腹腔镜手术CO2气腹用于治疗感染性外科疾病的研究进展

腹腔镜外科手术由于患者创伤小、康复快、住院时间短等优点,应用日渐广泛,并被用于治疗多种感染性腹部外科疾病。腹腔镜术后细胞因子改变及全身细胞免疫抑制轻于开腹手术,腹腔镜手术比开腹手术能更好地保留系统免疫功能,有使感染性外科疾病炎症趋于局限的作用,减少细菌播散。现将近年有关CO2气腹在这方面的研究进展做一综述。     

CO2气腹对炎症环境下巨噬细胞功能影响的实验研究

目的:测定模拟炎症环境下CO2气腹对巨噬细胞超氧阴离子释放和线粒体功能的影响,探讨炎症条件下CO2气腹腹腔镜手术的可行性。方法:将大鼠肺泡巨噬细胞系NR8383细胞株在37℃、5%CO2、95%湿度中培养传代后分为正常对照组、实验对照组及CO2气腹组。用酵母多糖诱发炎症环境,用酶标仪测定各组相应时间的自由基荧光值及450nm波长处线粒体吸光度OD值。结果:两项实验中正常对照组与实验对照组各时段的差异有统计学意义(P0.05)。CO2气腹组与实验对照组在1h、2h、4h及恢复常氧条件培养2h的差异有统计学意义(P0.05),恢复常氧条件培养4h与实验对照组的差异无统计学意义。结论:CO2气腹对巨噬细胞超氧阴离子释放及线粒体功能具有短暂可逆抑制,利于减轻局部炎症反应,保持机体的免疫功能。CO2气腹腹腔镜手术对感染性疾病是安全、有益的。     

右侧星状神经节阻滞对CO2气腹患者心血管反应的影响

CO2气腹可引起高碳酸血症，反射性地引起交感神经活性增强，同时也可间接刺激颈动脉体、主动脉体化学感受器，使血浆多巴胺、肾上腺素（N）、去甲肾上腺素（NE）、抗利尿激素和皮质醇（Cor）浓度升高，对伴有高血压、冠心病患者的危险性较大。星状神经节阻滞（SGB）可抑制气管插管时心血管反应，但对CO2气腹时心血管反应的影响有待进一步探讨。本研究拟探讨右侧SGB对CO2气腹患者心血管反应的影响。     

外周血炎症相关指标对微创腔内碎石术后尿脓毒血症早期预警的研究进展

正尿脓毒血症有发病机制不清、疾病进展快、病死率高、医疗费用高等特点。近些年来随着泌尿系统微创腔内碎石手术的推广,尿源性脓毒血症的发病率逐年升高,死亡率居高不下。对泌尿系统微创腔内碎石术后患者进行早期敏感指标检测,从而筛检出高危人群,并对其病情进行重点关注,对泌尿系统微创腔内碎石术后发生尿脓毒血症患者的早期诊断和早期治疗有着重要意义。现通过复习文献,对外周血炎     

CO2气腹对肿瘤细胞种植与生长的影响

目的　探讨腹腔镜手术中常用的气腹介质CO2 对径路口及腹腔内肿瘤细胞种植及转移的影响。方法　手术前 1h于 30只Wistar大鼠腹腔内注入R15肝癌细胞株 ,并按随机抽样法将大鼠均分为免气腹组、He气腹组和CO2 气腹组 3组 ,实验维持 2h、2 8d后宰杀动物 ,比较各组径路口及腹腔内肿瘤的种植及转移情况。结果　在径路口、肠浆膜层、肠系膜、大网膜和膈肌部位种植的肿瘤重量 :CO2 气腹组分别为 (32 6 .7± 2 30 .3)mg、(6 2 6 .2± 2 15 .9)mg、(476 .2± 2 0 4 .8)mg、(2 5 36 .5± 90 6 .7)mg及 (384 .5± 14 9.9)mg ;He气腹组分别为(2 35 .6± 10 7.3)mg、(414 .2± 14 8.4 )mg、(2 6 1.8± 92 .6 )mg、(16 33.4± 2 4 7.3)mg及 (2 2 0 .0± 5 7.9)mg ;免气腹组分别为 (14 5 .0± 4 2 .4 )mg、(2 2 1.5± 10 8.2 )mg、(2 12 .5± 10 9.6 )mg、(797.5± 335 .9)mg和 113.0mg。在各部位种植的肿瘤重量 ,CO2 气腹组均明显高于He气腹组和免气腹组 ,差异有显著性意义 (P<0 .0 5 ) ;He气腹组均高于免气腹组 ,但差异无显著性意义 (P>0 .0 5 )。结论　CO2 气腹与He气腹及免气腹相比 ,可促进腹腔内肿瘤细胞的种植与生长。     

