【作者】 张恒；

【导师】 王宁生；

【作者基本信息】 广州中医药大学 ， 中西医结合基础， 2009， 博士

【摘要】 术后肠粘连是腹部手术后常见并发症,也是引起粘连性肠梗阻最常见的原因。有文献报道术后肠粘连发生率高达79～90%,由于肠粘连导致粘连性肠梗阻可达40%,总死亡率为8%～13%,危害严重。发生肠粘连后,患者出现不同程度的腹痛、腹胀、恶心、呕吐、肛门排气减少;接受腹部中小手术病人中的1.2%及接受腹部大手术病人中的3.6%因术后肠粘连造成肠梗阻需再次手术或多次手术进行松解或重新排列;西医尚缺乏有效的治疗手段,而且粘连性肠梗阻一旦形成,难以根治,往往是手术松解一次,粘连加重一次,以致最后无法手术治疗。因此肠粘连的预防与治疗在临床工作中显得尤为重要。本课题处方来源于山西省中医药研究院名老中医临床经验总结。本处方临床以灌肠剂供患者使用,疗效显著。但由于灌肠剂剂型的局限性,患者使用不便,药物稳定性差,因此结合现代中药提取、纯化技术,制成既可以减少患者用药量、又能保证疗效,且使用方便、疗效快捷的一种中空栓剂——枳朴方中空栓。其特点和优势在于:①提高栓剂的质量稳定性:中空栓剂将药物包裹在中空栓壳内,避免药物与基质混合后容易发生硬度、色泽、熔点和熔变时限变化而造成的硬度效应,导致熔融时间变长、释药速度减慢;同时避免由于药物的暴露造成发生氧化、潮解、变质而影响疗效。②提高生物利用度,弥补普通栓剂基质与药物混合造成的释药困难,也可避免制作过程药物与基质混合加热引起的晶型改变而造成生物利用度下降。③与普通栓剂相比中空栓融变时间更短,中空栓外壳可以在人体肠道环境中很短时间内裂解,迅速释放出药物。④与其他用药途径相比,中空栓直肠给药,药物通过直肠直接吸收,可避免首过效应,提高生物利用度。课题组经过多年临床观察、文献资料搜集及药理实验研究基础上,提出该项目的研制。项目研制的成功,将极大地发挥中医药特色(中药配伍、药物剂型),填补中药新药在术后肠粘连防治领域的空白,且预期适宜用药人群广泛,必将有良好的应用前景及经济效益。本研究主要包括以下四方面的内容:1临床病历研究收集本院2005年1月～2008年1月术后肠粘连病例228例,其中经本方灌肠治疗114例,常规治疗114例。结果:本方灌肠治疗有效率为95.6%,常规治疗有效率为74.6%,两组有显著性差异(P＜0.05)。2枳朴方中空栓的制备过程2.1药物提取厚朴采用乙醇提取,通过实验验证65%乙醇浓度为最佳提取浓度。枳实、丹参、大腹皮三味药物,煎煮、浓缩、干燥,将干膏研成细粉。2.2中空栓制备将制备干膏研成细粉,过120目筛,用1,2丙二醇溶解成1g/mL的稠膏,灌装于混合脂肪酸甘油酯制成的空心栓壳中,制成中空栓。2.3质量控制的初步研究2.3.1参照中国药典(2005版一部)栓剂项下要求,对枳朴方中空栓进行初步质量控制标准研究。2.3.2参照中国药典(2005版一部),对枳朴方中空栓君药厚朴进行定性检测,结果:检出厚朴。3枳朴方中空栓药效学研究3.1枳朴方中空栓对二甲苯致小鼠耳肿胀实验3.1.1术后肠粘连多是由于异物刺激和炎症反应引起的,本实验旨在通过观察枳朴方中空栓对二甲苯致小鼠耳肿胀实验,阐释枳朴方中空栓的抗炎作用。3.1.2结合文献,将二甲苯抹在小鼠耳廓,制作小鼠耳肿胀实验模型,通过直肠给药,观察抗炎效果。3.1.3结果:枳朴方中空栓能有效减轻二甲苯导致的小鼠耳肿胀,说明枳朴方中空栓具有较好的抗炎效果。3.2枳朴方中空栓对小鼠肠蠕动的影响3.2.1术后肠粘连系在手术、异物刺激等作用下,导致肠蠕动减慢,胃肠功能减弱,本实验旨在通过观察枳朴方中空栓给药,观察对小鼠肠蠕动的影响。3.2.2结果:枳朴方中空栓可有效促进肠蠕动。4枳朴方中空栓防治术后肠粘连机制研究4.1枳朴方中空栓对术后肠粘连大鼠肠浆膜的影响4.1.1肠浆膜为疏松结缔组织外覆以间皮,肠浆膜的缺损是发生肠粘连的重要因素之一,其发生机制可能与下列因素有关:肠浆膜破损后,其表面可发生炎症反应,并有渗出,其中含有纤维蛋白等,渗出物相互融合而形成粘连。4.1.2查阅文献,制作术后肠粘连大鼠动物模型。通过大鼠直肠给药,观察枳朴方中空栓对术后肠粘连大鼠肠浆膜的影响。4.1.2.1取肠粘连大鼠回肠组织,制成标本,置扫描电镜下观察枳朴方中空栓对肠浆膜表面结构的影响。4.1.2.2取肠粘连大鼠回肠组织,制成标本,置透射电镜下观察枳朴方中空栓对肠浆膜超微结构的影响。4.1.2.3取肠粘连大鼠回肠组织,制成标本,光学显微镜下观察其病理变化。4.1.3结果:枳朴方中空栓能减少炎性渗出和纤维蛋白酶原渗出,保护和修复受损的肠浆膜,预防粘连形成。4.2枳朴方中空栓对术后肠粘连大鼠胃肠激素的影响4.2.1胃肠激素是调控胃肠正常运动功能的重要因素之一,它是由散在分布于消化道的内分泌细胞和肠神经系统神经元所分泌的起激素样作用的生物活性多肽,这些肽类物质既存在于胃肠道,也存在于脑组织中。胃动素、胃泌素、胰高血糖素均为影响胃肠运动功能的主要激素。文献报道胃动素、胃泌素可以促进胃肠蠕动,能明显加快胃电节律,诱发峰电位的产生,加强胃窦收缩,促进胃的排空;而胰高血糖素对胃肠运动起抑制作用。4.2.2查阅文献,制作术后肠粘连大鼠动物模型。通过大鼠直肠给药,观察枳朴方中空栓对术后肠粘连大鼠胃动素、胃泌素、胰高血糖素水平的影响。4.2.3结果:枳朴方中空栓能够提高胃动素、胃泌素水平,降低胰高血糖素水平。4.3枳朴方中空栓对术后肠粘连大鼠血浆FIB%、TNF-α、WBC计数的影响4.3.1手术会对腹膜或肠壁产生损伤,导致炎症反应或缺血,引起高浓度的炎症介质释放,辟如TNF-α、IL-1、IL-6,这些炎症介质均能独自或协同刺激间皮细胞产生一些纤维蛋白溶解酶原活化剂抑制因子PAI-1,破坏正常腹膜或肠壁的纤维蛋白溶解效能,导致其相互关联的活化酶与抑制酶之间失去平衡,纤维蛋白溶解酶原释放减少,纤维蛋白溶解受阻,纤维蛋白沉积,并与红细胞、白细胞、血小板等结合即形成粘连。其中TNF-α水平与腹腔内肠粘连关系最为密切,有人将其称之为腹腔内肠粘连形成标记。如果延长这些抑制因子的作用时间,可以使纤维蛋白组织的粘连形成永久性的纤维粘连。术后腹膜损伤,血小板会产生高浓度的TGF-β,诱导和趋化巨噬细胞和成纤维细胞,促进细胞增值,而且是细胞基质许多成份表达、合成、转化的主要调节剂,对肠粘连的发生也起到一定作用。4.3.2查阅文献,制作术后肠粘连大鼠动物模型。通过大鼠直肠给药,观察枳朴方中空栓对术后肠粘连大鼠肠粘连程度的影响。4.3.3查阅文献,制作术后肠粘连大鼠动物模型。通过大鼠直肠给药,观察枳朴方中空栓对术后肠粘连大鼠血浆FIB%、TNF-α、WBC计数的影响。4.3.4结果:枳朴方中空栓能降低血FIB%、TNF-α、WBC计数,显著减轻粘连程度。5结论本文通过文献、中空栓及实验研究,证实枳朴方中空栓防治术后肠粘连效果满意,其机制是多方面的:①枳朴方中空栓能够减轻术后炎证反映,减少炎性渗出,防止炎性渗出形成瘢痕;②枳朴方可以通过调节胃动素、胃泌素、胰高血糖素水平促进肠蠕动,缩短渗出物和肠管及腹膜的接触时间,降低肠粘连形成机会;③保护和修复受损的肠浆膜,维持和保护肠浆膜的完整性,保护外层间皮细胞,形成一层屏障,同时也可能通过控制成纤维细胞的增生和分泌功能,增强纤维蛋白溶解酶原活性,而预防或减轻肠粘连瘢痕的形成,预防术后肠粘连的发生。④影响血WBC、TNF-α含量、FIB%水平,从不同方面发挥防治术后肠粘连的作用。更多还原

