周健 高淳 唐學典

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·論著·

腹腔鏡膽囊切除術(shù)治療老年急性壞疽性膽囊炎對機體免疫功能的影響

周健 高淳 唐學典

目的 探討腹腔鏡膽囊切除術(shù)和開腹膽囊切除術(shù)治療老年急性壞疽性膽囊炎的療效及其對機體免疫功能的影響。方法 選擇就診治療的急性壞疽性膽囊炎的患者120例，按照隨機數(shù)字法將患者分為觀察組和對照組，每組60例。對照組予以開放膽囊切除術(shù)，觀察組予以腹腔鏡下膽囊切除術(shù)。觀察2組治療后的手術(shù)時間，術(shù)中出血量，肛門排氣時間，住院時間，視覺模擬評分(VAS)，消化生存質(zhì)量指數(shù)(GLQ)評分和并發(fā)癥發(fā)生情況，比較2組治療前后白介素(IL)-10、干擾素(INF)-γ、IL-2、IL-4、CD+3、CD+4、CD+8、CD+4/CD+8水平的變化。結(jié)果 觀察組手術(shù)時間、術(shù)中出血量、肛門排氣時間、住院時間、VAS評分和并發(fā)癥明顯短于或者少于對照組(P<0.01)，GLQ評分明顯優(yōu)于對照組(P<0.01)。2組治療前IL-10、INF-γ、IL-2、IL-4、CD+3、CD+4、CD+8、CD+4/CD+8水平差異無統(tǒng)計學意義(P>0.05)，治療后2組IL-10、IL-4、CD+3、CD+4和CD+4/CD+8水平較治療前明顯降低(P<0.01)，而INF-γ，IL-2 和CD+8水平較治療前明顯升高(P<0.01)，觀察組治療后IL-10、INF-γ、IL-2、IL-4、CD+3、CD+4、CD+8、CD+4/CD+8水平與對照組比較，差異有統(tǒng)計學意義(P<0.01)。結(jié)論 腹腔鏡膽囊切除術(shù)治療老年急性膽囊炎療效確切，明顯優(yōu)于開膽囊切除術(shù)，對機體的炎癥控制和緩解免疫漂移具有重要作用。

急性壞疽性膽囊炎；免疫功能；腹腔鏡；療效

急性壞疽性膽囊炎是肝膽外科的常見病，多發(fā)病，尤其老年患者有發(fā)病升高的趨勢。老年的急性壞疽性膽囊炎具有發(fā)病快，常常合并糖尿病，心臟病和高血壓等慢性疾病，治療難度大，故傳統(tǒng)的開腹手術(shù)往往具有手術(shù)時間長，術(shù)中出血量多和術(shù)后并發(fā)癥多等特點，使患者的免疫功能下降，對患者生存質(zhì)量造成嚴重的影響[1,2]。急性壞疽性膽囊炎患者機體出現(xiàn)免疫紊亂，主要表現(xiàn)細胞因子分泌紊亂和T細胞亞群的紊亂[3]。本組研究采用腹腔鏡膽囊切除術(shù)治療急性壞疽性膽囊炎，與傳統(tǒng)開腹手術(shù)進行比較，觀察對機體免疫功能的影響，報告如下。

1 資料與方法

1.1 一般資料 選擇2012至2015年在上海市長寧區(qū)天山中醫(yī)醫(yī)院就診治療的急性壞疽性膽囊炎的患者120例，按照隨機數(shù)字法將患者分為觀察組和對照組，每組60例。觀察組中，男32例，女28例；年齡60～85歲，平均年齡(72.36±9.35)歲；發(fā)病時間1～6 d，平均(2.36±0.19)d，合并高血壓19例，糖尿病11例和慢性支氣管炎6例。對照組中，男33例，女27例；年齡60～85歲，平均年齡(72.49±8.47)歲；發(fā)病時間1～6 d，平均(2.27±0.33)d；合并高血壓22例，糖尿病9例和慢性支氣管炎7例。2組患者均知情同意，排除患者有精神疾?。谎合到y(tǒng)疾??；自身免疫性疾病；惡性腫瘤；肝炎，肺結(jié)核和肺炎等感染性疾病；心肝腎等重要臟器障礙。2組年齡、性別比、發(fā)病時間有可比性。