CO2气腹对神经系统的影响(文献综述)

腹腔镜术中建立的气腹可引起颅内压、神经代谢、神经内分泌和自主神经系统兴奋性的变化 ,本文对产生的机制进行了分析     

腹腔镜CO2气腹对肿瘤生长与种植转移的影响及预防

CO2气腹促进肿瘤生长与种植转移的现象一直受到广泛关注，但其机制未能阐明，预防办法尚在探索。本文综述了近几年研究进展，推测改善腹腔酸性环境，纠正细胞酸中毒，可能是抑制CO2促进肿瘤细胞扩散的重要途径。     

不同CO2气腹压力对腹腔镜胆囊切除术后肩痛的影响

目的研究不同CO2气腹压力对腹腔镜胆囊切除术(LC术)后肩部疼痛的影响。方法将100例行LC术的患者随机分为两组,每组50例,分别设定气腹压力为1.2kPa(10mmHg)和2kPa(15mmHg)下行LC术。对比两组术后肩部疼痛发生率及程度。结果在1.2kPa下手术组,患者的术后肩部疼痛程度明显低于2kPa手术组,差异有统计学意义(χ2=22.698,P<0.05)。结论LC术后肩部疼痛的主要原因可能与人工气腹张力对膈肌牵拉刺激有关。在10mmHg低压气腹下行LC术,可显著降低LC术后肩部疼痛的发生率及程度。     

腹腔镜二氧化碳气腹致皮下气肿的临床分析

目的:探讨腹腔镜手术二氧化碳气腹致皮下气肿的原因、防治措施及处理方法。方法:回顾分析腹腔镜手术二氧化碳气腹导致皮下气肿187例患者的临床资料;其中64例重症患者气肿弥漫至肩、颈部或面部,PETCO2、Paw显著升高,SpO2下降,予以粗针头于气肿明显处穿刺抽气、降低气腹压力、增加潮气量、增快呼吸频率、尽快结束手术;123例轻症患者气肿局限于切口附近或肋缘胸壁,未特殊处理。结果:患者完全清醒,潮气量及呼吸频率恢复正常,PETCO2、SpO2指标正常后,拔除气管插管,皮下气肿于24～72 h后消失;合并气胸者行胸腔穿刺或闭式引流;2例患者拔管困难,转ICU。结论:术中规范操作,严密监测患者体征及SpO2、PETCO2等各项参数的变化,及时发现、正确处理皮下气肿,是避免发生不良后果的关键。     

腹膜后腔镜手术二氧化碳气腹并发皮下气肿临床观察

目的 探讨腹膜后腔镜手术中二氧化碳气腹并发皮下气肿对患者血流动力学、血气及麻醉苏醒的影响.方法 回顾分析87例择期行腹膜后腔镜肾癌根治手术患者,依据皮下气肿严重程度把患者分为3组:无皮下气肿患者组(A组,66例)、1级和2级的轻度皮下气肿患者组(B组,15例)、3级的重度皮下气肿患者组(C组,6例).B组和C组发生皮下气肿后行过度通气.分别于气腹前(T0)、气腹后30 min(T1)、气腹后60 min(T2)、气腹后90 min(T3)及手术结束时(T4)、拔管时、拔管后30 min监测患者血气、呼气末二氧化碳分压(end-tidal carbon dioxide partial pressure,PETO2)、心率(heart rate,HR)、平均动脉压(mean artery pressure,MAP),同时观察麻醉苏醒情况.结果 C组在T2～T4时间点的动脉血二氧化碳分压(partial pressureof carbon dioxide in artery,PaCO2)、PETCO2、HR、MAP值均显著高于A组(P＜0.05),pH值均显著低于A组(P＜0.05).C组患者术后呼唤睁眼时间[(16±6) min]显著长于A组[(11±3) min](P＜0.05),定向力恢复时间[(30±7) min]显著长于A组[(23±6) min](P＜0.05).C组拔管时PaCO2[(52±7) mmHg(1 mmHg=0.133 kPa)]显著高于A组[(45±4) mmHg](P＜0.05),拔管后30 min的PaCO2[(48±7)mmHg]显著高于A组[(39±4) mmHg(P＜0.05)].结论 后腹腔镜手术并发重度皮下气肿导致患者高碳酸血症,患者血压升高、HR加快,苏醒时间延长.     