【Abstract】 Postoperative intra-abdominal adhesion after abdominal surgery are common complications,but also adhesive intestinal obstruction caused by the most common cause.Literature has reported the incidence of postoperative intestinal adhesion up to 79%～90%,because of adhesion of adhesive intestinal obstruction caused by up to 40%,and the total mortality rate was 8%～13%against severe intestinal adhesion happened after the patients of different degree of abdominal pain,bloating,nausea,vomiting,anal exhaust reduced.Accept small abdominal surgery patients and 1.2%major abdominal surgery to receive 3.6%of patients because of postoperative intestinal adhesion intestinal obstruction caused by the need re-operation or more times surgical release or re-arranged.Western medicine is still a lack of effective treatment,but once the formation of adhesive intestinal obstruction,it is difficult to cure,surgery is often the first release,adhesion to increase once the final result,not surgery.Therefore intestinal adhesion prevention and treatment in clinical work seems particularly important.The topics prescription are from Professor Zhu Jinzhong in Shanxi Institute of Traditional Chinese medicine,has been used for nearly five decades of clinical experience.A long time,the prescription in clinical enema for patients to use,efficacy significantly.However,because of the limitations of enema formulations,patients using the inconvenience,bad drug stability.So to be on a hollow type suppositories——Zhipu hollow type suppositories,combined with modern traditional Chinese medicine extraction,purification technology,into a patient can reduce the dosage,but also ensures that the treatment effects,and easy to use,efficient drug efficacy.After initial experiments with satisfactory results.Task force members at after many years of clinical observation,data collection and literature repeatedly pharmacological experiments on basic research,the development of the project.Lies in its features and advantages:①Suppositories improve the quality of stability:Hollow drug suppositories wrapped in hollow shell,to avoid the drug and matrix mixture prone to hardness,color,melting point and melting caused by variable changes in time limits the hardness effect,melting caused by longer,slower rate of release;while avoiding exposure of the drug because of the occurrence causing oxidation,deliquescence,metamorphism affecting efficacy.②Improve bioavailability,to make up for the general matrix with the drug mixed suppositories caused by difficult delivery,but also can avoid the production process of drugs mixed with the matrix beat-induced changes in crystal form caused decreased bioavailability.③Compared with ordinary suppositories into shorter time variable,can be hollow suppositories shell at human intestinal environment in a very short period of time cracking,rapid release of drug.