【作者】 赵江宁；

【导师】 崔学教；

【作者基本信息】 广州中医药大学 ， 中西医结合临床， 2000， 硕士

【摘要】 随着现代医学外科手术技术的不断发展和进步，尤其是腹部外科和妇科复杂性手术的普遍开展，术后腹腔粘连具有很高的发生率，而所产生的严重并发症—粘连性肠梗阻，其发病率近五十年来呈上升趋势，危及患者的健康及生命，给患者、保险机构和国民经济带来巨大的经济损失。为探讨通腑泻热合剂预防术后腹腔粘连形成的作用机理，此研究从细胞因子和组织细胞形态学等方面进行临床和实验研究。 临床研究采用前瞻、对照、分层随机化的方法进行，将42例合格受试对象分为通腑泻热合剂治疗组和对照组，治疗组分别在术后第一天和第二天子通腑泻热合剂250ml保留灌肠，每日两次。观察纪录两组病例术后临床症状、体征及一般情况的分级计分、术后肠鸣音恢复时间、术后第一天灌肠前及术后第三天血TNF-α、IL-6、IL-8含量。结果提示：灌肠组患者的有关临床症状、体征和一般情况分级计分5.48±1.25较对照组明显降低（P＜0.05）；肠鸣音恢复时间37.48±3.34小时，灌肠组早于对照组，比较有显著性差异（P＜0.05）；术后第三天血TNF-α含量29.292±26.582pg/ml低于术后第一天灌肠前血TNF-α含量，差异有统计学意义（P＜0.05），而血IL-6含量56.344±90.458pg/ml、IL-8含量262.128±435.605pg/ml与对照组比较无显著性差异。临床观察未发现通腑泻热合剂灌肠影响腹部术后病人的胃肠吻合口和切口的愈合。经过临床实验观察说明：腹部手术后以通腑泻热合剂灌肠能明显减轻腹痛、腹胀、恶心、呕吐等临床症状及体征，能明显缩短患者的肠鸣音恢复时间，早期促进术后胃肠蠕动功能恢复，对胃肠吻合口及切口的愈合无不良影响，通腑泻热合剂灌肠能降低腹部手术后病人血TNF-α含量，可能抑制TNF-α在炎症前期的对中性粒细胞、肥大细胞等的介导作用，降低TNF-α对间皮细胞的介导作用，减少间皮细胞合成和释放PAI，—— 减轻腹腔粘连的程度。通腑泻热合剂灌肠对腹部手术后血 TNFQ含量的影 响以及与预防腹腔粘连形成的关系还有待以后更进一步的实验研究探讨。 实验研究采用肠浆膜夹伤及剥离擦伤的方法制成术后腹腔粘连的动物 模型。将模型动物随机分成六组：中药中剂量组、空白对照组、中药低剂量 组、中药高剂量组、生理盐水组、阳性药对照组，分别给予不同的处理。实 验结果表明：1．通腑泻热合剂能有效预防大鼠术后腹腔粘连的形成，在腹腔 粘连分级上，中药组与空白对照组、生理盐水组、阳性药对照组比较，差异 有统计学意义0功刀5入但中药三个剂量组之间比较差异不具有显著性（ P＞0刀5人2．通腑泻热合剂能降低血叫卜口含量，术后第三天中药中剂量组 与空白对照组血 TNF－Q含量的差异有显著性o＜0刀5人血 TNF－a含量与腹 腔粘连级别存在正相关，其相关系数为0．424，P司．013＜0．05，相关具有统 计学意义。3．通腑泻热合剂能降低腹腔粘连组织胶原纤维含量、I和＊胶原 纤维蛋白比率，使I型胶原的含量减少，Ill胶原纤维含量相对增多。4．经 浆膜损伤的腹腔粘连大鼠模型粘连组织中出现了成纤维细胞、巨噬细胞和血 管内皮细胞TGF－p；的表达，粘连组织以成纤维细胞的表达为主，从术后第 三天至术后第十四天这种表达呈逐渐增强的趋势，提示TGF－fi；与术后腹膜 愈合及腹腔粘连形成确有一定的关系。中药组术后第十四天粘连组织中的巨 噬细胞和部分内皮细胞表达TGF－fi；增强的现象是否与中药活血化瘀，改善 粘连局部的血液供应，防止粘连进一步发展有关尚需更深入的研究和探讨。 5．通腑泻热合剂对大鼠术后腹腔粘连组织超微结构影响的实验研究表明通 腑泻热合剂能稳定肥大细胞的细胞膜结构，减少肥大细胞内含有多种活性介 质的颗粒脱出；同时增强胃肠蠕动功能，可能影响了成纤维细胞与肥大细胞 之间直接紧密接触的条件，抑制胶原的合成，促进血管内皮细胞的增生和毛 细血管的生成，改善局部血液循环和供氧，抑制炎症反应，降低粘连发生率， 减轻粘连的严重程度。更多还原