Cerebrovascular reactivity to carbon dioxide in sepsis syndrome

Cerebral dysfunction in sepsis is common in critically ill adults. However, little is known of the effects of sepsis on cerebral haemodynamics. We studied 12 sedated and ventilated patients in whom sepsis had been established for > 24 h. Transcranial Doppler measurements of the middle cerebral artery flow velocity were made at normocapnia, then hypocapnia (-1 kPa) and hypercapnia (+1 kPa). From these data, cerebrovascular reactivity to carbon dioxide was calculated. Variables indicating disease severity, systemic cardiovascular status and outcome were also recorded. We found significant changes in cerebrovascular reactivity to carbon dioxide. Only three of 12 patients had a cerebrovascular reactivity to carbon dioxide in the normal range; seven patients had a reduced cerebrovascular reactivity to carbon dioxide, whereas in two patients it was raised. In this smaD sample, we could not find any trend of association between altered cerebrovascular reactivity to carbon dioxide and severity of illness, cardiovascular status or outcome. This study suggests that established sepsis profoundly affects the vascular tone and reactivity, not only of the systemic circulation, but also of the cerebral vasculature.     

������̼�����������˵�Ѫ������ѧ�ı���Ѫ��Ӱ��

目的 探讨二氧化碳气腹对心功能异常的老年人血流动力学和血气的影响。方法 将６０岁以上患胆囊疾病的老年人,合并心血管疾病和部分肺部疾病,心脏功能２级,随机分为腹腔镜胆囊切险术组（１４例）与剖腹组（１０例）。用监测仪观察诱导前、术前及术后５、１０、１５分钟和拔管后５、１０分钟的血流动力学和血气变化。结果 气腹后血压明显升高。８例病人心率减慢,２例心失常,均治愈。气腹后中心静脉压上升至拔管后,明显高于相     

Microcirculation and excretory function of the liver under conditions of carbon dioxide pneumoperitoneum

Background: To date, the effects of increased abdominal pressure, as given during carbon dioxide (CO₂) pneumoperitoneum, on hepatic microcirculation and biliary excretion are unknown.Methods: Using a custom-made peritoneal cavity chamber, we performed intravital microscopy of the left liver lobe under conditions of CO₂ pneumoperitoneum in a rat model. In addition, biliary excretion was assessed.Results: The establishment of a CO₂ pneumoperitoneum of 4 or 8 mmHg resulted in sinusoidal perfusion failure that was more pronounced in the periportal regions than in the midzonal and pericentral regions of the liver acinus. Biliary excretion was considerably reduced at an intraabdominal pressure of 8 mmHg. Leukocyte–endothelial cell interactions increased significantly in both hepatic sinusoids and postsinusoidal venules.Conclusion: Alterations in hepatic microcirculation and liver function must be taken into consideration in any kind of laparoscopic surgery and may be of particular clinical relevance in patients with liver pathology.     

Detection of aerosolized cells during carbon dioxide laparoscopy

Laparoscopic surgery for malignancy has been complicated by port-site recurrences. The exact mechanism has yet to be defined. In vitro studies suggest that carbon dioxide-induced tumor cell aerosolization may play a role. We have attempted to document this in a human model. Patients scheduled for elective laparoscopy underwent port placement and abdominal insufflation with carbon dioxide. A suction trap was then filled with 40 cc of normal saline solution and attached to an insufflation site on the port. The carbon dioxide effluent was directed through the sahne. The specimen was concentrated, resuspended, and transferred to a slide. A Papanicolaou stain was used. Thirty-five specimens were obtained. Fifteen patients (37%) had malignant disease, which was metastatic in eight. Five patients had carcinomatosis. In two of those with carcinomatosis, staining revealed a large number of malignant cells. Malignant cells were not found in any other patients. In two patients, however, aerosolized mesothelial cells were identified. Follow-up ranged from 2 to 7 months. One patient who displayed cellular aerosolization developed a port-site recurrence. We conclude that malignant cells are aerosolized but only during laparoscopy in the presence of carcinomatosis. It is unlikely that tumor cell aerosolization contributes significantly to port-site metastasis. Supported in part by a grant from United States Surgical Corporation. Presented at the Thirty’-Eighth Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington, D.C., May 11–14,1997.     

