【作者】 任东林；

【导师】 陈志强；

【作者基本信息】 广州中医药大学 ， 中医外科学， 2007， 博士

【摘要】 目的探讨应用小承气合剂促进结肠吻合术后胃肠动力恢复的效果及安全性方法该研究分临床研究及动物实验两部分。动物实验部分：将60只清洁级Wistar大鼠随机分为实验组(Ⅰ组)、对照组(Ⅱ组)，每组各30只。造模成结肠吻合术后，Ⅰ组给予小承气合剂灌服以促进术后胃肠动力恢复，Ⅱ组灌服以同样剂量净化自来水作对照。观察每组动物存活情况，若实验过程中有实验动物死亡，则立即剖腹探查，查看腹腔情况，寻找死亡原因，记录死亡率。全部动物分别于术后第3、7、14天，每组取10只动物进行剖腹探查，进行吻合口急性压力负载实验，及切取吻合口组织进行病理学研究，并采用专业图像分析软件(Image-pro plu 6.0)对组织成分进行定量分析。临床研究部分：选择2004年3月至2006年11月间，在广东省中医院外三科行结直肠吻合术的患者为研究对象，共106例，纳入标准：①意识清晰，理解能力可，愿意配合完成研究过程者(术前签署知情同意书)；②行一处结肠吻合者。将上述患者随机分为实验组(Ⅰ组)及对照组(Ⅱ组)，小承气合剂组方(大黄6g(后下)，厚朴10g，枳实10g，丹参30g)，Ⅰ组于术后4h开始鼻饲胃管滴入小承气合剂首剂，滴速1ml·min—1，4小时后再鼻饲翻煎剂，手术后第二天继续每日1服2剂的鼻饲灌服小承气合剂2次，直至术后排便、肠功能恢复。Ⅱ组术后按传统保持禁食直至术后第一次排气。Ⅰ组及Ⅱ组均在术后第4小时开始，观察并记录肠鸣音的恢复时间以及第一次排气、排便时间。所得数据以SPSS 13.0统计软件分析，采用t检验和X2检验。结果实验研究部分：1．实验动物存活情况：全部实验动物共死亡3只，实验组手术当天死亡1例(术中躁动，追加麻醉，术后2小时死亡，死亡原因为麻醉过量)。对照组术后第2天死亡1例，死亡原因为肠瘘、腹腔内感染；术后第3天死亡1例，见肠梗阻、肠管扩张、肠壁组织水肿。其余病例均健康存活。2．吻合口愈合情况：存活大鼠吻合口愈合良好，吻合口粘连分数：实验组：1.26±0.31；对照组：1.94±0.36。两者比较，P＜0.05。3．吻合口急性压力负载试验：两组术后第3、7天检测压力升高至40mmHg均未见吻合口破裂情况出现。术后第14天测两组吻合口破裂压，实验组为(139.47±7.05)mmHg，对照组为(96.71±4.73)mmHg，两组均数比较t检验，P＜0.05。4．吻合口组织病理研究：术后第3天，两组肠壁粘膜均已修复完整，但腺体欠发达，腺腔开口较小。粘膜层以下肉芽生长活跃，可见较多毛细血管及成纤维细胞增生。术后第7天，两组粘膜层腺体发育良好，与正常肠粘膜相近，肉芽中仍有较多毛细血管，其中小部分已化生成小血管。成纤维细胞增生，其周围已有明显胶原纤维形成，但胶原纤维束较细，排列稀疏。术后第14天，两组粘膜层与术后第7天时相似，肉芽组织处毛细血管较术后第7天减少，较多小血管生成，并见成纤维细胞周围较多胶原纤维形成。从大体组织病理学看，两组差别不明显。但进一步的胶原纤维分析发现：术后第3天，实验组吻合口成纤维细胞合成胶原较对照组活跃。两组胶原合成于术后第7天达高峰，并开始出现明显纤维化，但纤维束较细，纤维排列紊乱，实验组吻合口胶原纤维含量较对照组多；术后第7天之后胶原合成趋于稳定，但实验组胶原在定量分析上，实验组多于对照组，差异有显著性(P＜0.05)。术后第14天纤维束较粗，排列较整齐，但此时，实验组胶原纤比维含量与对照组相比无明显差异。VEGF染色发现：吻合口肉芽组织中毛细血管增生于第3天左右迅速增长并达高峰，实验组毛细血管密度大于对照组。术后第7天，毛细血管较术后第3天无明显增长，但见部分已化生成小血管，实验组毛细血管密度与对照组无明显差异。术后第14天，毛细血管量较术后第7天明显明显减少，见较多小血管生成，实验组毛细血管密度与对照组无明显差异。透射电镜研究发现：术后第7天实验组腺上皮细胞分泌功能活跃，细胞浆丰富，内含许多分泌颗粒，腺上皮细胞间连接紧密。而对照组腺上皮细胞分泌功能欠活跃，细胞浆较少，分泌颗粒较少，腺上皮细胞间连接欠佳。术后第7天实验组成纤维细胞增生活跃，胞浆较多，胞质丰富，细胞内质网、线粒体发达。而对照组成纤维细胞亦明显增生，但胞浆较少，胞质不丰富，核浆比较大，细胞内质网、线粒体不发达。术后第7天实验组成纤维细胞旁已有明显胶原纤维形成，胶原纤维细长，交叉排列，部分平行。而对照组成纤维细胞旁有明显胶原纤维形成，胶原纤维较短，交叉排列，部分平行，排列较实验组稀疏。临床部分：全部病例均无吻合口瘘等严重并发症出现，Ⅱ组有3例肠梗阻及1例切口裂开合并肠梗阻。在肠鸣音恢复时间及术后首次排气、排便时间等方面，Ⅰ组明显优于Ⅱ组。差异有显著性(P＜0.05)结论(1)小承气合剂促进结肠吻合术后的胃肠动力的恢复是有效的，可以明显的提早术后胃肠动力的恢复；(2)小承气合剂促进结肠吻合术后的胃肠动力恢复是安全的，不会增加吻合口瘘的风险；(3)临床研究证实，小承气合剂用于结直肠肿瘤术后的胃肠动力恢复，亦是合理的，不会增加肿瘤转移的风险，但远期结果尚需进行更深入的研究；(4)小承气合剂促进结肠吻合术后的胃肠动力恢复，可以降低术后近期的并发症，特别是肠粘连的发生率，动物实验的肠粘连分数显示，术后应用小承气和剂早期促进胃肠动力恢复，可显著降低吻合口肠粘连的发生程度；(5)小承气合剂可以促进大鼠结肠吻合口的胶原及肉芽组织增生，从而有利于组织愈合；(6)小承气合剂可以早期诱导大鼠结肠吻合口组织的毛细血管增生，从而对吻合口组织的再生及修复有利；(7)从透射电镜的结果来看，小承气合剂可以提高大鼠结肠吻合口组织的代谢状态，加快成纤维细胞成熟和胶原合成增多；(8)大鼠结肠吻合动物模型稳定，可控行强，造模容易，可以作为将来相关研究的借鉴和参考；(9)改良的吻合口急性压力负载实验，可以成为一个非常实用、操作简单和有价值的评价吻合口安全性的方法。更多还原

【Abstract】 Objective To research the safety and effect on motility recovery ofgastrointestinal using xiaochengqi mixsture after colonic anastomosis.Methods This study is composed of clinical research and animalexperiment. Part of experimental animal: A total of 60 cleaning wistar ratswere randomly divided into the treatment group（groupⅠ） and the controlgroup（groupⅡ）, each group has 30 rats. After colonic anastomosis, rats ofgroupⅠwere received xiaochengqi mixsture as nasal feeding to promote themotility recovery of gastrointestinal after surgery, compared with rats ofgroupⅡwho were received the same dosage of clear water as nasal feeding too. Toobserve the survival of rats in each group. In case of animal was dead duringthe experiment, we performed exploratory laparotomy immediately to examinethe condition of abdominal cavity, afterward we found out the cause of deathand recorded the mortality. All the rats were received exploratory