【作者】 张志刚；

【导师】 余佩武；

【作者基本信息】 第三军医大学 ， 外科学， 2009， 硕士

【摘要】 目的研究表明,传统的开腹胃肠外科手术由于手术本身和麻醉的影响,术后一段时间内正常的胃肠运动会受到显著抑制,严重时出现术后胃轻瘫、假性肠梗阻等,其创伤较大而恢复较慢,且患者疼痛不适感持续时间较长,胃肠道功能恢复较慢。腹腔镜胃肠手术创伤小、恢复快、术后并发症少等优点已逐渐成为共识。有研究表明腹部手术后胃肠激素的变化与术后胃肠功能恢复有关,但有关腹腔镜手术后胃肠激素变化的研究报道目前还比较少。为此本研究以腹腔镜与开腹胃癌手术患者为研究对象,测定手术前后血浆胃动素(motilin,MTL)、血管活性肠肽(vasoactive intestine peptide,VIP)和生长抑素(somatostatin,SS)的水平,同时观察术后胃肠道功能恢复情况,探讨腹腔镜胃癌手术后胃肠激素的变化对胃肠功能恢复的影响,以完善腹腔镜胃癌手术的理论依据和为术后恢复提供一定指导意义。方法(1)标本收集血浆标本取自2008年3月至10月在我科行择期手术治疗的胃癌患者,共56例(Ⅰ期-Ⅲa期),其中腹腔镜手术30例,开腹手术26例。两组患者性别、年龄、肿瘤分期、病理类型均无统计学差异。对所有受检者分别在术前、术后24,48,72h抽取空腹静脉血2-4ml,离心分离血浆并置于-80℃冰箱保存待测。所有患者均无腹部手术史,术前无肠梗阻和远处转移,肝肾功能正常,无糖尿病病史。手术前未进行放化疗,未使用影响胃肠动力和胃肠激素的药物。两组患者手术均采用全麻,手术方式均行远端胃癌D2根治术,患者均经术前胃镜和术后病理证实为胃癌。(2)胃肠激素的测定MTL、VIP、SS均采用放射免疫法测定,利用液相竞争抑制原理,采用非平衡法分别测定血浆样品中MTL、VIP和SS浓度。(3)术后胃肠功能恢复情况观察手术后每2小时听诊患者左右上下腹部四个区域,每区每次听诊3-5分钟,如在两个听诊区域发现肠鸣音≥3次/分钟认为是肠鸣音恢复,并记录时间;同时告之患者记住术后肛门最早排气的具体时间,加以记录。结果(1)两组患者均顺利完成腹腔镜或开腹远端胃癌D2根治术,均无并发症。术前腹腔镜组和开腹组之间MTL、VIP和SS血浆水平均无显著差异(P>0.05)。(2)腹腔镜组术后24,48h血浆MTL水平均较术前显著下降(P<0.05),术后72h恢复至术前水平。开腹组术后24,48,72h血浆MTL水平较术前也显著下降(P<0.05)。与开腹组相比,腹腔镜组术后24,48,72h血浆MTL水平均显著高于同时相开腹组且恢复较快(P<0.05)。(3)腹腔镜组术后24h血浆VIP水平较术前显著上升(P<0.05),术后48h恢复至术前水平。开腹组术后24,48h血浆VIP水平较术前也显著上升(P<0.05),至术后72h恢复至术前水平。与开腹组相比,腹腔镜组术后24,48h血浆VIP水平均显著低于同时相开腹组且恢复较快(P<0.05)。(4)腹腔镜组和开腹组手术后血浆SS水平均较术前显著下降(P<0.05),术后两组之间除48h时开腹组高于腹腔镜组之外(P<0.05),其余时相无显著差异(P>0.05)。至术后72h两组血浆SS水平仍显著低于术前水平(P<0.05)。(5)腹腔镜组术后肠鸣音恢复、首次肛门排气时间均显著早于开腹组(P<0.05)。(6)术后两组血浆MTL水平与术后肠鸣音恢复、首次肛门排气时间均呈正相关(P<0.05)。术后血浆VIP水平与术后肠鸣音恢复、首次肛门排气时间呈负相关(P<0.05)。SS与术后肠鸣音恢复及首次肛门排气之间无显著相关性(P>0.05)。结论(1)腹腔镜胃癌手术对血浆MTL、VIP的影响显著小于开腹胃癌手术,术后血浆MTL、VIP水平恢复均比开腹手术快。(2)腹腔镜胃癌手术后肠鸣音恢复和首次肛门排气时间均比开腹手术快。(3)腹腔镜胃癌手术后胃肠功能恢复较开腹手术快,胃肠激素的变化可能是其机制之一。更多还原

