接受膝关节微创外科手术患者围术期的应激反应

背景:微创以对患者最小的创伤和最小的生理影响与干扰同时又能获得或达到最佳的预期或治疗效果使得其应用价值不断提高,但微创外科围手术期的应激反应有待进一步观察。目的:分析膝关节微创外科围手术期创伤应激反应的激素水平、C-反应蛋白和机体能量代谢的变化。设计:观察对比分析。单位:湘南学院附属医院骨科,中南大学湘雅医院骨科。对象:选择2003-01/2004-04在湘南学院附属医院骨科和中南大学湘雅医院骨科就诊的16例收治膝关节半月板损伤患者及26例交叉韧带损伤患者,均为闭合性损伤,诊断标准:交叉韧带损伤患者经物理检查、抽屉试验结合CT、MRI检查确诊;半月板损伤患者经物理检查、研磨试验结合CT、MRI检查确诊,所有患者病情均符合切开关节手术指征。选择其中10例膝关节半月板损伤及12例交叉韧带损伤患者进行微创手术,为微创手术组。其余20例患者选择切开关节直视下手术,分为切开手术组。所有患者均对检测项目知情同意。方法:所有患者术前、术后1d和3d早晨分别抽取空腹静脉血,离体后2h内进行检测处理。①采用竞争性放射免疫法定量测定血清胰岛素及血清皮质醇水平,采用双抗体放射免疫法定量测定生长激素水平,采用散射比浊法测定C-反应蛋白水平。②应用间接能量测定仪在术前、术后1d和3d早晨分别测定患者的能量消耗,所有能量消耗的测定均由医学图形重症监测和桌面分析系统完成,根据间接测热理论,用计算机计算出能量消耗和呼吸商。主要观察指标:①患者术前、术后1d和3d静脉血胰岛素、生长激素、皮质醇水平。②患者术前1d、术后1d和3d静息能量消耗、呼吸商及C-反应蛋白水平。结果:纳入患者42例均进入结果分析。①术后3d切开手术组患者胰岛素水平低于手术前[(12.4±1.1),(17.5±2.2)mIU/L,P<0.05];术后1d切开手术组患者生长激素水平明显高于微创手术组[(2.8±0.9),(5.3±2.4)μg/L,P<0.05],术后3d微创手术组患者生长激素水平明显高于手术前[(1.4±0.5),(1.0±0.3)μg/L,P<0.05];术后1d切开手术组患者皮质醇水平明显高于微创手术组[(1.12±0.25),(0.59±0.11)μmol/L,P<0.05]。②切开手术组及微创手术组患者术后1d静息能量消耗分别为(1437.8±415.9),(1223.8±179.9)K,高于术前[(1186.4±297.4),(1160.7±158.6)K,P<0.05];微创手术组术后1,3d静息能量消耗分别为(1223.8±179.9),(1151.7±150.8)K,高于切开手术组[(1437.8±415.9),(1329.4±350.5)K,P<0.05]。③切开手术组及微创手术组患者术后1d呼吸商均为(0.8±0.05),低于手术前(0.9±0.11,0.9±0.15,P<0.05)。④微创手术组术后1,3d患者C-反应蛋白分别为(14.8±2.5),(34.37±7.5)mg/L,低于切开手术组[(64.1±14.4),(93.87±12.7)mg/L,P<0.05],但高于手术前[(8.0±0.11)mg/L,P<0.05]。结论:膝关节关节镜微创外科手术创外小,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。

Perioperative stress reaction results from minimally invasive surgery in the arthroscopy on knee joint

