章密密, 劉先武, 胡興明, 王 建
(江蘇省徐州市礦務(wù)集團(tuán)總醫(yī)院外科, 江蘇 徐州 221006)
腹腔鏡膽囊切除術(shù)治療急性結(jié)石性膽囊炎的療效及對(duì)免疫功能術(shù)后并發(fā)癥的影響
章密密, 劉先武, 胡興明, 王 建
(江蘇省徐州市礦務(wù)集團(tuán)總醫(yī)院外科, 江蘇 徐州221006)
目的探討腹腔鏡膽囊切除術(shù)(laparoscopic cholecystectomy,LC)治療急性結(jié)石性膽囊炎療效及對(duì)免疫功能、術(shù)后并發(fā)癥的影響。方法選取本院2015年3月至2017年2月期間收治的急性結(jié)石性膽囊炎患者88例為研究對(duì)象,采用隨機(jī)法隨機(jī)分為兩組。觀察組42例行LC術(shù),對(duì)照組46例行開(kāi)腹膽囊切除術(shù)(open cholecystectomy,OC)。比較兩組手術(shù)時(shí)間、術(shù)中出血量、術(shù)后排氣時(shí)間、住院時(shí)間、術(shù)后血清C反應(yīng)蛋白(CRP)和皮質(zhì)醇水平變化、術(shù)后CD3、CD4、CD8和CD4/CD8水平、NK細(xì)胞數(shù)變化以及術(shù)后并發(fā)癥情況。結(jié)果觀察組手術(shù)時(shí)間(72.36±12.62)min長(zhǎng)于對(duì)照組(P<0.05),術(shù)中出血量(173.63±22.65)mL少于對(duì)照組(P<0.05),術(shù)后排氣時(shí)間和住院時(shí)間分別為(21.74±7.96)h和(6.35±2.01)d,短于對(duì)照組(P<0.05);觀察組術(shù)后血清CRP和皮質(zhì)醇水平分別為(4.36±0.25)mg/dl和(257.83±10.74)ng/mL,低于對(duì)照組(P<0.05);觀察組術(shù)后CD3、CD4、CD8、CD4/CD8以及NK細(xì)胞數(shù)分別為(64.39±5.37)%、(35.74±3.81)%、(23.65±3.17)%、(1.51±0.08)和(16.46±2.85)%,均高于對(duì)照組(P<0.05);觀察組術(shù)后并發(fā)癥總發(fā)病率為4.76%,低于對(duì)照組并發(fā)癥總發(fā)病率19.57%(P<0.05)。結(jié)論LC治療急性結(jié)石性膽囊炎療效顯著,可有效減輕患者術(shù)后應(yīng)激反應(yīng)以及免疫功能抑制,降低并發(fā)癥發(fā)病率。
腹腔鏡膽囊切除術(shù); 開(kāi)腹膽囊切除術(shù); 急性結(jié)石性膽囊炎; 免疫功能; 并發(fā)癥
急性結(jié)石性膽囊炎是常見(jiàn)的肝膽外科疾病,是膽囊管被結(jié)石阻塞,導(dǎo)致膽汁在膽囊內(nèi)滯留,致病菌入侵后引起的急癥。女性為多發(fā)群體,臨床癥狀主要表現(xiàn)為上腹疼痛、發(fā)熱、惡心、嘔吐[1]。腹腔鏡膽囊切除術(shù)(laparoscopic cholecystectomy,LC)是較為成熟的外科微創(chuàng)手術(shù)之一,手術(shù)具有創(chuàng)傷小、對(duì)患者傷害輕、術(shù)后恢復(fù)快、安全性高等優(yōu)點(diǎn),因此被醫(yī)師和患者普遍認(rèn)可和接受[2]。本研究旨在探討LC和傳統(tǒng)開(kāi)腹膽囊切除術(shù)(open cholecystectomy,OC)治療急性結(jié)石性膽囊炎療效以及對(duì)患者術(shù)后免疫功能和并發(fā)癥影響,現(xiàn)在報(bào)道如下:
1.1一般資料:選取本院2015年3月至2017年2月期間收治的急性結(jié)石性膽囊炎患者88例為研究對(duì)象,采用隨機(jī)法隨機(jī)分為兩組。觀察組行LC術(shù),共42例,其中男18例,女24例,平均年齡(56.38±8.39)歲,平均病程(24.48±11.27)h,平均BMI為(24.87±0.54)kg/m2,單發(fā)性結(jié)石23例,多發(fā)性結(jié)石19例。對(duì)照組行OC術(shù),共46例,其中男19例,女27例,平均年齡(57.34±8.61)歲,平均病程(24.16±11.03)h,平均BMI為(24.64±0.51)kg/m2,單發(fā)性結(jié)石24例,多發(fā)性結(jié)石22例。兩組患者一般資料差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。本研究經(jīng)本院倫理委員會(huì)批準(zhǔn)同意。納入標(biāo)準(zhǔn):①符合急性結(jié)石性膽囊炎診斷標(biāo)準(zhǔn)[3];②發(fā)病后48h內(nèi)入院接受治療;③具有膽囊切除術(shù)手術(shù)指征;④患者均知情同意,并自愿簽署病人知情同意書。排除標(biāo)準(zhǔn):①慢性膽囊炎急性發(fā)作者;②合并有惡性腫瘤者;③伴有嚴(yán)重肝、腎、心功能不全者;④患有精神系統(tǒng)疾病者。