④Compared with other route of administration,hollow suppositories rectal administration,drug absorption directly through the rectum to avoid first-pass effect,improve the bioavailability.Development of the success of the project will greatly exert characteristics of Chinese medicine(TCM compatibility,drug dosage forms), fill the new Chinese medicine prevention and treatment of postoperative intestinal adhesion field blank,but the crowd is expected to appropriate medication extensive,the exact effect is bound to have a good application prospects and economic benefits.The purpose of this study include the following four aspects:1 Clinical medical researchThe collection of hospital in January 2005 to January 2008 after 228 cases of intestinal adhesion cases,by the side one of 114 cases of enema treatment,conventional treatment of 114 cases,the party enema treatment efficiency of 95.6%efficiency for conventional therapy has 74.6%the two groups have significant difference(P＜0.05).2 Zhipu hollow type suppositories preliminary preparation process2.1 Drug extractionHoupu is extracted by ethanol,through experiments the concentration of 65%ethanol concentration for optimal extraction.Zhishi,Danshen Dafupi are extracted by decoction,concentration,drying,dry powder into a paste institute.2.2 Process to determinePreparated dry plaster will have 120 mesh,using 1,2 propanediol dissolved into a thick paste of lg/mL,filling in the mixed fatty acid glyceride suppository made of hollow shells,made of hollow type suppositories.2.3 Preliminary study of quality control2.3.1 Reference to the Chinese Pharmacopoeia 2005 edition of suppositories under the requirements of the Zhipu hollow type suppositories to conduct a preliminary study of quality control standards.2.3.2 Reference to the Chinese Pharmacopoeia 2005 edition,Zhipu hollow type suppositories ventilation for determination of drug-jun.3 Study of pharmacodynamics on Zhipu hollow type suppositories3.1 Zhipu hollow type suppositories on xylene-induced mouse ear swelling test3.1.1 Postoperative intestinal adhesion are many incentives and because of foreign matter caused by anti-inflammatory,this experiment aims to observe the Zhipu hollow type suppositories on xylene-induced mouse ear swelling test explain Zhipu hollow type suppositories anti-inflammatory effect.3.1.2 Combination of literature,will be wiped xylene ear in mice,the production of mouse ear edema model,through the administration to observe the anti-inflammatory effect.3.1.3 The results Zhipu hollow type suppositories can effectively reduce the ear swelling of mice caused by xylene,that Zhipu hollow type suppositories has good anti-inflammatory effect.3.2 Zhipu hollow type suppositories the effects of peristalsis in mice3.2.1 Intestinal adhesion after surgery at damage,foreign bodies such as the role of stimulation,the cause slower peristalsis,gastrointestinal function,in this experiment is designed to observe the hollow Zhipu hollow type suppositories administration to observe the effects of peristalsis in mice.3.2.2 Through the India ink method,confirmed Zhipu hollow type suppositories can be effectively in promoting peristalsis4 Study mechanism of Zhipu hollow type suppositories on postoperative