腹腔镜微创治疗对肝硬化并发胆囊结石患者免疫水平及其并发症的影响

Laparoscopic surgery in patients with liver cirrhosis with gallbladder stones: Effect on immunity and complications

目的:探讨腹腔镜微创治疗对肝硬化并发胆囊结石患者免疫水平及其并发症的影响,为其研究提供可参考依据.方法:共纳入80例入住我院普外科诊断为肝硬化并发胆囊结石患者,采用随机数字法平均分为观察组与对照组两组,分别给予腹腔镜微创治疗及开腹手术治疗,观察患者手术过程中失血量、手术时间、引流量、住院时间等,比较两组的差异.抽取静脉血术后检测应激反应指标C-反应蛋白(C-reactive protein,CRP)、白介素-6(interleukins-6,IL-6)、肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α).于术前,术后1、3 d检测T淋巴细胞亚群(CD4、CD8)的含量.结果:观察组患者术中出血量、手术时间、术后引流量、引流时间、肛门排气时间及住院时间均明显低于对照组患者,两组间比较差异有统计学意义(165.84 mL±50.23 mL vs240.33 mL±150.56 mL,91.78 min±21.74 min vs 137.94 min±30.55 min,274.37 mL±121.15mL vs 418.53 mL±132.24 mL,2.34 d±1.46 d vs 5.72 d±1.84 d,1.33 d±0.73 d vs 2.73 d±1.33 d,8.43 d±1.24 d vs 11.54 d±3.22 d,均P<0.05).术后观察组患者CRP、IL-6、TNF-α水平均明显低于对照组患者,两组间差异比较有统计学意义(6.13 mg/L±1.64 mg/L vs 14.24mg/L±2.52 mg/L,9.44 pg/mL±1.65 pg/mL vs 12.82 pg/mL±1.54 pg/mL,10.42 pg/mL±1.64 pg/mL vs 19.83 pg/mL±1.53 pg/mL,均P<0.05).术前观察组患者CD4、CD8、CD4/CD8分别为42.53%±4.63%,29.32%±2.44%,1.65±0.26,对照组患者CD4、CD8、C D4/C D8分别为42.42%±4.64%,29.13%±2.64%,1.66±0.24,两组比较差异不明显(P>0.05);术后1 d观察组患者CD4、CD8、CD4/CD8分别为33.22%±2.52%,19.83%±2.53%,1.11±0.23,对照组患者CD4、CD8、CD4/CD8分别为28.24%±2.74%,14.24%±2.52%,0.73±0.33,两组均有明显下降,与术前相比差异有统计学意义(P<0.05);术后3 d观察组患者C D4、C D8、C D4/C D8分别为39.42%±2.64%,24.44%±2.65%,1.43±0.24,对照组患者CD4、CD8、CD4/CD8分别为34.12%±2.34%,19.82%±2.54%,1.04±0.22,两组均有上升,与术后1 d相比差异有统计学意义(P<0.05);术后1、3 d观察组CD4、CD8、CD4/CD8均明显高于对照组,两组差异比较有统计学意义(P<0.05).术后观察组患者出现感染、低蛋白血症的例数少于对照组患者,两组间比较差异有统计学意义[3(7.5%)vs 10(25.0%),4(10.0%)vs 12(30.0%),P<0.05];凝血功能障碍比较差异不明显[8(20.0%)vs10(25.0%),P>0.05].结论:腹腔镜微创治疗对肝硬化并发胆囊结石患者创伤小、恢复快,同时对患者应激反应及免疫功能的影响小,且不良反应的发生率亦较开腹治疗降低,值得临床推广应用.

AIM： To study the effect of laparoscopic surgery on immunity and complications in patients with liver cirrhosis and gallbladder stones. METHODS： Eighty patients with liver cirrhosis and gallbladder stones were randomly divided into either an observation group or a control group. Patients in the observation group under- went laparoscopic surgery, and patients in the control group underwent open surgery. Arterial blood samples were taken to determine plasma concentrations of adrenaline, norepinephrlne and dopamine. Intraoperative blood loss, opera- tive time, flow rate, and length of hospital staywere recorded. C-reactive protein （CRP）, inter- leukin-6 （IL-6）, tumor necrosis factor-α （TNF-α）, and T lymphocyte subsets （CD4, CD8） were de- termined. RESULTS： Intraoperative blood loss, opera- tive time, postoperative flow and drainage time, anal exhaust time and hospital stay in the observation group were significantly lower than those in the control group （165.84 mL ± 50.23mL vs 240.33 mL ± 150.56 mL, 91.78 min ± 21.74 min vs 137.94 min ± 30.55 min, 274.37 mL ± 121.15 mL vs 418.53 mL ± 132.24 mL, 2.34 d ± 1.46 d vs 5.72 d ± 1.84 d, 1.33 d ± 0.73 d vs 2.73 d ± 1.33 d, 8.43 d ± 1.24 d vs 11.54 d ± 3.22 d, P 〈 0.05 for all）. The levels of CRP, IL-6 and TNF-~ in the observation group were significantly lower than those in the control group （6.13 mg/ L ± 1.64 mg/L vs 14.24 mg/L ± 2.52 mg/L, 9.44 pg/mL ± 1.65 pg/mL vs 12.82 pg/mL ± 1.54 pg/mL, 10.42 pg/mL ± 1.64 pg/mL vs 19.83 pg/mL ± 1.53 pg/mL, P 〈 0.05 for all）. Preop- eratively, there were no significant differences in the percentages of CD4＋ and CD8＋ lympho- cytes or CD4/CD8 ratio between the observa- tion group and control group （42.53% ± 4.63% vs 42.42% ± 4.64%, 29.32% ± 2.44% vs 29.13% ± 2.64%, 1.65 ± 0.26 vs 1.66 ± 0.24, P 〉 0.05 for all）. On postoperative days 1 and 3, the percentages of CD4＋ and CD8＋ lymphocytes and CD4/CD8 ratio were significantly higher in the observa- tion group than in the control group （day 1： 33.22% ± 2.52% vs 28.24% ± 2.74%, 19.83% ± 2.53% vs 14.24% ± 2.52%, 1.11 ± 0.23 vs 0.73 ± 0.33, P 〈 0.05 for all; day 3： 39.42% ± 2.64% vs 34.12% ± 2.34%, 24.44% ± 2.65 vs 19.82% ± 2.54%, 1.43 ± 0.24 vs 1.04 ± 0.22, P 〈 0.05 for all）. The percentages of CD4＋ and CD8＋ lymphocytes and CD4/CD8 ratio were significantly higher on postoperative days 1 and 3 in both groups compared with preoperative values （P 〈 0.05 for all）. The percentages of patients develop- ing infection and hypoalbuminemia were sig- nificantly lower in the observation group than in the control group （7.5% vs 25.0%, 10.0% vs30.0%, P 〈 0.05）. The incidence of blood coagu- lation dysfunction did not differ significantly between the two groups （20.0% vs 25.0%, P 〉 0.05）. CONCLUSION： Compared with open surgery, laparoscopic surgery is associated with less trauma, more rapid recovery, lower effect on immune function and response, and lower inci- dence of adverse reactions in patients with liver cirrhosis and gallbladder stones.