1.2治療方法:觀察組:患者均行LC術(shù)。術(shù)前常規(guī)禁飲禁食,全身麻醉,氣管插管,并監(jiān)護(hù)生命體征。患者取頭高腳低體位,于臍下緣做一切口,長(zhǎng)度約為10mm,建立氣腹,維持CO2氣腹壓力10~13mmHg。置入腹腔鏡鏡頭,然后于肝圓韌帶右側(cè)和腋前線交匯肋弓處下緣處穿刺,置入腹腔鏡器械,在腹腔鏡下探查腹腔,包括肝臟情況、膽囊情況以及周圍組織粘連情況,明確膽囊動(dòng)脈和膽囊管后,將其夾閉并切斷,采用電灼法徹底止血,然后采用無(wú)菌手套取出切下的膽囊。腹腔反復(fù)沖洗,仔細(xì)檢查后,于膽囊窩處常規(guī)置管引流,并關(guān)閉切口。對(duì)照組:患者均行OC術(shù)。術(shù)前常規(guī)禁飲禁食,全身麻醉,氣管插管,并監(jiān)護(hù)生命體征。于右側(cè)肋緣下緣做一切口,長(zhǎng)度10~12cm,將器官、組織分離,明確膽總管、膽囊三角、膽囊管等解剖結(jié)構(gòu)位置關(guān)系后,結(jié)扎并切斷膽囊動(dòng)脈和膽囊管,然后切除膽囊(逆行或順行方法)。徹底止血后,反復(fù)沖洗腹腔并仔細(xì)檢查,于膽囊窩處常規(guī)置管引流,并關(guān)閉切口。
1.3觀察指標(biāo):①觀察并記錄兩組手術(shù)時(shí)間、術(shù)中出血量、術(shù)后排氣時(shí)間、住院時(shí)間。②于術(shù)前和術(shù)后1d,采集患者靜脈血2~3mL,低溫離心取上清,采用免疫比濁法檢測(cè)血清C反應(yīng)蛋白(CRP)水平,采用間接競(jìng)爭(zhēng)法檢測(cè)血清皮質(zhì)醇水平,試劑盒均購(gòu)自上海江萊生物有限公司。③于術(shù)前和術(shù)后1d,采用CytoFLEX流式細(xì)胞儀(美國(guó)貝克曼公司)檢測(cè)血清CD3、CD4、CD8和CD4/CD8水平、NK細(xì)胞數(shù)。④觀察并記錄兩組術(shù)后并發(fā)癥情況。
觀察組手術(shù)時(shí)間長(zhǎng)于對(duì)照組(P<0.05),術(shù)中出血量少于對(duì)照組(P<0.05),術(shù)后排氣時(shí)間以及住院時(shí)間短于對(duì)照組(P<0.05),差異均有統(tǒng)計(jì)學(xué)意義,見(jiàn)表1;兩組術(shù)前各應(yīng)激指標(biāo)比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),術(shù)后,血清CRP和皮質(zhì)醇水平均升高(P<0.05),觀察組升高幅度小于對(duì)照組(P<0.05),差異有統(tǒng)計(jì)學(xué)意義,見(jiàn)表2;兩組術(shù)前各免疫功能指標(biāo)比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),術(shù)后,觀察組CD3、CD4、CD8、CD4/CD8水平以及NK細(xì)胞數(shù)高于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05),見(jiàn)表3;觀察組術(shù)后總并發(fā)癥發(fā)病率低于對(duì)照組(P<0.05),見(jiàn)表4。
表1 兩組手術(shù)相關(guān)指標(biāo)和住院時(shí)間比較
表2 兩組術(shù)后應(yīng)激指標(biāo)變化比較
注:與同組術(shù)前比較,1)P<0.05;與對(duì)照組比較,2)P<0.05
表3 兩組手術(shù)前后免疫功能指標(biāo)變化比較
注:與同組術(shù)前比較,1)P<0.05;與對(duì)照組比較,2)P<0.05
表4 兩組術(shù)后并發(fā)癥發(fā)生情況比較
OC術(shù)曾是急性結(jié)石性膽囊炎患者臨床治療的標(biāo)準(zhǔn)術(shù)式,具有視野寬闊、解剖關(guān)系清晰、療效確切等優(yōu)點(diǎn),但同時(shí)存在對(duì)機(jī)體損傷大、術(shù)后疼痛感強(qiáng)、康復(fù)慢等缺點(diǎn)[4]。隨著醫(yī)療水平的發(fā)展和醫(yī)師技術(shù)的提高,LC術(shù)已逐漸在急性結(jié)石性膽囊炎治療中展開(kāi),并獲良好效果。有研究指出,LC術(shù)與OC術(shù)治療急性結(jié)石性膽囊炎療效相當(dāng),而且安全性高[5,6]。