Carbon dioxide pneumoperitoneum prevents mortality from sepsis

Background Carbon dioxide (CO₂) pneumoperitoneum has been shown to attenuate the inflammatory response after laparoscopy. This study tested the hypothesis that abdominal insufflation with CO₂ improves survival in an animal model of sepsis and investigated the associated mechanism. Methods The effect of CO₂, helium, and air pneumoperitoneum on mortality was studied by inducing sepsis in 143 rats via intravenous injection of lipopolysaccharide (LPS). To test the protective effect of CO₂ in the setting of a laparotomy, an additional 65 animals were subjected to CO₂ pneumoperitoneum, helium pneumoperitoneum, or the control condition after laparotomy and intraperitoneal LPS injection. The mechanism of CO₂ protection was investigated in another 84 animals. Statistical significance was determined via Kaplan– Meier analysis for survival and analysis of variance (ANOVA) for serum cytokines. Results Among rats with LPS-induced sepsis, CO₂ pneumoperitoneum increased survival to 78%, as compared with using helium pneumoperitoneum (52%; p < 0.05), air pneumoperitoneum (55%; p = 0.09), anesthesia control (50%; p < 0.05), and LPS-only control (42%; p < 0.01). Carbon dioxide insufflation also significantly increased survival over the control condition (85% vs 25%; p < 0.05) among laparotomized septic animals, whereas helium insufflation did not (65% survival). Carbon dioxide insufflation increased plasma interleukin-10 (IL-10) levels by 35% compared with helium pneumoperitoneum (p < 0.05), and by 34% compared with anesthesia control (p < 0.05) 90 min after LPS stimulation. Carbon dioxide pneumoperitoneum resulted in a threefold reduction in tumor necrosis factor-α (TNF-α) compared with helium pneumoperitoneum (p < 0.05), and a sixfold reduction with anesthesia control (p < 0.001). Conclusion Abdominal insufflation with CO₂, but not helium or air, significantly reduces mortality among animals with LPS-induced sepsis. Furthermore, CO₂ pneumoperitoneum rescues animals from abdominal sepsis after a laparotomy. Because IL-10 is known to downregulate TNF-α, the increase in IL-10 and the decrease in TNF-α found among the CO₂-insufflated animals in our study provide evidence for a mechanism whereby CO₂ pneumoperitoneum reduces mortality via IL-10-mediated downregulation of TNF-α. Supported by R01-GM062899-02, National Institutes of Health, Bethesda, MD. Presented at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Ft. Lauderdale, Florida, 13–16 April 2005     

Haemodynamic changes during low-pressure carbon dioxide pneumoperitoneum in young children

BACKGROUND: Both mechanical and pharmacological effects may contribute to the haemodynamic consequences of carbon dioxide (CO2) pneumoperitoneum. The aim of the present study was to evaluate the haemodynamic effects of low-pressure pneumoperitoneum [intra-abdominal pressure (IAP) 5 mmHg] in young children (< 3 years). METHODS: Thirteen children, aged 6-36 months, ASA physical status I-III, who were scheduled for laparoscopic fundoplication for gastro-oesophageal reflux were investigated in the head-up position (10 degrees ). Noninvasive thoracic electrical bioimpedance cardiac index (CI), stroke volume index (SVI), heart rate (HR), mean arterial pressure (MAP) and peak inspiratory pressure (PIP) were recorded, together with PetCO2 and PaCO2 at five time points: before insufflation, 20, 35 and 70 min after start of CO2 insufflation and 12 min after desufflation. During insufflation, minute ventilation was not adjusted and the IAP was maintained at 5 mmHg. RESULTS: During insufflation, PetCO2 increased from 29 +/- 4 to 37 +/- 5 mmHg (P < 0.001) and PaCO2 increased from 31 +/- 4 to 39 +/- 5 mmHg (P < 0.01). CI increased from 2.39 +/- 0.86 to 2.92 +/- 0.94 l x min-1 x m2 (P < 0.01), HR increased from 108 +/- 10 to 126 +/- 22 b x min-1 (P < 0.01), MAP increased from 52 +/- 10 to 63 +/- 9 (P < 0.05) and PIP increased from 16 +/- 3 to 18 +/- 3 cm H2O (P < 0.001). There were no changes in SVI and arterial oxygen saturation. CONCLUSIONS: We conclude that low-pressure CO2 pneumoperitoneum (with IAPs not exceeding 5 mmHg) for laparoscopic fundoplication in infants and children does not decrease their cardiac index.