腹腔镜胆囊切除术对细胞因子、内皮素和C反应蛋白水平的影响

目的:探讨开腹与腹腔镜胆囊切除术(LC)2种方法对胆囊疾病患者血中细胞因子、内皮素和C反应蛋白的影响,比较两种方法对机体损伤的程度及安全性。方法:选择行剖腹胆囊切除术(OC)患者50例,LC患者50例,分别于术前和术后抽取静脉血检测IL-2、IL-6、NK细胞活性、CD4/CD8、内皮素、C反应蛋白含量并进行比较。结果:OC组IL-2和NK细胞活性术后较术前下降(P<0.05),IL-6术后较术前明显上升(P<0.01)。IL-6术后OC组较LC组上升(P<0.05)。OC组IL-2术后较LC组降低(P<0.05)。CD4/CD8未发现明显变化。OC组血中内皮素术后含量明显高于LC组患者(P<0.01),C反应蛋白于术后亦高于LC组。结论:研究表明LC损伤小,是一种安全可靠的手术方式。     

腹腔镜胆囊切除术后患者肝功能及免疫功能的变化

目的:观察腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)对患者肝功能及免疫功能的影响。方法:回顾分析2010年1月至2012年1月为胆囊结石患者行开腹胆囊切除术(open cholecystectomy,OC)(n=65)及LC(n=65)的临床资料,对比两组患者肝功能及免疫功能的变化。结果:两组患者术后血清ALT、AST、TBIL均较术前升高,术后第5天恢复至正常水平。术后第1天、第3天,OC组ALT、AST、TBIL水平明显低于LC组,差异有统计学意义(P<0.05);免疫学指标IgA、IgM、IgG两组患者手术前后均无明显改变,差异无统计学意义(P>0.05)。结论:LC可造成患者肝功能明显升高,但术后可迅速恢复,对免疫功能无影响。     

腹腔镜胆囊切除术与开腹胆囊切除术对肝功能影响的比较研究

目的 对腹腔镜胆囊切除术（LC）与开腹胆囊切除术（OC）手术前后肝功能的临床资料进行对比研究，旨在观察术后肝功能变化规律及两种术式对肝功能的影响有无差异，并为今后手术病例及术式选择提供依据。方法 选择胆囊良性病变且肝功能正常需行胆囊切除术者作为研究对象。将30例病人分为LC组和OC组，并分别按开放法或腹腔镜方法实施胆囊切除术。术前、术后第1、3、7天，分别取空腹外周静脉血测定肝功能指标，包括ALT、AST、TBIL、DBIL、GGT、ALB、ALP。结果 两组病人年龄构成及术前肝功能无显著差异，LC与OC术后各项指标变化趋势相同。LC与OC术后血清ALT、AST、TBIL均较术前升高；上述指标术后第3天即明显下降，至术后第7天达正常水平，且所有病人术后顺利恢复。LC与OC术后血清ALB均有下降，血清DBIL、GGT、ALP均无显著变化。结论 本研究结果表明：（1）LC与OC对肝功能均有影响，但仅为一过性现象，不影响病人恢复；（2）在全麻下，腹腔内气腹压力为12～15mmHg时，LC对肝功能的影响与OC相比无显著性差异，说明在此情况下施行LC是安全的。     

雷米芬太尼对腹腔镜胆囊切除术患者IL-6、IL-8和IL-10的影响

目的观察全麻下雷米芬太尼与芬太尼对腹腔镜胆囊切除术(LC)患者白细胞介素(IL)-6、IL-8和IL-10的影响。方法20例LC患者,随机分为两组,每组10例。雷米芬太尼组(Ⅰ组)和芬太尼组(Ⅱ组),分别测定麻醉诱导前、气腹手术前、气腹手术后0.5h、术毕0.5h、术后24h的血清IL-6、IL-8和IL-10的水平。结果IL-6、IL-8和IL-10在创伤后1~1.5h开始升高,IL-6的变化最早,IL-8、IL-10在手术结束时逐渐升高,IL-6、IL-8在术后24h仍在继续上升(P<0.05),而IL-10则有不升或缓升趋势。IL-10对IL-6和IL-8的升高有一定的平衡作用。组间比较,术后24hⅠ组IL-6、IL-8较Ⅱ组都有明显升高(P<0.01)。结论与芬太尼相比,雷米芬太尼可更为有效地减轻创伤刺激后IL-6、IL-8和IL-10的释放。     

