腹腔镜肝切除术中不同气腹压对气栓及术后炎症反应的影响

Effects of pneumoperitoneal pressure on air embolism duringlaparoscopic hepatectomy and degree of postoperative inflammation

目的探讨不同气腹压对腹腔镜肝切除术中气栓的形成、严重程度、持续时间及术后炎症反应程度的影响。方法本研究为前瞻性研究，选取2015年6月至2016年7月邵逸夫医院拟行腹腔镜肝脏切除患者50例，采用随机数字表法分为2组，术中分别设置气腹压15 mmHg（P15组，n＝25）及12 mmHg（P12组，n＝25）。术中使用经食管超声心动图（TEE）监测气栓形成、严重程度及最严重气栓持续时间；同时监测患者生命体征、动脉血气、呼气末二氧化碳分压（PETCO2）；采用乙二胺四乙酸（EDTA）抗凝管收集患者术前及术后0、12、24 h静脉血各2 ml，测定血浆白细胞介素-6（IL-6）、肿瘤坏死因子-α（TNF-α）及白细胞介素-10（IL-10）水平；记录手术时间、术中出血量及术后住院时间等。结果50例患者均有气栓形成，其中P15组、P12组严重气栓分别占76%（n＝19）、52%（n＝13）；P15组最严重气栓持续时间为（58.0±22.6）s，P12组为（36.6±17.8）s，差异有统计学意义（t＝3.71，P〈0.01）。P15组术中并发症发生率为24%，高于P12组的4%，差异有统计学意义（χ^2＝4.15，P〈0.05）。术后12 h P15组促炎因子IL-6、TNF-α分别为[685.66（435.18～935.52）ng/L, 31.00（18.29～41.15）ng/L]，均高于P12组的[480.50（255.28～685.34） ng/L，21.00（14.87～31.64） ng/L], 差异均有统计学意义（均P〈0.05），而术后12 h P15组抗炎因子IL-10为18.00（5.75～30.55） ng/L, 低于P12组的26.89（15.03～38.00） ng/L, 差异有统计学意义（P〈0.05）。两组患者的手术时间、术中出血量及术后住院时间差异均无统计学意义（均P〉0.05）。结论腹腔镜肝切除术中较高的气腹压可能导致严重气栓形成，且持续时间增加，加重术后炎症反应。

ObjectiveTo investigate the incidence and severity of embolicevents, and degree of postoperative inflammation when pneumoperitoneal pressures 15 mmHg and 12 mmHg were used during laparoscopic hepatectomy. MethodsA computer-generated 1∶1 randomization protocol was used to assign fifty patients to either the 15 mmHg（P15, n=25） or 12 mmHg（P12, n=25） group. Throughout the surgery, air embolisms were detected by transesophageal echocardiography （TEE） and graded based on their size. Vital signs, arterial blood gases （ABG）, PETCO2 levels, blood loss, operative time and postoperative hospital stays were monitored. 2 ml blood samples were taken before and after operation finished 0, 12 and 24 h by using EDTA anticoagulated tubes in order to detect the IL-6, TNF-α and IL-10 level in plasma. ResultsCO2 embolism occurred in 100% of the enrolled patients. The frequencies of severe air embolism were 76%（n=19） in P15 group and 52% （n=13） in P12 group, respectively. The duration of severe embolism episodes in P15 group was much longer than that in P12 group[（58.0±22.6） s vs（36.6±17.8）s, t=3.71, P〈0.01]. The incidence of complications in group P15 was 24%, which was higher than that in group P12 of 4%（χ^2=4.15, P〈0.05）. The postoperative pro-inflammatory cytokine IL-6 and TNF-α in group P15 at the point of 12 hour after operation[685.66（435.18-935.52）ng/L, 31.00（18.29-41.15）ng/L]were statistically higher than those in group P12 [480.50（255.28-685.34） ng/L, 21.00（14.87-31.64） ng/L, P〈0.05], whereas the anti-inflammatory cytokine IL-10 in P15 group[18.00（5.75-30.55） ng/L]was statistically lower than the P12 group [26.89（15.03-38.00） ng/L, P〈0.05]. There was no statistical difference in operative time, blood loss and postoperative hospital stay between the two groups. ConclusionThe higher pneumoperitoneal pressure during laparoscopic hepatectomy causes more serious gas embolism, prolongs embolic duration and lead to more sever inflammatory response.