laparotomyat the third, 7th, 14th days after operation, we took 10 rats from each groupevery time to carry through acute pressure load test, then we got the tissueof anastomotic stoma to make pathological research, moreover the quantitativeanalysis of component of anastomotic stoma was performed by dint ofprofessional image sofeware. Part of clinical research: 106 patients withcolorectal anastomosis were researched in the third general surgery ofGuangzhou University of TCM from March 2004 to November 2006. Inclusioncriteria:①clear consciousness, good comprehension ability, who were acceptedto accomplish the research（signing for the operation approval before surgery）;②only one site of colonic anastomosis. These patients were randomly dividedinto the treatment group（groupⅠ） and the control group（groupⅡ）, Patients of the first group were received primary mixsture （Dahuang 6g（later）, Houpu10g, Zhishi 10g, Dangshen 30g） of xiaochengqi by nasal feeding just 4 hoursafter surgery, the speed of dripping is 1ml·min^-1, 4 hours later they werereceived secondary decoction of xiaochengqi in the same way. We continued todo these measures at the second day until patients who had the fist defecationwhich indicated the motility recovery of gastrointestinal. In the controlgroup, patients were accepted fasting until fist exhaust or pass stool intraditional way. We begin to record the time of borborygmus, fist exhaust anddefecation 4 hours after surgery. Using the statistical software SPSS13.0database to obtain the result through statistics analysis adopting the T andX² test.Results Part of animal experiment: 1. The survival ratio of experimentalanimal: There were three animals dead in all, one of them died in the treatmentgroup at the day of surgery（it was fidgety during operation, we superaddedanaesthetic, however it died 2 hours after surgery, the reason may be excessiveanaesthetic）. There was one dead of intestinal leakage and celiac infectionat the second day after surgery in the groupⅠ, another was dead of ileus,bowel distention and intestinal edema at the third day, the others weresurvival. 2. The condition of anastomotic concrescence: the anastomotic stomaof survival rats healed well, the fraction of anastomotic conglutination intwo groups was 1.26±0.31、1.94±0.36 respectively. There was significantdifference（P＜0.05）between them. 3. Acute pressure load-test of anastomoticstoma: pressure of two groups went up to the 40 mmHg at the 3rd、7th day ofpost-operation and none of them appeared anastomotic dehiscence. We detectedthe fracted pressure of anastomotic stoma at the 14th day after the operation,groupⅠis 139.47±7.05mmHg, and groupⅡis 96.71±4.73mmHg, comparing twogroups means by T test, P＜0.01. 4. Pathological research on anastomotic tissue:at the third day of post-operation, the intestinal mucosa of the two groupshad already repaired completely, but gland wasn’t prosperous, glandular cavitywas less. Granulation under mucous layer grew actively, there were much morehyperplasia of blood capillary and fibroblast. At the 7th day after theoperation, the mucosal gland of two groups grew well, and it was near to thenormal intestinal mucosa, there were much more granulation in blood capillary,a fraction of them already turned to small blood vessel. At the 14th day afterthe operation, there were ont only hyperplasy in fibroblast, but also collagenous fibers obviously formed around them, but there was thinerfasciculi, sparse