intestinal adhesion in rats 4.1 Zhipu hollow type suppositories on postoperative intestinal adhesion in rats the effects of gastrointestinal hormones4.1.1 Are gastrointestinal hormones regulating gastrointestinal function and normal exercise one of the important factors,it is scattered in gastrointestinal endocrine cells and enteric nervous system neurons by secretion of hormones from the role of bioactive peptides,these peptides existing is the gastrointestinal tract,but also in the brain tissue.Normal physiological circumstances gastrointestinal hormones through central, peripheral and ENS play a role in regulating gastrointestinal motility.Motilin, Gastrin,Glucagon affect gastrointestinal motor function are the main hormones.Reported in the literature motilin,gastrin can promote gastrointestinal peristalsis,can significantly accelerate the gastric electric rhythm,evoked spike generation,strengthening of antral contraction,and promote gastric emptying,and glucagon on gastrointestinal motility from inhibition.Motilin,gastrin after abdominal surgery on gastrointestinal function has a certain impact,low levels of gastrin may lead to gastrointestinal dysfunction,reduced power.4.1.2 Literature review,the production of rat model of postoperative intestinal adhesion.Through the rat rectal administration,observe the effect of Zhipu hollow type suppositories on postoperative intestinal adhesion in rats motilin,gastrin,glucagon levels.4.1.3 The results that Zhipu hollow type suppositories can improve MTL, Gas levels and lower levels of Glu.4.2 Zhipu hollow type suppositories on postoperative intestinal adhesion in rats the effects of serosal.4.2.1 Intestinal serosa outside for loose connective tissue covered with mesothelial,intestinal serosa happen adhesion defects are one of the important factors,its mechanism may be related to the following factors:intestinal serosal damage,its surface can happen inflammatory response and exudation,which may contain,such as fibrin,exudate and the formation of adhesions integration.4.2.2 Literature review,the production of rat model of postoperative intestinal adhesion.Through the rat rectal administration,observe the effect of Zhipu hollow type suppositories on postoperative intestinal adhesion in rats the effects of intestinal serosa. 4.2.2.1 Check adhesion of rat ileum organization,made of specimens,home scanning electron microscope to observe the effect of Zhipu hollow type suppositories intestinal serosal surface structure.4.2.2.2 Check adhesion of rat ileum organization,made of specimens,home projection electron microscope to observe the effect of Zhipu hollow type suppositories Ultrastructure of intestinal serosa.4.2.2.3 Check adhesion of rat ileum organization,made of specimens, observed the changes of pathological.4.2.3 The results that Zhipu hollow suppositories can reduce the inflammatory exudation and exudative plasminogen,the protection and restoration of damaged intestinal serosa to prevent adhesion formation.4.3 Zhipu hollow type suppositories on postoperative intestinal adhesion in rat plasma