腹腔镜胃癌根治术不同气腹压力对肠道的影响

目的探讨腹腔镜胃癌根治术中不同CO2气腹压力对肠黏膜损伤及肠功能恢复的影响。方法前瞻性将2011年6月至2012年6月间上海第二军医大学长征医院胃肠外科收治的早期和局部进展期远端胃癌患者48例入组，根据患者意愿分为开腹胃癌D：根治术（12例，开腹组）：腹腔镜胃癌根治术加D2淋巴结清扫术36例（LG组），按气腹压力低、中、高设为8～10mmHg（LP组）、11—13mmHg（MP组）和14—16mmHg（HP组），随机将腹腔镜手术患者分到各组，每组12例。对比分析LG组中3种不同气腹压力组与开腹组的并发症发生情况和手术前后肠黏膜的病理形态、血浆D．乳酸水平及肠道功能恢复情况。结果LG组中3种不同气腹压力组与开腹组患者术前各基本参数比较，差异无统计学意义（均P〉0．05）。术后并发症发生率LG组（8．3％）低于开腹组（41．7％，P〈0．05）。开腹组术后肠黏膜损伤不明显；LG组中，LP组、MP组和HP组术后肠黏膜损伤程度分别为0～1级、1～2级和2-3级，HP组明显较LP组和MP组黏膜损伤程度严重（P〈0．05）。手术前血浆D．乳酸水平各组间比较，差异无统计学意义（P〉0．05）；而术后各组分别与术前比较，差异均具有统计学意义（P〈0．05）；但HP组术后血浆D哥L酸检测水平最高，与其他3组比较，差异均具有统计学意义（P〈0．05）。且HP组术后肠鸣音出现时间、排气时间及进食时间均较其他3组长，差异有统计学意义（P〈0．05）。结论腹腔镜胃癌根治术安全微创优势明显，但较高气腹压力不利于术后肠黏膜和肠功能的恢复，术中应在保证手术视野清晰的情况下尽量降低气腹压力。

Impact of different pneumoperitioneal pressure on pathomorphism and function of intestines following laparoscopic radical gastrectomy

Objective To investigate the influence of different pressures of CO2 pneumoperitioneum on pathomorphism and function of intestines following laparoscopic gastrectomy（LG）. Methods Forty-eight gastric cancer patients were prospectively enrolled in the study. Among them, 36 patients scheduled for elective LG were randomly assigned to low pressure group （LP）, middle pressure （MP）, and high pressure group （HP） with 12 cases in each group. The COs pneumoperitoneum pressure was maintained at 8-10 mmHg in LP, 11-13 mmHg in MP, and 14-16 mmHg in HP. The control group was open gastrectomy group（OG） in 12 cases. The intestinal pathomorphism and level of plasma D-lactic acid before, during and after operation, and postoperative intestinal function of four groups were examined and compared. Results There were no statistical differences in preoperative data among the four groups （all P〉0.05）. LG group was associated with a lower rate of surgical complications than OG （8.3% vs. 41.7%, P〈0.05）. No obvious damage of intestinal mucosa was found in OG group. Damage degree of intestinal mucosa after operation in LP, MP and HP groups was 0-1, 1-2, and 2-3 respectively. There was significant change in intestinal pathomorphism after operation in both HP and MP groups. The levels of D-lactic acid before operation were not significantly different among all the four groups, but increased significantly in each group after operation（all P〈0.05）. HP group had the highest level of plasma D-lactic acid and presented with delayed bowel sound return （4.5 d）, time to first flatus （5.4 d）, and intake （6.0 d） ascompared to the other 3 groups （all P〈0.05）. Coneluslons Laparoscopic radical gastrectomy is safe and minimally invasive. Higher pneumoperitoneal pressure is harmful to the recovery of intestinal mucosa and function. Therefore the pneumoperitioneum pressure should be maintained as low as possible under clear visualization during operation.