1.2 方法

1.2.1 治療方法：對照組予以開放膽囊切除術(shù)，觀察組予以腹腔鏡下膽囊切除術(shù)。2組術(shù)前均予以控制基礎(chǔ)性疾病，均予以禁食，禁水。腹腔鏡膽囊切除術(shù)：在全麻下，取仰臥位，采用三孔法，建立二氧化碳氣腹，壓力為9～12 mm Hg，采用頭高腳底位，左側(cè)傾斜，充分暴露膽囊，先游離胃腸和大網(wǎng)膜與膽囊的粘連，顯露膽囊。膽囊底部切開現(xiàn)予以減壓，并予以鈦夾夾閉，提起膽囊頸部，辨認Calot 三角，用電鉤和吸引器分離Calot 三角，游離出膽囊頸管，膽囊動脈分別予以可吸收夾夾閉。對于膽囊頸管結(jié)石的患者，先將膽囊切開，充分沖洗膽囊頸管，將結(jié)石取出后再予以夾閉。對于解剖不清楚，難以完整切除膽囊的患者，將膽囊部分切除，在將膽囊黏膜予以燙除。確切止血和清除體內(nèi)殘留的膽汁，放置引流管一根。開腹膽囊切除術(shù)：采用右上腹小切口進腹，采用順逆結(jié)合的方式切除膽囊。余腹腔鏡膽囊切除術(shù)類似。

1.2.3 視覺模擬評分(VAS)和生存質(zhì)量指數(shù)(GLQ):VAS，無痛為0分，劇痛為10分，分數(shù)越高，疼痛越重。GLQ評價患者的生存質(zhì)量，包括主觀癥狀、生理狀態(tài)、心理狀態(tài)、日常生活狀態(tài)及社會活動狀態(tài)。共36項目，每個項目0～4分，總分0～144分，分值越高，健康狀態(tài)越好。

2 結(jié)果

2.1 2組手術(shù)情況和術(shù)后恢復比較 觀察組的手術(shù)時間、術(shù)中出血量、肛門排氣時間、住院時間和VAS評分明顯短于或者少于對照組(P<0.01)，GLQ評分明顯優(yōu)于對照組(P<0.01)。觀察組術(shù)后膽管損傷1例，惡心嘔吐2，膽漏1例，其并發(fā)癥發(fā)生率為6.67%(4/60)；對照組切口感染2例，膽漏2例，惡心嘔吐3例，其并發(fā)癥發(fā)生率11.67%(7/60)，觀察組與對照組的并發(fā)癥發(fā)生率差異無統(tǒng)計學意義(P>0.05)。見表1。

表1 2組手術(shù)情況和術(shù)后恢復比較

組別手術(shù)時間(min)術(shù)中出血量(ml)肛門排氣時間(h)住院時間(d)VAS評分(分)GLQ評分(分)并發(fā)癥[例(%)]觀察組61.65±13.5965.18±10.7922.34±8.673.94±0.853.75±1.06117.36±12.344(6.67)對照組84.67±21.74110.39±14.8554.68±10.647.86±1.165.62±1.15102.39±11.487(11.67)t(χ2)值6.95519.07818.25221.1149.2626.8800.400P值0.0000.0000.0000.0000.0000.0000.527

2.2 2組治療前后IL-10、INF-γ、IL-2和IL-4水平的變化 2組治療前的IL-10、INF-γ、IL-2和IL-4水平差異無統(tǒng)計學意義(P>0.05)，治療后2組IL-10和IL-4水平較治療前明顯降低(P<0.01)，而INF-γ和IL-2水平較治療前明顯升高(P<0.01)，觀察組的降低或者升高水平更為明顯(P<0.01)。見表2。

表2 2組治療前后IL-10，INF-γ，IL-2和IL-4水平的變化

組別IL-10(pg/ml)治療前治療后INF-γ(pg/ml)治療前治療后IL-2(pg/ml)治療前治療后IL-4(pg/ml)治療前治療后觀察組32.94±5.6712.64±4.12*25.19±5.1946.38±9.37*21.33±5.6734.94±8.67*38.19±5.4919.49±4.15*對照組32.68±6.1915.95±5.18*25.26±4.8940.26±7.65*21.41±4.6728.67±6.68a38.25±6.4523.91±5.14*t值0.2403.8740.0763.9190.0844.4370.0555.183P值0.8110.0000.9400.0000.9330.0000.9560.000

注：與治療前比較，*P<0.01

組別CD+3(%)治療前治療后CD+4(%)治療前治療后CD+8(%)治療前治療后CD+4/CD+8治療前治療后觀察組68.19±7.1663.49±5.46*33.64±4.1931.65±2.94*23.61±2.3427.68±2.96*1.42±0.151.14±0.11*對照組68.23±7.6456.43±5.34*33.59±4.0327.69±3.57*23.56±2.1629.74±2.34*1.43±0.120.93±0.09*t值0.0307.1610.0676.6330.1224.2290.40311.445P值0.9760.0000.9470.0000.9030.0000.6880.000