arrangement. At the 14th day of post-operation, the mucouslayer of two groups were similar to condition of the 7th day, but bloodcapillary decreased in the granulation tissue, more small vessels formed, andmore collagenous fibers formed surrounding fibroblast compared to the 7thday. The two groups have no significant difference in grosshistological-pathological. But more analysis of collagenous fiber found that:At the third day of post-operation, anastomotic fibroblasts of groupⅠcollagen synthesized more actively than groupⅡ. Collagenous anabolismof two groups reached to peak at the 7th day of post-operation, it also beginedto appear obvious fibrosis, but there was thiner fasciculi, disorganizedarrangement. Compared with groupⅡ, the amount of anastomotic collagen contentwas much more in groupⅠ, Later of the 7th day post-operation, the anabolismof collagen tends to stable, but groupⅠwas much more than groupⅡin thequantitative analysis, there was significant difference（P＜0.05）between themAt the 14th day post-operation, fiber bundle was quite thick, orderlyarrangemen, but there was no significant difference in the amount ofcollagenous fiber between two groups. The VEGF dye found is that: capillaryhyperplasia of the anastomotic granulation tissue increased quickly aroundthe 3rd day and reached to peak, the density of blood capillary in the groupⅠwas bigger than the groupⅠ. At the 7th day post-operation, blood capillaryhad no obvious growth conparing with the third day, but some of them alreadyturned tosmall blood vessel, there was no significant difference in the densityof blood capillary between two groups. Compared with the 7th daypost-operation, the amount of blood capillary obviously decreased at the 14thday. Much blood vessel came into being, there was no significant differencein the density of blood capillary between two groups. The research bytransmission electron microscopy: At the 7th day post-operation, the excretivefunction of glandular epithelial cell in groupⅠwas active, there were alsoabundant cytoplasm which contained much secretory granule, the glandularepithelial cell adjoined tightly. Compared with groupⅠ, there was less activehyperplasia of fibroblasts, less cytoplasm, less secretory granule, inferiorconnection among glandular epithelial cell in groupⅡ. At the 7th daypost-operation, there were active hyperplasia of fibroblasts, more kytoplasm,abundant cytoplasm, developed cell endoplasm net and mitochondria in groupⅠ. Compared with groupⅠ, there was also active hyperplasia of fibroblasts,but there were less kytoplasm, not abundant cytoplasm, bigger nucleoplasm andundeveloped cell endoplasm net and mitochondria in groupⅡ. At the seventh daypost-operation, collagenous fibre obviously formed by the side of fiber cellin groupⅠ. The collagenous fibre was long and thin, alternate arrangement,part of them was paratactic. Compared with groupⅡcollagenous fibre obviouslywas shorter, also it arranged more sparse than groupⅠ. The part of clinicalresearch: there were no sever complications such as anastomotic leakage inall the patients, three had ileus and one had dehiscence of incision incombination with ileus in groupⅡ, patients in groupⅠwere distinct betterthan groupⅡsuch as the time of borborygmus, fist exhaust and defecation,and so no.Conclusion It is effectively and safely of xiaochengqi mixture to promote themotility recovery of gastrointestinal after colonic anastomosis.更多还原