腹腔镜胆囊切除术对机体炎症免疫反应的影响

目的:对比研究腹腔镜胆囊切除(laparoscopic cholecystectomy,LC)和开腹胆囊切除术(open choleaptectomy,OC)对机体炎症免疫反应的影响.方法:检测胆囊结石患者(LC及OC各30例)术前、术后1 h、术后1 d、术后2 d的外周血T淋巴细胞亚群、WBC计数、C反应蛋白(C-reactive protein,CRP)及白介素-6(IL-6)的变化并进行对比研究.IL-6值的检测用酶联免疫吸附法(ELISA),T细胞亚群用流式细胞仪检测.结果:OC组术后2 d,成熟T淋巴细胞(CD3)、辅助性T淋巴细胞(CD4)、CD4/抑制性T淋巴细胞(CD8)比值较术前下降(P<0.05),且同LC组相比较,OC组明显低于LC组(P<0.01).OC组术后1 d或/和术后2 d WBC计数、CRP、IL-6均较术前明显升高(P<0.01),且与LC组相比较,OC组明显高于LC组(P<0.01).结论:LC对机体炎症免疫反应影响小,有利于LC术后的恢复.     

腹腔镜胆囊切除术对患者肝功能及C反应蛋白水平的影响

目的：探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）与开腹胆囊切除术（open cholecystectomy,OC）两种术式对患者肝功能的影响。方法：随机将慢性胆囊炎合并胆囊结石患者75例分为LC组40例,OC组35例,分别于术前及术后第1、3、5天抽取外周静脉血2ml,检测以下指标：血清总胆汁酸（TBA）、丙氨酸氨基转移酶（ALT）、天冬氨酸氨基转移酶（AST）、血清总胆红素（TBIL）、γ-谷氨酸转肽酶（γ-GT）、碱性磷酸酶（ALP）以及C反应蛋白（CRP）。结果：LC组和OC组手术后第1天与第3天TBA、ALT、AST、TBIL及CRP均升高,LC组的CRP升高较OC组更加显著（P〈0.05）。手术后第5天两组各项指标均恢复至正常水平,两组无显著差异。结论：腹腔镜胆囊切除术与开腹胆囊切除术相比,对肝功能的影响无明显差异,实施腹腔镜胆囊切除术安全可行。     

IL-6强化的肠外营养对肝硬化大鼠肝切除术后残肝的影响

目的 探讨白细胞介素-6(IL-6)强化的肠外营养(PN)对肝硬化大鼠肝切除术后残肝的影响.方法 6只正常大鼠为正常对照组(A组),24只肝硬化大鼠随机分为4组(B～E组,n＝6);B组:肝硬化术前组,C组:肝切除+颈内静脉插管术后1 d组,D组:肝切除术后行PN 5 d组,E组:肝切除术后行PN+IL-6 5d组.测大鼠肝功能,炎症反应和脂质过氧化指标.肝组织ALB mRNA的表达.结果 与D组比较,E组血清AST、ALT、ALP显著下降(P＜0.05),血清ALB显著升高(P＜0.05);血清IFN-γ、TNF-α、MDA显著下降(P＜0.05),血清SOD活性显著升高(P＜0.05);肝组织ALB mRNA表达显著升高(P＜0.05).结论 PN+IL-6可以加快肝硬化大鼠肝切除术后肝功能的恢复,减轻炎症反应和脂质过氧化损伤,促进肝脏蛋白合成.     

腹腔镜胆囊切除术对老年患者肝肾功能影响的临床研究

目的:探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)与传统开腹手术对老年患者肝肾功能的影响。方法:回顾分析2009年6月至2013年6月为118例70岁以上老年患者行胆囊切除术的临床资料,其中65例行LC(LC组),53例行开腹胆囊切除术(open cholecystectomy,OC组)。对比两组患者手术时间、术中出血量、术后住院时间、术后并发症及手术前后肝肾功能指标的变化情况。结果:118例患者均成功完成手术,LC组在术后住院时间、术后进食时间及术后并发症方面优于OC组(P<0.05);与术前相比,两组患者术后第1天肝功能指标AST、ALT、ALP、TBIL及肾功能指标BUN、SCr均有所升高,差异有统计学意义(P<0.05);术后第5天,LC组上述指标基本下降至术前水平,而OC组仍高于术前水平(P<0.05)。两组间相比,术后第1天、第5天,OC组患者AST、ALT、ALP、TBIL、BUN、SCr均高于同时点LC组(P<0.05)。结论:LC患者创伤小,术后康复快,对肝肾功能影响较小;在严格把握手术适应证的前提下,实施个体化治疗原则,为老年患者行LC是安全、可行的。     

