不同全麻下腹腔镜结肠癌切除术病人围术期细胞免疫功能的比较

ComparisOn of perioperative cellular immune function in patients undergoing laparoscopic surgery for colo. rectal cancer under different general anesthesia protocols

目的比较在相同麻醉深度下不同全麻对腹腔镜结肠癌切除术病人围术期细胞免疫功能的影响。方法择期行腹腔镜结肠癌切除术的病人90例，年龄40-64岁，体重50-85kg，性别不限，ASA分级Ⅰ或Ⅱ级。采用分层随机法，将患者随机分为3组（n=30）：全凭静脉麻醉组（Ⅰ组）、吸入全麻组（Ⅱ组）和静吸复合全麻组（Ⅱ组）。Ⅰ组静脉注射咪达唑仑、舒芬太尼和维库溴铵，TCI异丙酚和瑞芬太尼麻醉诱导；TCI异丙酚和瑞芬太尼，间断静脉注射维库溴铵维持麻醉。Ⅱ组吸入七氟醚麻醉诱导，吸入七氟醚，间断静脉注射维库溴铵维持麻醉。Ⅲ组静脉注射咪达唑仑、舒芬太尼和维库溴铵，TCI异丙酚和瑞芬太尼麻醉诱导，TCI异丙酚和瑞芬太尼，吸入七氟醚，间断静脉注射维库溴铵维持麻醉。术中采用Nareotrend指数监测麻醉深度，维持Narcotrend指数37。64。于麻醉诱导前30min（T0）、切皮后2h（T1）、术毕（T2）和术后24h（T1）时采外周静脉血样，采用流式细胞术测定T淋巴亚群CD3^＋、CD4^＋、CD8^＋和NK细胞的水平，计算CD4^＋/CD8^＋。结果与Tn时比较，Ⅱ组T2时CD3^＋、CD4^＋、CD4^＋／CD8^＋和NK细胞水平降低，Ⅲ组T2时NK细胞水平降低（P〈0．05）；与Ⅰ组比较，T2时Ⅱ组CD3^＋、CD4^＋、CD4^＋／CD8^＋和NK细胞水平降低，Ⅲ组NK细胞水平降低（P〈0．05）；与Ⅲ组比较，T2时Ⅱ组CD3^＋和CD4^＋水平降低（P〈0．05）。结论与吸入麻醉和静吸复合麻醉比较，静脉注射咪达唑仑、舒芬太尼和维库溴铵，TCI异丙酚和瑞芬太尼麻醉诱导，TCI异丙酚和瑞芬太尼，间断静脉注射维库溴铵维持麻醉对腹腔镜结肠癌切除术病人围术期细胞免疫功能的抑制程度低。

Objective To compare the effects of different general anesthesia protocols on perioperative cellular immune function in patients undergoing laparoscopic surgery for colorectal cancer. Methods Ninety ASA Ⅰ or Ⅱ colorectal cancer patients aged 40-64 yr weighing 50-85 kg undergoing laparoscopic surgery were randomly divided into 3 groups （ n = 30 each） ： group total intravenous anesthesia （group Ⅰ ） ; group inhalational anesthesia （group Ⅱ ） and group combined intravenous-inhalational anesthesia（ group Ⅲ ） Anesthesia was induced with iv midazolam, sufentanil, TCI of propofol and remifentanil and vecuronium in groups Ⅰ and Ⅲ. In group Ⅰ anesthesia was maintained with TCI of propofol and ＂remifentanil and intermittent iv boluses of vecuronium, while in group m with inhalation of sevoflurane and intermittent iv boluses of vecuronium. In group Ⅱ anesthesia was induced and maintained with inhalation of sevoflurane and intermittent iv boluses of vecuronium. Narcotrend index was used to monitor depth of anesthesia and maintained at 37-64 during operation. Venous blood samples were taken for determination of the levels of T lymphocyte subsets （CI）3^＋ , CD4^＋ , CD8^＋ , CD4^＋/CD8^＋） and natural killer cells at 30 min before induction of anesthesia （T0）, 2 h after skin incision （T1）, at the end of operation （T2） and 24 h after operation （T3 ）. Results The levels of CD3 ^＋ , CD4 ^＋, CD4 ^＋/CD8 ^＋ and rtatural killer ceils were significantly decreased at T2 in group Ⅱ , while the levels of natural killer cells were decreased at T2 in group m as compared with the baseline at To, and were significantly lower than those in group Ⅰ . The levels of CD3^＋and CD4 ^＋ were significantly lower at T2 in group Ⅱ than in group m Conclusion Intravenous anesthesia with midazolam, propofol, sufentanil, remifentanil and vecuronium has less inhibitory effect on perioperative cellular immune function than inhalational anesthesia and combined intravenous-inhalational anesthesia in patients undergoing laparoscopic surgery for colorectal cancer.