【Abstract】 lntra-abdominal adhesions remain a common problem in general surgical practice. In order to investigate the preventive mechanism in the postoperative pcritoneal adhesion with “ToiigFiiXieRe” Eiiteroclysis, tim researehes arc mile in lie aspects of cell factor and histolo ical tnorphl(dujy Cli meal prospective rattdomii.ed controlled ade tn 42 case abdominal post-operation. 42 cases arc divided into 2 groups at randenv cases treated with 250rn1 “TongFuXieRe”enteroclysis for 2 days and two times per day after operation, the others not treated with the enteroclysis. Some indexes including in the times of bowel sound after operation ,contents of blood IL-6,IL-8 and TNF-α in the first day and the third day after operation respectively are detected. The results show that in the treated group the time of bowel sound recorded after operation is 37.48±3.34 hours, the content of TNF-α is 29.292±26.582Pg/ml with significant differences compared with control group, while contents of IL-6 record as 56.344± 90.448Pg/ml and the contents of IL-8 record as 262.128±435.6O5Pg/ml, without si~nifieant differences between treated group and control group. It suggests that enemaed with “TongFuXierRe”enteroclysis after abdominal operation can promote gastrointestinal motility in earlier after operation and inhibit reaction of inflammatory cells by TNF-α in early inflammatory passage and so decrease the mediated role of releasing PAl by human peritoneal mesothelial cells during peritoneal inflammation. All these effects contribute to the preventive of inflammatory and preventive of postoperative peritoneal adhesion. To investigate the prophylactic effects of “TongFuXieRe”enteroelysis on peritoneal adhesions in the model postoperative peritoneal adhesions of SD rat with ileum trauma clippeded by forceps, Rats are divided into 6 groups at random: 3 groups enemaed with different dose of “TongFuXieRe”enteroclysis, enemaed with normal saline, enemaed with Fibrin glue and control group. The results show that: 1 .“TongFuXieRe”enteroclysis inhibits the peritoneal adhesion formation. The scores of peritoneal adhesion in “TongFuXieRe”enteroclysis groups are significantly lower than that in the other groups, while the scores of peritoneal adhesion are not different obviously among “TongFuxXieRe”enteroclysis groups in different doses. 2. “TongFuxXieRe”enteroclysis decreases the levels of blood TNF-α significantly. There were marked difference between the blood TNF-α of “TongFuxXieRe” enteroclysis group and control group in the third day after operation. The correlation between the blood TNF-α and the scores of peritoneal adhesion is significant at the 0.05 level. The blood TNF-α levels may be important indicator of predicting and prognosis of peritoneal adhesive severity.3. The total collagen and collagen type Ⅰ and Ⅲ are showed distinctly by picrosirius red and polarization microscopy, VG staining and morphometrics analysis. “TongFuxXieRe”enteroclysis decreases the contents of the total collagen and collagen type Ⅰ and inhibits the collagen systhesis in the peritoneal adhesive tissues. 4. The expression of TGF-β1 in the peritoneal adhesion tissues during the different period after operation appears to be regularly in pattern with irnmunohistochemical method. There are positive signal showed in fibroblasts, vascular endothelium cells and macrophages. The positive level of TGF- β1 in fibroblasts is found to be significantly higher in “TongFuxXieRe”enteroclysis group than that in control group in the forth day and the更多还原