【Abstract】 ObjectiveResearch show that postoperative inhibition of gastrointestinal movement in tradition abdominal surgery is obviously, which was affected by operation and anesthesia. Seriously, there would be postoperative gastroparesis, intestinal pseudo obstruction and so on.Which prolong the recovery time and increase physical pain of the patients. The application of laparoscopy improve the postoperative recovery from reduced trauma and postoperative complications. Reseaches have show that changes of gastrointestinal hormones correlated to the gastrointestinal movement under operation. But few reports concering about the relationship between gastrointestinal hormones and laparoscopic surgery. So we evaluated the changes of serum levels of three gastrointestinal hormones: motilin(MTL), vasoactive intestine peptide(VIP) and somatostatin(SS) in two group of gastric cancer patients, who receiving either radical laparoscopy-assisted or open gastrectomy. Meanwhile the recovery of postoperative gastrointestinal function was also recorded. The purpose of this study was to investigate the changes of gastrointestinal hormones effects on gastrointestinal function postoperative and the possible mechanism after laparoscopy-assisted gastrectomy. We want this research can provide some instructions for further application of laproscopy technology in clinical treatment and postoperative care.METHODS(1) Samples collectionThis study included two groups of 56 patients with gastric cancer receiving gastrectomy in our department. From March to Octobe 2008, 30 patients were performed by laparoscopy, the other 26 patients received open gastrectomy. Fast venous blood was taken as follow: prior to operation,24h ,48h and 72h after operation. Samples were collected and centrifugated, then separated plasma samples were stocked -80℃until assayed. All patients have no abdominal surgery before this hospitalization, no obstruction and distant metastasis were detected preoperative. Liver and renal function were normal in all patients. Patients had no diabetes, no radiotherapy and chemotherapy preoperative. Drugs affect gastrointestinal motility and secretion of gastrointestinal hormone were permitted perioperative.Two groups were anesthetized under general anesthesia, all patients receive radical distal gastrectomy with D2 lymphadenectomy. The gastric cancer of all patients were diagnosed by endoscopy examination preoperative and pathological biopsy postoperative.(2) Determination of gastrointestinal hormonesThe serum level of MTL, VIP and SS were determined by radioimmunoassay (RIA). Serum levels of MTL,VIP and SS in samples were tested by competitive binding reaction with non-equilibrium method.(3) Observation of the recovery of gastrointestinal functionPatients were auscultated for as long as five minutes in each of the four quadrants of the abdomen to determine whether bowl sounds were present. We presumed the recovery of bowel sounds only if the bowel sounds were auscultated more than 3 times/min in two or more of the quadrants. The first flatus postoperative was also recorded.RESULT(1) Radical distal gastrectomy with D2 lymphadenectomy was performed successfully in all patients either by laparoscopy-assisted or open technology. No specific postoperative complications were observed in patients in hospital. There were no significant difference of serum MTL,VIP and SS levels preoperative between two groups (P>0.05)(2)Serum levels of MTL in both groups were significantly decreased compared with those of the preoperative period (P<0.05). However levels of MTL in laparoscopic group were higher than those in open group in 24,48 and 72 postoperative hours (P<0.05). They returned to preoperative level at 72h after operation in laparoscopic group, but we did not observe those in open group at the same time.(3)Meanwhile serum levels of VIP in two groups were significantly higher than those of the preoperative period. The serum VIP levels in laparoscopic group were lower than those date in open group in 24 and 48 postoperative hours (P<0.05). It returned to preoperative levels at 48 hours after operation in laparoscopic group, but the recovery time is 72 hours in open group. (4) Serum levels of SS in two groups both decreased significant with the levels of preoperative(P<0.05). There were no significant difference of levels of SS postoperative between two groups, except for open group were significant higher than those in laparoscopic group 48 postoperative hours. And the levels of SS were still significant lower than preoperative levels in both groups in 72 postoperative hours.(5)The recovery time of bowel sounds and first flatus postoperative in laparoscopy group were both significant shorter than the time of open groups (P<0.05).(6)Postoperative serum levels of MTL were positive correlated with the time of bowel sound recovery and first flatus after operation in two groups(P<0.05). Meanwhile postoperative serum levels of VIP were negative correlated with those date in two groups(P<0.05). But serum levels of SS has no correlation with those date in both groups(P>0.05).CONCLUSION(1) Laparoscopy-assisted gastrectomy had significant less effects on serum level of MTL, VIP than open gastrectomy. The recovery time of serum level of MTL and VIP in laparoscopy group were faster than those in open group.(2) The recovery time of bowel sounds and first flatus postoperative were significant shorter in laparoscopic group.(3)The recovery period of gastrointestinal movement was shorter in gastric cancer patients treated by laparoscopy than in those by laparotomy. One of the reasons probably correlated with the less changes of some gastrointestinal hormone.更多还原