本研究比較了LC術(shù)和OC術(shù)治療急性結(jié)石性膽囊炎療效,結(jié)果顯示,觀察組在術(shù)中出血量、術(shù)后排氣時(shí)間以及住院時(shí)間等方面均優(yōu)于對(duì)照組,但手術(shù)時(shí)間長(zhǎng)于對(duì)照組,提示LC術(shù)相對(duì)于OC術(shù),可有效減少術(shù)中出血量,促進(jìn)胃功能恢復(fù),縮短患者住院時(shí)間,由于LC術(shù)視野相對(duì)狹窄,操作難度相對(duì)較大,所以手術(shù)時(shí)間相對(duì)延長(zhǎng),與吳袁生[7]等研究結(jié)果一致,患者恢復(fù)較快與手術(shù)切口較小,術(shù)中對(duì)組織損傷較輕等因素有關(guān)。手術(shù)創(chuàng)傷會(huì)使機(jī)體代謝功能、神經(jīng)內(nèi)分泌功能發(fā)生一定變化,引起術(shù)后應(yīng)激反應(yīng)[8]。CRP是在IL-6誘導(dǎo)下由肝細(xì)胞合成的急性時(shí)相反應(yīng)蛋白,其在機(jī)體受到創(chuàng)傷或感染時(shí)迅速升高,是反映創(chuàng)傷程度和應(yīng)激反應(yīng)強(qiáng)度的靈敏指標(biāo)[9]。皮質(zhì)醇是由腎上腺釋放的應(yīng)激激素,當(dāng)機(jī)體受到急性創(chuàng)傷時(shí),皮質(zhì)醇激素則大合成并釋放,使血液中檢測(cè)水平顯著升高,是臨床常用應(yīng)激反應(yīng)指標(biāo)[10]。本研究結(jié)果顯示,兩組術(shù)前血清CRP和皮質(zhì)醇水平差異無(wú)統(tǒng)計(jì)學(xué)意義,術(shù)后均升高,但觀察組術(shù)后血清CRP和皮質(zhì)醇水平低于對(duì)照組,提示LC術(shù)可抑制術(shù)后CRP和皮質(zhì)醇水平升高,患者應(yīng)激反應(yīng)較輕。
手術(shù)創(chuàng)傷不僅會(huì)引起機(jī)體應(yīng)激反應(yīng),還會(huì)不同程度抑制機(jī)體免疫功能,主要表現(xiàn)為免疫功能因子水平降低。CD3、CD4、CD8均為T淋巴細(xì)胞亞群因子,在正常生理情況下,起到免疫維持作用。NK細(xì)胞可直接殺傷腫瘤細(xì)胞、抗病原體感染、調(diào)節(jié)免疫功能,且對(duì)正常細(xì)胞無(wú)損傷,是機(jī)體重要免疫細(xì)胞之一。本研究通過(guò)細(xì)胞流式儀檢測(cè)了血清中T淋巴細(xì)胞亞群變化以及NK細(xì)胞數(shù),結(jié)果顯示,兩組術(shù)前CD3、CD4、CD8、CD4/CD8以及NK細(xì)胞數(shù)差異無(wú)統(tǒng)計(jì)學(xué)意義,術(shù)后均有所降低,但觀察組降低幅度小于對(duì)照組,提示術(shù)后兩組患者免疫功能均受到抑制,LC術(shù)相對(duì)于OC術(shù),可有效減輕免疫抑制反應(yīng),增強(qiáng)機(jī)體抵抗力,減少術(shù)后病菌入侵。觀察組術(shù)后膽漏1例、胃腸道反應(yīng)1例,總并發(fā)癥發(fā)病率為4.76%,對(duì)照組切口感染4例、膽漏3例、胃腸道反應(yīng)2例,總并發(fā)癥發(fā)病率為19.57%,差異有統(tǒng)計(jì)學(xué)意義,提示LC術(shù)可降低患者術(shù)后并發(fā)癥發(fā)病率。
綜上所述,對(duì)于急性結(jié)石性膽囊炎患者,采用LC術(shù)治療不僅創(chuàng)傷小、患者恢復(fù)快,而且可有效改善患者術(shù)后血清CRP、皮質(zhì)醇水平和免疫功能細(xì)胞水平,減輕術(shù)后應(yīng)激反應(yīng)以及免疫抑制,減少術(shù)后并發(fā)癥,相對(duì)于OC術(shù),具有較明顯優(yōu)勢(shì)。
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EffectsofLaparoscopicCholecystectomyonEfficacyofAcuteCalculousCholecystitisandImmuneFunctionandPostoperativeComplications
ZHANGMimi,LIUXianwu,HUXingming,etal
(TheGeneralHospitalofXuzhouMiningGroup,JiangsuXuzhou221006,China)