腹腔镜胆囊切除围手术期创伤应激、酸碱平衡和能量代谢

目的　研究腹腔镜胆囊切除术 (LC)围手术期创伤应激激素水平、C反应蛋白和机体能量代谢与开腹胆囊切除术 (OC)的差异。　方法　慢性结石性胆囊炎患者 2 6例 (LC组 14例 ,OC组 12例 ) ,于术前 1d、术后 1d和 3d晨分别检测血C 反应蛋白 (CRP)、生长激素、皮质醇和胰岛素。同时测定静息能量消耗 (REE)和呼吸商 (RQ)。　结果　胰岛素在OC患者术后第 3天与术前比较有明显下降。生长激素、C 反应蛋白和皮质醇上升在OC术后明显高于LC(P <0 0 5 )。 2组患者静息能量消耗(REE)术后较术前显著增加 ,而术后OC患者REE明显高于LC患者 (P <0 0 5 )。 2组患者呼吸商(RQ)术后比较术前均有显著下降。LC组动脉血氧分压与氧饱和度术后 1d明显下降 ,第 3天恢复。LC组术后 3dBE明显高于OC组。　结论　腹腔镜手术创伤小 ,应激水平低 ,对患者代谢影响小 ,有益于机体应激激素、氮平衡和能量代谢的恢复。气腹可以引起体内酸血症和肺血灌流不足。     

不同气腹压对老年患者腹腔镜胆囊切除术后肝功能的影响

目的探讨不同气腹压对老年患者腹腔镜胆囊切除术(LC)后肝功能的影响及其可能机制。方法选择60岁以上老年患者行LC76例,根据术中CO2气腹压水平将患者分为3组,即低气腹压组(LP组,n=20)腹内压(IAP)维持在1.3kPa水平、标准气腹压组(SP组,n=33)IAP维持在1.6kPa水平和高气腹压组(HP组,n=23)IAP维持在2.0kPa水平。其中SP组根据术中气腹维持时间再细分为两个亚组,即A亚组(时间>50min),B亚组(时间≤50min)。各组患者分别于术前、术后1d及术后4d抽取静脉血测定血清ALT、AST含量并进行对比研究。结果SP组和HP组的血清ALT、AST水平均在术后1d明显升高(P<0.01),其中HP组升高较SP组明显(P<0.01),而LP组升高不明显(P>0.05)。SP组在术后4d血清ALT、AST基本恢复至正常水平,而HP组虽有下降,但多数患者仍高于正常水平。SP组中的A亚组术后1d血清ALT、AST升高水平明显高于B亚组(P<0.01)。结论腹腔镜胆囊切除术中建立的CO2气腹可能引起老年患者术后一过性肝功能异常,且与CO2气腹压的高低和维持时间有关。     

乌司他丁对肝脏肿瘤切除术患者肝脏缺血-再灌注损伤的保护作用

目的观察乌司他丁对肝脏肿瘤切除术患者肝脏缺血-再灌注损伤的保护作用。方法选择32例ASAⅠ～Ⅲ级拟行肝脏肿瘤切除术的患者,随机均分为乌司他丁组(U组)和对照组(C组)。U组:乌司他丁12000U/kg加在生理盐水50ml中,麻醉诱导后切皮前经颈内静脉泵入;C组:注入等量的生理盐水。在切皮时(T1)、缺血后10min(T2)、再灌注10min(T3)、30min(T4)、1h(T5)、术后1d(T6)、2d(T7)抽取静脉血测定血浆中谷草转氨酶(AST)、谷丙转氨酶(ALT)、超氧化物歧化酶(SOD)活性,丙二醛(MDA)水平、白细胞介素1β(IL-1β)、白细胞介素6(IL-6)、肿瘤坏死因子(TNF-α)浓度。结果与T1时比较,T3～T6时两组的AST、ALT活性、MDA水平、IL-1β、IL-6、TNF-α浓度均明显升高;SOD活性明显降低(P<0.05)。与C组比较,T2～T7时U组的AST和ALT活性明显降低;T3～T5时MDA水平、IL-1β、IL-6和TNF-α浓度均明显降低;T3～T5时SOD活性明显升高(P<0.05)。结论乌司他丁能抑制氧自由基生成和炎症因子的释放,对肝脏缺血-再灌注损伤具有保护作用。     

