腹腔镜胆囊切除术中不同气腹压力对患者肝肾功能及呼吸功能的影响

Effects of different pneumoperitoneum pressure on liver,kidney and respiratory function during laparoscopic cholecystectomy

目的 探析腹腔镜胆囊切除术中不同气腹压力对患者肝肾及呼吸功能的影响。方法 收集行腹腔镜下胆囊切除术的患者240例，按数字表法随机分为低气压组（n＝120），高气压组（n＝120）。分别于术前1 d、术后第1 d、术后第3 d监测肝、呼吸功能相关指标包括：丙氨酸氨基转移酶（ALT）、谷草转氨酶（AST）、总胆红素（TBIL）、间接胆红素（IBIL）、直接胆红素（DBIL）、白蛋白（A）、球蛋白（G）、总蛋白（TP）、乳酸脱氢酶（LDH）、碱性磷酸酶（ALP）、谷氨酰转肽酶（GGT）、尿素氮（BUN）、血清肌酐（Scr）、β2-微球蛋白（β2-MG）含量、深吸气量（IC）、用力肺活量（FVC）、第1秒用力呼吸容积（FEV1）、最大呼气流速（PEF）、肺活量（VC）、最大通气量（MVV）、最大呼吸中段流速（FEF 25%～75%）水平；术前10 min、术中第1小时、术后第1天监测肾功能相关指标，并分别进行比较。结果 肝功能指标：在术前1 d，高压组与低压组ALT、AST、TBIL等肝功能指标均在参考值范围内，组间差异均无统计学意义（均P〉0.05）；在术后第1天，高压组与低压组的ALT、AST、TBIL、LDH指标均较术前增高（t＝4.132，P＝0.023；t＝4.231，P＝0.021；t＝3.615，P＝0.043；t＝4.561，P＝0.331；t＝4.645，P＝0.014；t＝4.793，P＝0.012；t＝4.135，P＝0.025；t＝4.561，P＝0.037），且高压组在ALT、AST、TBIL、IBIL、A、LDH、GGT指标上较低压组增高明显（t＝3.429，P＝0.045；t＝3.656，P＝0.041；t＝3.144，P＝0.043；t＝4.014，P＝0.041；t＝2.947，P＝0.032；t＝3.415，P＝0.039；t＝2.893，P＝0.029）；在术后第3天，高压组与低压组的TBIL、DBIL、LDH、GGT等各项指标与术前接近，基本上恢复正常（t＝1.342，P＝0.037；t＝1.275，P＝0.039；t＝1.893，P＝0.028；t＝1.413，P＝0.032；t＝1.348，P＝0.035；t＝1.289，P＝0.037；t＝1.899，P＝0.026；t＝1.453，P＝0.024），且高压组在ALT、AST、IBIL、LDH指标上仍较低压组明显增高（t＝4.132，P＝0.036；t＝4.653，P＝0.029；t＝3.567，P＝0.038；t＝4.112，P＝0.031）。呼吸功能指标：两组患者在不同气腹压力下，术前1 d呼吸功能指标均在参考值值范围内，差异无统计学意义；术后第1天及术后第3天，与低压组相比差异均有统计学意义（t＝1.786，P＝0.017；t＝1.823，P＝0.014；t＝1.463，P＝0.012；t＝1.855，P＝0.011；t＝1.931，P＝0.018；t＝1.991，P＝0.013；t＝2.314，P＝0.019；t＝1.427，P＝0.021；t＝1.721，P＝0.019；t＝1.854，P＝0.018；t＝1.775，P＝0.023；t＝1.764，P＝0.022；t＝1.938，P＝0.019；t＝1.897，P＝0.020）。肾功能指标：两组在术前10 min、术中第1小时、术后第1天的BUN、Scr、β2-MG水平差异均无统计学意义（均P〉0.05）；BUN的水平在围手术期变化无统计学意义（P〉0.05）；高压组及低压组Scr、β2-MG在术中第1小时、术后第1天均较术前10 min有明显升高（t＝1.912，P＝0.017，t＝1.867，P＝0.021；t＝1.862，P＝0.020，t＝1.752，P＝0.032；t＝1.378，P＝0.029，t＝1.419，P＝0.026；t＝1.568，P＝0.023，t＝1.927，P＝0.019）。结论 二氧化碳（CO2）气腹对患者的肝功能有一过性损害，适当降低气腹压力有利于患者肝功能的保护；CO2气腹会产生可逆性的肾损害，并且降低气腹压力对肾功能的改善无多大影响；CO2气腹压力较高时对患者呼吸功能影响较大，术中应密切监测患者呼吸功能。