BACKGROUND: As it results in minimal trauma and physical influence or interference, and a better curative effect, the minimally invasive surgery is preferred in clinic. However, the perioperative stress reaction of minimally invasive surgery needs further study.OBJECTIVE: To evaluate the levels of neurohormone, C-reactive protein (CRP) and the changes of resting energy expenditure (REE) resulted from the operative stress reaction due to minimally invasive surgery in arthroscopy on knee joint.DESIGN: Controlled observation and analysis.SETTING: Department of Orthopaedics, Affiliated Hospital of Xiangnan University and Department of Orthopaedics,Xiangya Hospital of Central South University.PARTICIPANTS: Sixteen patients with meniscal lesions in knee and 26 with cruciate ligament injury, which were closed injury, were selected from the Department of Orthopaedics of Affiliated Hospital of Xiangnan University and Xiangya Hospital of Central South University between January 2003 and April 2004. Meniscal lesions were diagnosed according to the physical examination, drawer test combined CT and MRI examination, and the patients were in accordance with the indication of arthrotomy; cruciate ligament injury according to the physical examination, grinding test combined CT and MRI examination. Those with open injury, body multiple injury, combined injury and emergency operation were excluded. Ten patients with meniscal lesions and 12 with cruciate ligament injuries underwent minimally invasive surgery on knee joint as minimally invasive surgery group (MIS). The others were given traditionally invasive surgery on knee joint as the traditional group. The informed consent was obtained from the patients.METHODS: Fasting venous blood was taken on the morning of 1 day before, and 1 and 3 days after operation, which was analyzed within 2 hours after sampling. ①All hormones were quantitatively assayed. Serum insulin was determined by competitive radioimmunoassay (RIA); growth hormones levels by double-antibody RIA; serum cortisol by competitive RIA; CRP by nephelometry, respectively. ②Energy metabolism detection: The energy consumption was assessed by indirect calorimeter on the morning of 1 day before, 1 day and 3 day after operation, respectively. All the detection was performed by medical graphics critical care monitor desktop analysis system. Based on the indirect calorimeter theory,REE and respiratory quotient (RQ) were figured out.MAIN OUTCOME MEASURES: ①Concentrations of insulin, growth hormones and cortisol of patients at 1 day before, 1 day and 3 day after operation; ②Resting energy consumption, RQ and CRP of patients at 1 day before, 1 day and 3 day after operation.RESULTS: Totally 42 patients were involved in the result analysis. ①On the third postoperative day, the insulin levels of the traditional group were lower than those before operation [(12.4±1.1), (17.5±2.2) mlU/L, P ＜ 0.05]; On the first postoperative day, the levels of growth hormone of the traditional group were significantly higher than the MIS group [(2.8±0.9), (5.3±2.4) μg/L, P ＜ 0.05], and on the third day after operation, the levels of the MIS group were remarkably increased compared with those before operation [(1.4±0.5), (1.0±0.3) μg/L, P ＜ 0.05]; the cortisol levels of the traditional group on the first postoperative day were higher than the MIS group [(1.12±0.25), (0.59±0.11) μmol/L, P ＜ 0.05]. ②REE levels of the traditional group and MIS group on the first day after operation were(1437.8±415.9) and (1223.8±179.9) K,higher than those before operation [(1 186.4±297.4), (1 160.7±158.6) K, P ＜ 0.05]; on the first and third days after operation, REE levels of the MIS group were higher than the traditional group [(1 223.8±179.9), (1 151.7±150.8) K;(1 437.8±415.9), (1 329.4±350.5) K, P ＜ 0.05]. ③RQ of the traditional group and MIS group on day 1 after operation were all (0.8±0.05), lower than that before operation (0.9±0.11, 0.9±0.15, P ＜ 0.05). ④On the first and third days after operation, CRP of the MIS group were lower than the traditional group [(14.8±2.5), (34.37±7.5) mg/L; (64.1±14.4),(93.87±12.7) mg/L, P ＜ 0.05], but higher than that before operation [(8.0±0.11) mg/L, P ＜ 0.05].CONCLUSION: Minimally invasive surgery on knee joint results in less trauma, low stress reaction and slight influence on metabolism of patients, moreover, it benefits the restoration of stress hormones, nitrogen balance and energy metabolism.