Th1-like and Th2-like cytokines in patients undergoing open versus laparascopic cholecystectomy

The advantages of laparoscopic (LC versus, open cholecystectomy (OC) seems to be related to minimal invasive procedure and to the moderate inflammatory response. The aim of this study is to define the involvement of Th1 (IFN-gamma) and Th2 (IL-4, IL-6, IL-10, IL-13) cytokines production in vivo and in vitro in patients undergoing OC or LC. In 42 patients undergoing LC (n = 22) and OC (n = 20) Th1-like and Th2-like was evaluated before operation and at 6, 24 and 48 hours after operation for white blood cell counting and cytokines (IL-4, IL-6, IL-10, IL-13, IFN-gamma, TNF-alpha) in the sera and in the supernatants from circulating mononuclear cells stimulated with phytohemagglutinin or lipopolysaccharide. The acute phase response cytokine, IL-6, appeared significantly increased following OC than after LC. All other cytokines did not very significantly. In vitro data shows a reduction of IFN-gamma and increase in Th2-like cytokines in OC patients compared with the basal value. In LC subjects we observed an high production of IFN-gamma associated to an increase of Th2-like cytokines, like IL-10 and IL-13, even though IL-4 and IL-6 were unmodified. In contrast to OC, LC did not significantly affect immunocompetence, maintaining a moderate inflammatory response and an adequate balance between Th1 and Th2 cytokine. Furthermore, the strong activation of cells producing Th1-like cytokines in LC patients following mitogen activation indicated a consistent anti-microbial activity, that was not detectable in OC patients, that showed after activation only a Th2 response.     

奥曲肽预处理对围术期肝脏缺血-再灌注损伤保护作用的临床研究

目的探讨奥曲肽预处理对围术期肝脏缺血-再灌注损伤保护作用及可能的机制。方法选择88例肝脏手术患者,随机分为研究组45例,对照组43例,术中行肝门阻断。研究组患者于手术前1h给予奥曲肽0.2mg皮下注射,对照组于手术前1h给予生理盐水1ml皮下注射。观察术前(T0)、术后6h(T1)、24h(T2)及7d(T3)时血清丙氨酸氨基转移酶(ALT)、天冬氨酸氨基转移酶(AST)、乳酸脱氢酶(LDH),肿瘤坏死因子α(TNF-α)及白细胞介素1β(IL-1β)的变化,手术部位切除后取标本行超氧化物歧化酶(SOD)、髓过氧化物酶(MPO)的检测。采用TUNEL法检测肝组织中的凋亡细胞数。结果 T0时两组之间ALT、AST、LDH及TNF-α、IL-1β差异无统计学意义。T1时两组ALT、AST、LDH及TNF-α、IL-1β明显高于T0时(P<0.05),对照组又明显高于研究组(P<0.05)。T2时两组ALT、AST、LDH开始下降,但仍然高于T0时(P<0.05),T3时恢复正常范围,而T2、T3时TNF-α、IL-1β降至正常范围。研究组肝组织MPO明显低于对照组(P<0.05),而SOD明显高于对照组(P<0.05)。肝组织中的凋亡细胞数对照组为(67.79±5.25)明显高于研究组(44.32±5.16)(P<0.01)。结论奥曲肽对围术期肝脏缺血-再灌注损伤有保护作用,其可能的机制为稳定细胞膜、抑制炎性反应及细胞凋亡。     

Systemic inflammation and immune response after laparotomy vs laparoscopy in patients with acute cholecystitis,complicated by peritonitis

