益生菌制剂对结直肠癌患者围手术期的影响

Effects of perioperative probiotics administration on patients with colorectal cancer

目的探讨酪酸梭菌二联活菌对结直肠癌患者围手术期的影响及其作用机制。方法我院2011年5月至7月共70例限期行结直肠癌手术患者，采用随机数字表法分为试验组（n=35）和对照组（n=35）。两组于术前5d至术后7d每日分别给予酪酸梭菌二联活菌制剂和安慰剂，于术中采集结直肠组织标本，超微电镜下观察肠上皮紧密连接结构，采用Westernblot和实时RT—PCR技术分析肠黏膜上皮细胞紧密连接蛋白的表达，采用UssingChamber技术评估肠上皮通透性。术后第7天收集患者粪便标本和血标本，采用末端限制性片段长度多态性（T—RFLP）技术分析粪便菌群多样性，并采用细菌培养方法对特定细菌进行定量检测。记录患者术后首次排气排便时间、腹泻腹胀发生率、全身炎症反应及术后感染并发症等临床参数。结果与对照组比较，试验组的结直肠黏膜上皮紧密连接超微结构明显改善，Western blot和RT—PCR均证实试验组的紧密连接蛋白occludin、claudin-1和ZO-1的蛋白和mRNA表达水平显著提高（蛋白：P均〈0．001；mRNA：P=0．005、0．001、0．006），跨膜电阻增加[（28．3±5．2）Ω·cm2比（22．1±4．7）Ω·cm2，P=0．002]，对大分子物质甘露醇的通透性降低[（0．91±0．17）％比（1．65±0．33）％，P〈0．001]；肠道菌群的T—RFLP及细菌培养检测发现，试验组肠道菌群多样性增加（P=0．006），肠道双歧杆菌[（143．4±35．9）比（100．0±0．0），P=0．002]和乳酸杆菌[（111．3±52．9））比（100．0±0．0），P〈0．001]生长增加，产气荚膜梭菌生长减少[（66．2±23．7）比（100．0±0．0），P〈0．001]。临床观察发现，试验组术后排气[（2．5±1．7）d比（4．5±2．0）d，P〈0．001]和排便时间[（5．0±1．3）d比（6．3±1．1）d，P=0．002]显著缩短，腹泻（20％比40％，P=0．005）和腹胀发生率降低（35％比60％，P=0．021）。结论酪酸梭菌二联活菌用于结直肠癌患者围手术期可有效增强肠黏膜上皮屏障功能，维护肠道菌群稳态，显著缩短结直肠癌患者术后首次排气、排便时间，降低腹泻和腹胀发生率，促进肠功能恢复。

Objective To evaluate the effects of perioperative probiotics administration on patients with colorectal cancer and to explore its possible mechanism. Methods Seventy patients with colorectal cancer who were scheduled to undergo radical colorectomy at Shanghai Sixth People＇s Hospital between May 2011 and July 2011 were randomly divided with random number table into the control group （n = 35 ） and the treatment group （ n = 35 ）. The two groups in 5 days preoperatively and 7 days postoperatively were given daily doses of probiotics preparation consisting of two combined live bacteria and placebo, respectively. The structure of intestinal epithelial tight junction was observed by electron microscopy in colorectal tissue specimens collected during the operation. The expression of tight junctional protein was detected using Western blot and real-time RT-PCR technology. Intestinal epithelial permeability was evaluated by Ussing Chamber system. Stool samples and blood samples were collected on the 7th day after operation. The diversity of faecal flora was analyzed by terminal restriction fragment length polymorphism （T-RFLP） technique, and the quantitative detection of specific bacteria was conducted by bacterial culture. Clinical parameters including the first exhaust and defecate time, distension and diarrhea incidence, systemic inflammatory response, and postoperative infective complications were recorded. Results Compared with the control group, the treatment group showed better intestinal epithelial tight junction ultrastructure. The expression of tight junction proteins occludin, claudin- 1, and ZO- 1 （protein ： all P 〈 0. 001 ; mRNA ： P = 0. 005, 0. 001, 0. 006） and the transepithelial electrical resistance [ （28.3 ± 5.2） Ω· cm2 vs. （ 22. 1 ± 4. 7） Ω· cm2, P = 0. 002 ] were significantly increased, the large molecule permeability [ （0. 91 ± 0. 17 ） % vs. （ 1.65 ± 0. 33 ） %, P 〈 0. 001 ] reduced, the diversity of intestinal flora （P = 0. 006） increased, the growth of intestinal Bifidobacteria [ （ 143.4 ± 35.9） vs. （ 100. 0 ± 0. 0）, P = 0. 002 ] and Lactobacilli [ （ 111.3 ± 52. 9） vs. （ 100. 0 ± 0. 0）, P 〈 0. 001 ] promoted, and the growth of Clostridium perfringens [ （66. 2 ±23.7） vs. （ 100. 0 ±0. 0）, P 〈0. 001 ] inhibited in the treatment group. The treatment group also showed shorter postoperative exhaust [ （2.5 ± 1.7） d vs. （4. 5 ±2. 0） d, P 〈0. 001 ] and defecate time [ （5.0±1.3） dvs. （6.3±1.1） d, P=0.002], lower incidence of diarrhea （20% vs. 40%, P=0. 005） and abdominal distension （35 % vs. 60% , P=0. 021）. Conclusion Probiotics used perioperatively in patients with colorectal cancer can effectively enhance the intestinal epithelia barrier function, maintain the homeostasis of gut flora, shorten the postoperative first exhaust and defecate time, reduce the incidence of diarrhea and abdominal distension, and promote the recovery of intestinal function.