和M+K組。我們除了紀錄病人腸道功能恢復的時間之外，並加入時間因素影響的線性迴歸分析。結果顯示添加ketorolac與否與術後腸胃道功能恢復有顯著的相關性，而嗎啡消耗量和術後腸胃道功能恢復的相關性反而不如預期明顯。此一結果顯示影響術後腸胃道功能恢復因素的眾多，而以往對於增加嗎啡消耗量影響腸胃道功能的觀念似乎被過分強調了。
近年來對於發炎反應與其媒介物與腸胃道功能的基礎研究越來越多，其中有許多研究結果顯示發炎反應與術後腸胃道功能恢復是息息相關的。我們的研究結果也顯示加ketorolac在嗎啡經靜脈病人自控式止痛裝置中除了有降低類嗎啡使用量效應(opioids sparing effects)之外，可能還有其他的因素影響手術後腸胃道功能的回復。比如說ketorolac抑制發炎反應的效應就有可能是影響的因素之一。因此，我們建議：如果病人選擇術後使用嗎啡經靜脈病人自控式止痛裝置，應該將添加ketorolac納入多方位照護的選項之中。

Background： Postoperative ileus (PI) is the transient impairment of bowel motility due to surgical trauma and associated physiological responses. Postoperative ileus results in patient discomfort, increases gastrointestinal risks, prolongs hospital stay and increases medical expenses. We devised two studies to investigate the effects of patient-controlled analgesia (PCA) of morphine with or without ketorolac on bowel functions in patients after colorectal surgeries.
Methods： Study 1: A total of 79 patients who received elective colorectal resection were randomly allocated into two groups receiving intravenous PCA morphine (M group) or intravenous PCA morphine plus ketorolac (M+K group). Recovery of bowel functions (bowel movement, passage of flatus, and soft diet intake), pain scores, morphine consumption, time for first ambulation, and opioid-related side-effects were recorded.
Study 2: We collected data on 102 patients who received elective colorectal resection. The patients were randomly allocated into 2 groups receiving intravenous patient-controlled analgesia (IVPCA) morphine (M group) or IVPCA morphine plus ketorolac (M+K group). Time-scale morphine consumption (per 12 hours), recovery of bowel functions (the first bowel movement and passage of flatus), pain scores, and opioids-related side effects were recorded.
Results： Study 1: Patients in the M+K group received 29% less morphine than patients in the M group with comparable pain scores. The first bowel movement (1.5 [0.7 - 1.9] vs. 1.7 [1.0 - 2.8] days, P<0.05) and the first ambulation (2.2 ± 1.0 vs. 2.8 ± 1.2 days, P<0.05) were significantly earlier in the M+K group as compared to the M group. The time of the first flatus passing, the first intake of soft diet, and the duration of hospital stay were not significantly different between the two groups.
Study 2: Patients in the M+K group received 18.3% less amount of morphine than those in the M group within 72 postoperative hours. The maximal opioids-sparing effects of ketorolac appeared in 12-24 postoperative hours. The onset of the first bowel movement and the passage of flatus were significantly less in the M+K group as compared to the M group. The M group showed a 5.25 times more risk to inducing PI, a result comparable with the M+K group in colorectal surgery patients.
Conclusions： Addition of ketorolac to IVPCA morphine demonstrated clear opioid-sparing effect and benefits on the shortening of the duration of bowel immobility. We suggest that adding ketorolac to morphine IVPCA be included in the multimodal postoperative rehabilitation program for early restoration of normal bowel function.

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