Objective To investigate the effects of different pneumoperitoneum pressure on liver,kidney and respiratory function during laparoscopic cholecystectomy.Methods 240 patients who received laparoscopic cholecystectomy,were selected.They were divided into low pressure group（n=120）and high pressure group（n=120）.The indicators of liver and respiratory function（ALT,AST,TBIL,IBIL,DBIL,A,G,TP,LDH,ALP,GGT,BUN,Scr,β2-MG,IC,FVC,FEV1,PEF,VC,MVV,FEF25%~75%）were monitored on the 1st day before operation and on the 1st,3rd day after operation.The indicators of kidney function were monitored at preoperative 10min,intraoperative 1h and postoperative 1 day.Results Liver function index：on the preoperative 1 day,the ALT,AST,TBIL were in the reference range,there were no statistically significant differences between the high pressure group and low pressure group（all P〉0.05）.On the 1st day after operation,the AST,TBIL,ALT and LDH index in the two groups were increased（t=4.132,P=0.023;t=4.231,P=0.021;t=3.615,P=0.043;t=4.561,P=0.331）（t=4.645,P=0.014;t=4.793,P=0.012;t=4.135,P=0.025;t=4.561,P=0.037）,and the ALT,AST,TBIL,IBIL,A,LDH,GGT in the high pressure group were higher than those in the low pressure group（t=3.429,P=0.045;t=3.656,P=0.041;t=3.144,P=0.043;t=4.014,P=0.041;t=2.947,P=0.032;t=3.415,P=0.039;t=2.893,P=0.029）.On the 3rd day after operation,the TBIL,DBIL,LDH,GGT index in the two groups were closed to the normal value（t=1.342,P=0.037;t=1.275,P=0.039;t=1.893,P=0.028;t=1.413,P=0.032;t=1.348,P=0.035;t=1.289,P=0.037;t=1.899,P=0.026;t=1.453,P=0.024）,and the ALT,AST,IBIL,LDH of the high pressure group were significantly higher than those of the low pressure group（t=4.132,P=0.036;t=4.653,P=0.029;t=3.567,P=0.038;t=4.112,P=0.031）.Respiratory function index：at preoperative 1 day,the respiratory function indicators of the two groups were within the reference range,the differences between the two groups were not statistically significant（all P〉0.05）.On the 1st and 3rd after operation,those indicators had statistically significant differences between the two groups（t=1.786,P=0.017;t=1.823,P=0.014;t=1.463,P=0.012;t=1.855,P=0.011;t=1.931,P=0.018;t=1.991,P=0.013;t=2.314,P=0.019;t=1.427,P=0.021;t=1.721,P=0.019;t=1.854,P=0.018;t=1.775,P=0.023;t=1.764,P=0.022;t=1.938,P=0.019;t=1.897,P=0.020）.Renal function index：at preoperative 10 min,intraoperative 1 h,and the 1st day after operation,the BUN,Scr and β2-MG levels had no statistically significant differences between the two groups（all P〉0.05）.The level of BUN had no obvious change in the perioperative period（P〉0.05）.The Scr,β2-MG in the two groups were significantly increased at intraoperative 1 h and the 1st day after operation compared with preoperative 10min（t=1.912,P=0.017,t=1.867,P=0.021;t=1.862,P=0.020,t=1.752,P=0.032;t=1.378,P=0.029,t=1.419,P=0.026;t=1.568,P=0.023,t=1.927,P=0.019）.Conclusion CO2 pneumoperitoneum has transient damage to the patients＇ liver function,and lower pneumoperitoneum pressure is useful to the protection of liver function;CO2 pneumoperitoneum can lead to reversible kidney damage and reducing the pneumoperitoneum pressure has little effect on renal function;higher CO2 pneumoperitoneum pressure should influence respiratory function,therefore respiratory function should be closely monitored.