Objective: To explore the effects of laparoscopic cholecystectomy (LC) on the efficacy of acute calculouscholecystitis and immune function and postoperative complications.Methods88 cases of patients with acute calculous cholecystitis treated in our hospital from March 2015 to February 2017 were selected for the study and divided into two groups: the observation group (n=42, treated with LC surgery) and the control group(n=46, treated with open cholecystectomy/OC) according to the random number table method. The operative time, intraoperative blood loss, postoperative exhaust time, hospital stays, the changes of postoperative serum C-reactive protein (CRP)levels and cortisol levels, postoperative levels of CD3, CD4, CD8 and CD4/CD8, NK cells changes and postoperative complications were compared between the two groups.ResultsThe operative time was (72.36±12.62) min in the observation group, which was significantly longer than that of the control group (P<0.05). The intraoperative blood loss amount was (173.63±22.65) ml in the observation group, which was significantly less than that in the control group (P<0.05). The postoperative exhaust time and hospital stays were (21.74±7.96) h and (6.35±2.01) d, which were significantly shorter than those of the control group (P<0.05). The levels of serum CRP and cortisol were (4.36±0.25) mg/dl and (257.83±10.74) ng/ml respectively in the observation group, which were significantly lower than those in the control group (P<0.05). The percentage of CD3, CD4, CD8, CD4/CD8 and NK cells were (64.39±5.37)%, (35.74±3.81)%, (23.65±3.17)%, (1.51±0.08) and (16.46±2.85) %in the observation group, which were significantly higher than those in the control group (P<0.05). The total incidence rate of postoperative complications was 4.76% in the observation group, which was significantly lower than that in the control group with19.57% (P<0.05).ConclusionsLC can have a significant effect, and can effectively reduce the patient's postoperative stress response and immune function inhibition, and reduce the incidence rate of complications in the treatment of acute calculous cholecystitis.
Laparoscopic cholecystectomy; Open cholecystectomy; Acute calculous cholecystitis; Immune function; Complications
1006-6233(2017)11-1810-04
江蘇省衛(wèi)生科技攻關(guān)項(xiàng)目,(編號(hào):10563)
王 建
A
10.3969/j.issn.1006-6233.2017.11.014