术中腹腔灌注化疗及术后营养支持对进展期胃癌术后肠黏膜屏障功能及免疫功能的影响

目的探讨术中腹腔灌注化疗（HIIC）及术后营养支持对进展期胃癌患者肠黏膜通透性和免疫功能的影响。方法将2007年12月至2008年12月间江苏省肿瘤医院胃肿瘤诊疗中心收治的65例进展期胃癌,患者按随机数字表法随机分为EN组（术后早期肠内营养,20例）、HIIC加EN组（HIIC加术后早期肠内营养．22例）和HIIC加PN组（HIIC加术后肠外营养,23例）。分别于术前1d及术后3、7、12d,应用高效液相色谱检测其尿L／M比值,应用流式细胞术检测外周血CD4＋、CD8＋和自然杀伤（NK）细胞比例及CD4／CD8细胞比值。结果术前1d,EN组、HIIC加EN组和HIIC加PN组患者L／M值分别为0．0280＋0．0183、0．0305＋0．0208和0．0298±0．0229;术后3d,3N患者L／M值均明显升高（0．1235±0．0611、0．1648±0．0571和0．1702±0．0628）,与术前比较,差异均有统计学意义（P〈0．05）,其中HIIC加EN组和HIIC加PN组明显高于EN组（P〈0．05）;之后,3组L／M值均开始回落．至术后12d,EN组（0．0278±0．0217）和HIIC加EN组（0．0336±0．0235）L／M值已回落至术前水平（均P〉0．05）。而HIIC加PN组（0．0616±0．0430）仍明显高于术前水平及其他两组（均P〈0．05）。与术前1d相比,术后12dEN组和HIIC加EN组患者CD4＋细胞比例、CD4／CD8比值均明显升高（均P〈0．05）;且HIIC加EN组和HIIC加PN组CD4＋细胞比例显著低于EN组（均P〈0．05）。结论HIIC会加重进展期胃癌患者术后肠黏膜通透性的损伤,并一定程度地抑制细胞免疫功能：而术后早期肠内营养支持能够改善HIIC引起的肠黏膜通透性损害。

Effect of intraoperative intraperitoneal chemotherapy and postoperative nutritional support on intestinal permeability and cellular immune function in patients with advanced gastric cancer

Objective To investigate the effect of hyperthermic intraoperative intraperitoneal chemotherapy （HIIC） and postoperative nutritional support on the intestinal permeability and the cellular immunity function in patients with advanced gastric cancer. Methods All the patients diagnosed as advanced gastric cancer in the Gastric Tumor Diagnosis and Treatment Center of Jiangsu Cancer Hospital were randomly divided into three groups using random digit table： （1）EN group treated with enteral nutrition during postoperative period; （2）HIIC ＋EN group treated with HIIC combined with postoperative enteral nutrition; （3）HIIC ＋PN group treated with HIIC combined with postoperative parenteral nutrition. Index of lactulose/mannitol（L/M） ratio was used to evaluate the permeability of intestinal mueosa. The percentage of CD4＋, CD8＋ and NK cell, the ratio of CD4/CD8 T cell in peripheral blood were tested by flow eytometry. The time points of these measurements were the day before surgery, postoperative days （POD） 3, 7, and 12. Results Compared with the day before surgery（POD-l）, the ratio of L/M on POD＋3 increased significantly in all the three groups（0.1235±0.0611 vs. 0.0280±0.0183, 0.1648 ±0.0571 vs. 0.0305 e0.0208, 0.1702 ±0.0628 vs. 0.0298 ±0.0229） （P〈0.05） and then decreased gradually. The L/M ratio of EN （0.0278±0.0217） and HIIC＋EN （0.0336±0.0235） groups recovered to the baseline on POD＋12, however HIIC＋PN group still had elevated L/M ratio （0.0616±0.0430）. The percentage of CD4＋17 cell and the ratio of CD4/CD8 in HIIC＋EN group and HIIC＋ PN group were significantly lower than those in EN group （P=0.033, P=0.002, respectively）. Compared with the POD-l,the percentage of CD4＋T cell and the ratio of CD4/CD8 in HIIC＋EN group and EN group on POD＋12 were increased significantly （P〈0.05）. Conclusions HIIC may cause significant increase in intestinal permeability and inhibit cellular immunity in patients undergoing radical resection for advanced gastric cancer. Mucosal permeability can be reversed by enteral nutrition.