不同麻醉和镇痛方法对直肠癌根治术患者细胞免疫的影响

Effects of anesthetic and analgesic protocols on cellular immunity in patients undergoing radical resection of rectal carcinoma

目的:观察不同麻醉和镇痛方法下直肠癌根治术患者术中和术后外周静脉血T淋巴细胞亚群和自然杀伤(NK)细胞数量的变化。方法:选择60例择期直肠癌根治术患者,随机分为两组:A组采用全凭静脉麻醉,术后行患者自控静脉镇痛;B组采用硬膜外阻滞复合静脉全麻,术后行患者自控硬膜外镇痛,每组30例。分别于麻醉前(T0)、切皮后2h(T1)、术后2h(T2)和术后24h(T3)抽取两组患者静脉血,流式细胞术测定T淋巴细胞亚群、活化T细胞和NK细胞数量的变化,并记录两组在T2和T3时点的视觉模拟评分(VAS)。结果:两组T1时点CD3+、CD3+CD4+、CD3+HLA-DR+和NK细胞较T0明显下降(P<0.05),B组于T1时降到最低,A组于T2时降到最低,在T1～T3时点B组各指标明显高于A组(P<0.05),T3时点B组各指标恢复到T0水平,而A组仍明显低于T0水平(P<0.05)。T2和T3时点B组VAS评分均明显低于A组(P<0.05)。结论:硬膜外复合静脉全麻辅以硬膜外镇痛比全凭静脉麻醉辅以静脉镇痛对直肠癌根治术患者围术期细胞免疫抑制更轻,能更好地保护患者的细胞免疫功能。

Objective To investigate the changes in the number of peripheral venous blood T lymphocyte subsets and natural killer （NK） cells using different anesthetic and analgesic protocols on cellular immune function in patients undergoing radical resection of rectal carcinoma during the intraoperative and postoperative period. Methods Sixty ASA I or Ⅱ patients undergoing selective radical resection of rectal carcinoma were randomly divided into 2 groups to receive either intraoperative general anesthesia and postoperative intravenous analgesia （group A, n = 30） or intraoperative general anesthesia combined with epMural anesthesia and postoperative epidural analgesia （group B, n = 30）. The venous blood samples were obtained from the patients before anesthesia induction （To）, 2 h after skin incision （T1）, 2 h （Tz） and 24 h （T1） after the end of operation. The T-lymphocyte subsets, activated T cells and NK cells were measured by flow eytometry. Visual analogue scale （VAS） was observed at T2 and T3. Results The percentages of CD3＋, CD3＋CD4＋, CD3＋HLA-DR＋ and NK cells in both groups began to decrease significantly at T1 comparing to those at To, with the lowest level at T1 in group B and at T2 in group A. From T1 to T3, the values in group B were significantly higher than those in group A （P 〈 0.05）. At T3, the values in group B recovered to the level of T0, but the levels in group A were significantly lower than those of To （P 〈 0.05）. The VAS scores in group B were significantly lower than those in group A at T2 and T3 （P 〈 0.05）. Conclusions The operation using general anesthesia combined with epidural anesthesia and postoperative epidural analgesia produces less immune suppression than that using intraoperafive general anesthesia and postoperative intravenous analgesia. The former can effectively protect the cellular immune function in patients.