远端缺血预处理对老年患者胃肠道恶性肿瘤根治术后早期心肌损伤的影响

Effect of remote ischemic preconditioning on early myocardial injury in elderly patients undergoing radical resection of gastrointestinal malignant tumor

目的探讨远端缺血预处理(RIPC)对老年患者胃肠道恶性肿瘤根治术后早期心肌损伤的影响。方法选择行胃肠道恶性肿瘤根治术的老年患者59例,男43例,女16例,年龄65~85岁,BMI 18~35 kg/m^(2),ASAⅡ或Ⅲ级。将患者随机分为两组:远端缺血预处理组(RIPC组,n=27)和对照组(C组,n=32)。RIPC组于麻醉后、手术开始前进行3个循环的RIPC,每个循环行单侧下肢缺血5 min,再灌注5 min;C组不做处理。两组麻醉方案和手术操作均相同。记录术后24、48 h的肌钙蛋白I(cTnI)、C反应蛋白(CRP)、白细胞介素-6(IL-6)、丙二醛(MDA)、超氧化物歧化酶(SOD)、内皮型一氧化氮合成酶(eNOS)、诱导型一氧化氮合成酶(iNOS)浓度,以及术后48 h D-二聚体、纤维蛋白降解产物(FDP)浓度。记录心肌损伤(cTnI≥0.2μg/L)以及术后30 d内的主要心血管不良事件的发生情况。结果与C组比较,RIPC组术后24、48 h cTnI明显降低,术后24 h CRP、IL-6明显降低,术后24、48 h MDA明显降低,术后48 h eNOS、iNOS明显升高,D-二聚体、FDP浓度明显降低(P<0.05)。两组心肌损伤、术后30 d主要心血管不良事件的发生率差异无统计学意义。结论远端缺血预处理能降低胃肠道恶性肿瘤根治术后早期心肌损伤标志物cTnI的释放,减轻术后炎症反应、氧化应激、高凝状态并改善血管内皮功能,但不能降低心肌损伤以及术后30 d内主要心血管不良事件的发生率。

Objective To explore the effect of remote ischemic preconditioning(RIPC)on early myocardial injury in elderly patients undergoing radical resection of gastrointestinal malignant tumor.Methods Fifty-nine elderly patients,43 males and 16 females,aged 65-85 years,BMI 18-35 kg/m^(2),ASA physical statusⅡorⅢ,who underwent radical resection of gastrointestinal malignant tumors were selected.The patients were randomly divided into two groups:the remote ischemic preconditioning group(group RIPC,n=27)and the control group(group C,n=32).Group RIPC underwent three cycles of RIPC after anesthesia and before surgery,each cycle consisting of 5 minutes of unilateral lower limb ischemia and 5 minutes of reperfusion.Group C did not undergo any treatment.The anesthesia regimen and surgical procedures were the same in both groups.The levels of cardiac troponin I(cTnI),C-reactive protein(CRP),interleukin-6(IL-6),malondialdehyde(MDA),superoxide dismutase(SOD),endothelial nitric oxide synthase(eNOS)and inducible nitric oxide synthase(iNOS)24 and 48 hours after operation were measured and recorded.The concentrations of D-dimer and fibrin degradation products(FDP)48 hours after operation were measured and recorded.The occurrence of myocardial injury(cTnI≥0.2μg/L)and major adverse cardiovascular events within 30 days after surgery were recorded.Results Compared with group C,cTnI in group RIPC was significantly reduced 24 and 48 hours after operation,CRP and IL-6 were significantly reduced 24 hours after operation,MDA was significantly reduced 24 and 48 hours after operation,eNOS and iNOS were significantly increased 48 hours after operation,and the concentrations of D-dimer and FDP were significantly reduced(P<0.05).There was no significantly difference in the incidence of myocardial injury and postoperative major adverse cardiovascular events between two groups within 30 days after surgery.Conclusion Remote ischemic preconditioning can reduce the release of early myocardial injury marker cTnI after radical resection of gastrointestinal malignant tumor,reduce postoperative inflammatory response,oxidative stress and hypercoagulable state,as well as improve vascular endothelial function,but it cannot reduce the incidence of myocardial injury and major adverse cardiovascular events within 30 days after surgery.