【作者】 刘海涛；

【导师】 张雪峰；

【作者基本信息】 大连医科大学 ， 普通外科学， 2007， 硕士

【摘要】 目的:大肠癌(Colorectal cancer)是我国常见的恶性肿瘤之一,近年来发病率呈上升趋势。手术切除仍是目前治疗大肠癌最主要且有效的手段。近年来,腹腔镜技术在世界范围内得到迅速推广和应用。许多临床研究表明,腹腔镜大肠癌手术能获得与传统手术相同的疗效,而且具有手术创伤小、术后恢复快、住院时间短等优点。与传统手术一样,腹腔镜手术对机体的免疫、神经内分泌及代谢反应均有影响。国内外的一些研究证明,内皮素(endothelin ET)浓度的变化可作为评价外科应激反应强弱的重要指标。而且,外周血ET和一氧化氮(nitrogen monoxidum NO)含量的测定与创伤程度关系密切,并可作为创伤程度的评估指标。手术后血清白细胞介素-6(interleukin-6 IL-6)和C-反应蛋白(C-reactive protein CRP)在应激状态下可以明显升高,其含量与所受到的创伤成正比,是反映组织损伤程度的早期敏感指标。并且IL-6对体液免疫和细胞免疫均有调节作用。本课题旨在对开腹与腹腔镜大肠癌手术患者的术前、术后ET、NO、IL-6和CRP的变化进行比较,以探讨两种手术方法治疗大肠癌对机体应激反应的影响。方法:(1)研究对象:选择在自2006年6月至2007年3月沈阳军区总医院普通外科大肠癌手术的患者共35例,其中腹腔镜组15例;选择同一时期依据术前检查认为适于行腹腔镜手术,但不接受腹腔镜手术的患者20例,设为开腹组作为对照。入组标准:1、术前经病理证实为大肠癌;2、术前评估可行根治手术者。排除标准:糖尿病、Ⅲ期高血压病、血管痉挛性心绞痛、嗜铬细胞瘤、甲亢、有症状的动脉粥样硬化、慢性肾炎、肝硬化病、溃疡性肠炎、病毒性肝炎、处于十二指肠溃疡活动期以及术后有并发症、输液反应等。麻醉方式取静吸复合麻醉。两组患者的性别、年龄、身高、体重、手术方式及术后病理分期相同或相似。(2)研究方法:应用放射免疫( Radioimmunity, RAI)、硝酸还原酶法( Nitrale reduetase, NR)和散射比浊法(nepheloturbidity)检测腹腔镜组与开腹组病人术前、术后、术后第1、3和5天的ET、IL-6、NO和CRP值。(3)统计方法:采用SPSS11.0软件进行统计处理,所有术前、术后资料以均数±标准差( )表示,进行t检验及两变量关联性分析。P<0.05为差异有显著性意义。结果:1.内皮素:两组病人手术开始时ET无显著性差异。腹腔镜组手术结束时ET下降,但无显著性差异;术后第1天ET显著下降(p<0.05);术后第2天ET开始升高,与手术开始时仍有显著差异(p<0.05);术后第3天恢复至手术开始时水平。开腹组手术前后ET无显著变化。两组间术后未出现显著性差异。2.一氧化氮:两组病人手术开始时NO无显著性差异。两组病人NO手术结束时均有明显下降(p<0.01)。但术后第2天开腹组NO恢复至手术开始时水平,此时开腹组高于腹腔镜组(p<0.01)。腹腔镜组于术后第3天恢复至手术开始时水平,两组间无显著差异。3.白介素-6:两组病人术前IL-6无显著性差异。两组病人手术结束时IL-6均明显升高,与手术开始时相比均有显著性差异(p<0.01),此时开腹组明显高于腹腔镜组(p<0.01)。术后第5天腹腔镜组IL-6恢复至手术开始时水平,开腹组仍明显高于腹腔镜组(p<0.05)。4.C反应蛋白:两组病人术前CRP无显著性差异。两组病人手术结束时CRP均明显升高,与手术开始时相比均有显著性差异(p<0.01),此时开腹组明显高于腹腔镜组(p<0.01)。两组病人术后第5天C反应蛋白仍显著高于手术开始时水平(p<0.05;p<0.01),两组间也有显著差异(p<0.05)。结论:腹腔镜大肠癌手术对ET、NO、IL-6和CRP的影响小,比开腹手术应激反应轻、强度低、持续时间短。更多还原