AIM: To evaluate acute cholecystitis, complicated by peritonitis, acute phase response and immunological status in patients treated by laparoscopic or open approach. METHODS: From January 2002 to May 2012, we conducted a prospective randomized study on 45 consecutive patients (27 women, 18 men; mean age 58 years). These subjects were taken from a total of 681 patients who were hospitalised presenting similar preoperative findings: acute upper abdominal pain with tenderness, involuntary guarding under the right hypochondrium and/or in the flank; fever higher than 38 ℃, leukocytosis greater than 10 × 10 9 /L or both, and ultrasonographic evidence of calculous cholecystitis possibly complicated by peritonitis. These patients had undergone cholecystectomy for acute calculous cholecystitis,complicated by bile peritonitis. Randomly, 23 patients were assigned to laparoscopic cholecystectomy (LC), and 22 patients to open cholecystectomy (OC). Blood samples were collected from all patients before operation and at days 1, 3 and 6 after surgery. Serum bacteraemia, endotoxaemia, white blood cells (WBCs), WBC subpopulations, human leukocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin-1 (IL-1) and IL-6, and C-reactive protein (CRP) were measured at 0, 30, 60, 90, 120 and 180 min, at 4, 6, 12, 24 h, and then daily (8 A.M.) until post-operative day 6.RESULTS: The two groups were comparable in the severity of peritoneal contamination as indicated by the viable bacterial count (open group = 90% of positive cultures vs laparoscopic group = 87%) and endotoxin level (open group = 33.21 ± 6.32 pg/mL vs laparoscopic group = 35.02 ± 7.23 pg/mL). Four subjects in the OC group (18.1%) and 1 subject (4.3%) in the LC group (P < 0.05) developed intra-abdominal abscess. Severe leukocytosis (range 15.8-19.6/mL) was observed only after OC but not after LC, mostly due to an increase in neutrophils (days 1 and 3, P < 0.05). This value returned to the normal range within 3-4 d after LC and 5-7 d after OC. Other WBC types and lymphocyte subpopulations showed no significant variation. On the first day after surgery, a statistically significant difference was observed in HLA-DR expression between LC (13.0 ± 5.2) and OC (6.0 ± 4.2) (P < 0.05). A statistically significant change in plasma elastase concentration was recorded post-operatively at days 1, 3, and 6 in patients from the OC group when compared to the LC group (P < 0.05). In the OC group, the serum levels of IL-1 and IL-6 began to increase considerably from the first to the sixth hour after surgery. In the LC group, the increase of serum IL-1 and IL-6 levels was delayed and the peak values were notably lower than those in the OC group. Significant differences between the groups, for these two cytokines, were observed from the second to the twenty-fourth hour (P < 0.05) after surgery. The mean values of serum CRP in the LC group on post-operative days (1 and 3) were also lower than those in the OC group (P < 0.05). Systemic concentration of endotoxin was higher in the OC group at all intra-operative sampling times, but reached significance only when the gallbladder was removed (OC group = 36.81 ± 6.4 ρg/mLvs LC group = 16.74 ± 4.1 ρg/mL, P < 0.05). One hour after surgery, microbiological analysis of blood cultures detected 7 different bacterial species after laparotomy, and 4 species after laparoscopy (P < 0.05). CONCLUSION: OC increased the incidence of bacteraemia, endotoxaemia and systemic inflammation compared with LC and caused lower transient immunological defense, leading to enhanced sepsis in the patients examined.     

腹腔镜胆囊切除术对机体就激反应的影响

目的 研究腹腔镜胆囊切除术对机体应激反应的影响。方法 将70例胆囊炎、胆囊结石患者随机分成腹腔镜胆囊切除组（LC）和开腹胆囊切除组（OC）。术前和术后第1,3,5,7d采集外周静脉血,测定白细胞介素1β（IL-1β）,肿瘤坏死因子α（TNF-α）,白细胞介素6（IL－6）和C－反应蛋白（CRP）。结果 两组手术前后IL－1β和TNF-α均无明显差异（P＞0．05）,两组间手术前后比较也无明显差异（P＞0．05）;两组手术后IL－6第1d升至最高,与术前及术后第3,5,7d比较有高度显著差异（P＜0．01）而术前与术后第3,5,7d比较无显著差异（P＞0．05）,两组之间比较亦无显著差异（P＞0．05）;两组手术后CRP第1,3,5d均较术前有明显升高（P＜0．05）,以术后第1和第3d升高最明显,而两组之间比较无显著差异（P＞0．05）。结论 LC对机体应激反应与OC相比没有明显差异。     

Inflammatory response in open and laparoscopic cholecystectomy

The modifications of IL-6. CRP, ceruloplasmin, alpha 1 antitrypsin, fibrinogen, transferrin, albumin and leukocytes counts have been evaluated after traditional open cholecystectomy (OC) or laparoscopic cholecystectomy (LC). Forty-two patients were included in this study, 20 underwent to OC and 22 underwent to LC. Serum samples were performed before surgery and at distance of 6, 24, 48 and 168 hours. The results show a more significant increase in acute phase inflammatory response after OC compared with LC as attested by highest values of leukocytosis, IL-6, CRP, fibrinogen and alpha 1 antitrypsin and lower levels of albumin. In conclusion, after LC, the phase acute response is attenuate and it can explain the reduced period of convalescence of patients treated with LC.