麻醉与术后镇痛方法对老年直肠癌患者T细胞亚群的影响

目的： 观察不同麻醉及镇痛方法对老年直肠癌患者围手术期外周血T淋巴细胞亚群的影响。方法： 40例按美国麻醉医师学会（American Society of Anesthesiologists，ASA) Ⅱ-Ⅲ级年龄65岁以上的直肠癌行根治术患者，根据麻醉和术后镇痛方法不同随机分为2组，每组20例。Ⅰ组为静脉复合全麻，术后经静脉给芬太尼(13 μg/kg)自控镇痛；Ⅱ组为静脉复合全麻联合腰部硬膜外阻滞，术后硬膜外吗啡5 mg＋罗派卡因100 mg自控镇痛，分别于麻醉前、术毕、术后24、48、120 h 5个时点从颈内静脉抽取静脉血，采用流式细胞仪测定外周血T淋巴细胞亚群CD3⁺、CD4⁺、CD8+,同时测定各时点皮质醇水平，并用视觉模拟评分（VAS），判定术后镇痛效果。结果： 2组患者均有较好的术后镇痛效果，Ⅰ组患者VAS评分于术后24 h、 48 h明显高于Ⅱ组（P<0.01），2组患者在术毕、术后24 h、 48 h血浆皮质醇水平均明显升高(P<0.05或P<0.01)，Ⅱ组在术毕、术后24 h升幅明显小于Ⅰ组（P<0.05），与麻醉前相比，术毕、术后24 h、48 h，2组CD3+、CD4+、CD4/CD8均明显下降(P<0.01)；术后120 h Ⅱ组各指标恢复(P>0.05)； Ⅱ组于术后48 h CD4+、术后120 h CD3⁺、CD4⁺、CD4/CD8明显高于Ⅰ组(P<0.05或P< 0.01)。结论： 全麻复合腰部硬膜外麻醉能减轻围手术期应激反应及其对T细胞亚群的影响，提示全麻复合腰部硬膜外阻滞可能是老年肿瘤患者和免疫功能低下者较为合适的的麻醉方法。

The influence of anesthesia and means of postoperative pain control on T lymphocyte subtypes of blood in patients with rectal cancer

AIM: To evaluate the influence of anesthesia and different means of postoperative pain control on the T-lymphocyte during the perioperative period in patients with rectal cancer.METHODS: 40 adult patients, aged 65 or older, of American Society of Anesthesiologists (ASA) class 2-3 were divided into two groups according to the type and means of postoperative pain managements. Group Ⅰ (n=20) received intravenous anesthesia and patient controlled analgesia(PCA), fentanyl (13 μg/kg) for post pain; group Ⅱ (n=20) received intravenous anesthesia plus lumber epidural anesthesia and epidural PCA of morphine 5 mg plus ropivacaine 100 mg for post operative pain. Blood samples from internal jugular vein were obtained before surgery, at the completion of surgery and 24, 48, and 120 h post surgery for detecting CD3⁺, CD4⁺, CD4/CD8 counts of peripheral T-lymphocytes. In addition, blood cortisol level and pain intensity were assessed by visual analogue score (VAS)at each time point. RESULTS: Baseline(before anesthesia) values of CD3⁺,CD4⁺, CD4/CD8 in patients were messured and there was a significant decrease of all these values from completion of surgery to 48 h after surgery in both groups (P<0.01). However, group Ⅱ showed a higher CD4⁺ at 48 h, higher CD3⁺,CD4⁺, CD4/CD8 at 120 h post surgery than group Ⅰ (P<0.05). Patients in both groups obtained good pain relief post surgery,but VAS in group Ⅱ were significantly lower than those in group Ⅰ at 24 and 48 h post surgery (P<0.01). Compared with baseline, blood cortisol levels in both groups increased markedly at completion of surgery, and at 24, 48 h after surgery (P<0.01),while the increased cortisol level in group Ⅱ at completion of surgery and 24 h after surgery was less than that in group Ⅰ (P<0.05).CONCLUSION: Combined intravenous anesthesia with lumber epidural anesthesia appears to reduce the perioperative stress response and exerts less negative effects on the T-lymphocytes, suggesting that such a means of anesthesia might be more suitable to the elderly patients with rectal cancer.