【Abstract】 ObjectiveColorectal cancer is one of the malignant tumor of digestive tract with high morbidty, which has a intensive disease rate have had a tendency of increase for the past few years. Surgical operation is the most effective treatment. In recent years, laparoscopic surgery has been developing rapidly allover the world. Many studies indicated that laparoscopic colorectal operation was as effective as laparotomy and had significant advantages such as milder pain, less abdominal interference, less complication, more rapid rehabilitation, and shorter length of stay. Laparoscopic surgery has effect on immune, neuroendocrine and metabolic reaction as laparotomy. Some studies have proved that changes of serum endothelin(ET) might be an important index for evaluating the magnitude of suigical stress response. Furthemore, concentration of ET and nitrogen monoxidum(NO) in peripheral blood may be useful in the evaluation of trauma. Serum interleukin-6(IL-6) and C-reactive protein(CRP) levels increased significantly after operation, they are proportional to the severity of surgical trauma and sensitive indexes of reflecting degree of injury. IL-6 can accommodates humoral-mediated immunity and cell-mediated immunity. In this study, the endothelin(ET)、nitrogen monoxidum(NO)、interleukin-6(IL-6) and C-reactive protein(CRP) level pre- and post-operation were contrasted between the patients received laparoscopic colectomy and laparocolectomy, in order to investigate the effects of the physical stress impacted by the two therapies.Methods1.Objects: 35 patients suffering colorectal cancer in our department, from Jun. 2006 to March. 2007 were examined. 15 of them accepted laparoscopy-assisted colectomy (laparoscopic group) and 20 patients who didn’t accepte laparoscopy were performed with laparocolectomy ( laparotomy group). Pationt’s in both groups were not complicated with complication、infusion reaction、vital organic and systemic diseases(hypertensive disease, diabetes mellitus, anginosis, chromaffin tumor, hyperthyreosis, Symptomatic atherosclerotic, chronic nephritis, liver cirrhosis, coronary artery disease, helcenteritis, virus hepatitis, duodenal ulcer, etc.). The patients were undergone anesthesia with tracheal intubation com-bined with intravenous anesthesia. Gender, age, height, body weight , modus operandi and postoperative pathological staging of the patients were similar between the two groups.2.Methods: Prospective study were adopted. Radioimmnnology(RAI)、Nitrale reduetase(NR) and nepheloturbidity were used to detect of ET、IL-6、NO and CRP levels at pre- and post-operation,the 1st, 2nd, 3rd and 5th day after operation in two groups.3.Statistical analysis: All data were processed by SPSS11.0 software package. T test was used for analysing Pre- and post-operative measurement data. The data were expressed as mean±standard deviation( ). Correlation between two variables was performed by means of linear regression. There is considered to be statistical significant when p<0.05.Results1.ET: No statistical significant deference between the two groups on ET level pre-operation was found. ET level of post-operation of laparoscopic group was lower than pre-operation’s, but there was had no significant deference; ET level of 1st day post-operation was significantly lower than pre-operation’s(p<0.05); ET level of 2nd day post-operation started to raise and were still lower than pre-operation’s markedly(p<0.05), which restored to pre-operation at the 3rd day after operation . ET levels between pre- and post-operation of laparotomy group had no significant deference. ET levels of post-operation of both two groups had no statistical significance.2.NO: No statistical significant deference between the two groups on NO level pre-operation was found. NO level of post-operation in both groupswere lower than pre-operation’s significantly (p<0.01). The NO level of the laparotomy group restored to pre- operation’s at the 2nd day after operation, was higher than the level of laparoscopic group markedly (p<0.01), which restored to previous at the 3rd day after operation.3.IL-6: No statistical significant deference between the two groups on IL-6 level pre-operation was found. IL-6 levels of post-operation of the two groups were higher than pre-operation’s significantly(p<0.01), and IL-6 level of the laparoscopic group was lower than the laparotomy group markedly (p<0.01), IL-6 level of restored to previous at the 5th day after operation, at the same time IL-6 levels between two groups still had statistical significant deference(p<0.05).4.CRP: No statistical significant deference between the two groups on CRP level pre-operation was found. CRP levels of post-operation in the two groups were higher than pre-operation’s significantly(p<0.01). CRP levels of 5th day after operation in both groups were higher than pre-operation’s significantly(p<0.05; p <0.01),and CRP levels between two groups had statistical significant deference.(p<0.05). ConclusionsLaparoscopic colectomy causes less effects on ET、NO、IL-6 and CRP than laparotomy in patients.Compared with laparotomy, the laparoscopic colectomy imposes less impact on physical stress.更多还原