注：與治療前比較，*P<0.01

3 討論

本組研究表明腹腔鏡膽囊切除術(shù)治療老年急性壞疽性膽囊炎的療效明顯優(yōu)于開腹膽囊切除術(shù)，主要表現(xiàn)手術(shù)時間短，出血量少，術(shù)后疼痛程度輕，術(shù)后腸道功能恢復快和術(shù)后胃腸生存質(zhì)量明顯提高，可能與腹腔鏡膽囊切除術(shù)更有利于肝臟功能的恢復，避免了疼痛給患者帶來痛苦。本組研究還發(fā)現(xiàn)腹腔鏡膽囊切除術(shù)胃腸生存質(zhì)量明顯優(yōu)于開腹手術(shù)治療老年急性壞疽性膽囊炎，說明腹腔鏡膽囊切除術(shù)在提高患者術(shù)后生存質(zhì)量方面具有重要意義。腹腔鏡膽囊切除術(shù)較開腹手術(shù)具有以下優(yōu)勢[4-8]：由于創(chuàng)口較小手術(shù)無瘢痕，患者易于接受微創(chuàng)的概念；術(shù)中術(shù)野更為清晰，解剖更為精細，清除炎性組織更為徹底，術(shù)后恢復更快；手術(shù)時間短，術(shù)中出血少；術(shù)后患者恢復快，術(shù)后住院時間短。當然術(shù)中應注意[9]：術(shù)中對Calot 三角區(qū)的解剖特別重要，由于急性壞疽性膽囊炎炎癥極為嚴重，三角區(qū)的解剖常常不清楚，常常需要從膽囊床往膽囊頸部解剖，需要鈍性分離，避免盲目地使用電凝。對于三角區(qū)很致密的水腫和粘連，可行逆行膽囊切除術(shù)，或者做部分膽囊切除，殘余膽囊壁粘連燙除。

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Effects of laparoscopic cholecystectomy on immune function of patients with senile acute gangrenous cholecystitis

ZHOUJian*,GAOChun,TANGXuedian*.

*TheSecondDepartmentofSurgery,TianshanTCMHospitalofChangningDistrict,Shanghai200051,China

Objective To compare the therapeutic effects of laparoscopic cholecystectomy and open cholecystectomy on senile acute gangrenous cholecystitis,and to observe their effects on immune function of patients. Methods One hundred and twenty elderly patients with acute gangrenous cholecystitis who were admitted and treated in our hospital from January 2012 to December 2015 were divided into observation group (n=60) and control group (n=60) according to random number table. The patients in control group were treated by open cholecystectomy, however, the patients in observation group were treated by laparoscopic cholecystectomy.After treatment the operation time, intraoperative hemorrhage volume,the time of passage of gas by anus, hospitalization time, visual analogue scales (VAS), gastrointestinal living quality index (GLQ) and incidence rates of complications were observed and compared between two groups. Moreover the levels of interleukin (IL)-10, interferon (INF)-γ, IL-2, IL-4, CD+3, CD+4, CD+8,CD+4/CD+8were detected and compared between two groups before and after treatment. Results The operation time, intraoperative hemorrhage volume, time of passage of gas by anus, hospitalization time, VAS and incidence rates of complications in observation group were significantly shorter or lower than those in control group (P<0.01), however, GLQ scores in observation group were superior to those in control group (P<0.01). Before treatment there were no significant differences in the levels of IL-10, INF-γ, IL-2, IL-4, CD+3, CD+4, CD+8CD+4/CD+8between two groups (P>0.05), however,after treatment the levels of IL-10,IL-4,CD+3,CD+4and CD+4/CD+8were significantly decreased in both groups,as compared with those before treatment (P<0.01). Moreover there were significant differences in the levels of IL-10,INF-γ,IL-2,IL-4,CD+3,CD+4,CD+8,CD+4/CD+8after treatment between two groups (P<0.01).Conclusion The laparoscopic cholecystectomy has obvious therapeutic effects on senile acute gangrenous cholecystitis,which is superior to open cholecystectomy,which plays an important role in controlling inflammation and alleviate immunological drift.

acute gangrenous cholecystitis; immune function; laparoscopy; curative effects

10.3969/j.issn.1002-7386.2016.23.011

200051 上海市長寧區(qū)天山中醫(yī)醫(yī)院外二科(周健、唐學典)；上海市交通大學醫(yī)學院附屬同仁醫(yī)院普外科(高淳)

唐學典，200051 上海市長寧區(qū)天山中醫(yī)醫(yī)院外二科；

E-mail：zhjian2003@163.com

R 575.61

A

1002-7386(2016)23-3561-04

2016-03-31)