FIB%,TNF-α,WBC count of the impact4.3.1 When the peritoneal inflammatory response resulting in injury or ischemia occurs,caused by high concentrations of inflammatory mediators release,the provision of such as TNF-α,IL-1,IL-6,both alone or in synergy to stimulate the mesothelial cells produce some fibrin plasminogen activator inhibitor PAI-1,destruction of the normal peritoneal fibrinolysis performance,resulting in its interrelated activase and inhibit the loss of the balance between enzyme,plasminogen release decreased fibrinolysis blocked,fibrin deposition and erythrocyte,leukocyte,platelet,etc.can be combined with the formation of adhesions.One of TNF-αlevel and intra-abdominal adhesions is most closely related to,someone called the intra-abdominal adhesion formation markers.If the extension of the role of these inhibitory factor time,can make fibrin tissue adhesion formation of permanent fibrous adhesions.Peritoneal injury,platelets produce high concentrations of TGF-β,induction and chemotaxis of macrophages and fibroblasts,and promote value-added cells and stromal cells are the expression of many components,synthesis,transformation of the main regulator of intestinal adhesion happen must also play a role.4.3.2 Literature review,the production of rat model of postoperative intestinal adhesion.Through the rat rectal administration,observe the effect of Zhipu hollow type suppositories on postoperative intestinal adhesion intestinal adhesion in rats degrees. 4.3.3 Literature review,the production of rat model of postoperative intestinal adhesion.Through the rat rectal administration,observe the effect of Zhiph hollow type suppositories on postoperative intestinal adhesion in rat plasma FIB%,TNF-α,WBC count impact.4.3.4 The results that Zhipu hollow type suppositories can significantly reduce the degree of adhesion,lower blood FIB%,TNF-α,WBC count. 5 ConclusionsThrough literature,hollow type suppositories and experimental studies confirmed that Zhipu hollow hollow type suppositories satisfactory control of postoperative intestinal adhesion,the mechanisms are manifold:①Zhipu hollow hollow type suppositories to reduce inflammation after certification to reflect a decrease of inflammatory exudate to prevent the formation of inflammatory exudate scar;②Zhipu hollow hollow type suppositories can adjust motilin,gastrin,glucagon levels to promote peristalsis and shorten the exudate and intestinal and peritoneal contact time,reducing opportunities for intestinal adhesion formation;③Protection and restoration of damaged intestinal serosa,maintain and protect the integrity of intestinal serosa to protect the outer layer of mesothelial cells,forming a layer of barrier, but also may control the proliferation of fibroblasts and the secretion function of reinforcing fibers protein,plasminogen activity,and prevent or reduce the formation of scar adhesion:the prevention of the occurrence of postoperative intestinal adhesion;④Affect blood WBC,TNF-αcontent,FIBlevel of play from a different role in prevention and treatment of postoperative intestinal adhesion.更多还原