【作者】 贾红伟；

【导师】 孙天胜；

【作者基本信息】 山西医科大学 ， 骨外科学， 2010， 硕士

【摘要】 目的：多发伤的治疗中常会涉及到肝缺血再灌注损伤,严重多发创伤后肝脏的缺血耐受性及手术时机的选择是不确定的,本实验观察多发骨折合并肝缺血再灌注损伤后肝缺血耐受性变化及不同骨折治疗时机对肝损害的影响。方法：采取动物实验,第一部分：建立多发骨折合并肝缺血再灌注损伤模型,72只SD大鼠随机分成三组(每组18只),骨折(Fracture, F)组、肝缺血再灌注损伤(Hepatic Injury,HI)组、骨折+肝损伤(Fracture+ Hepatic Injury, F+HI)组。对照组为假手术(Sham)组(6只)。假手术组仅行腹部皮肤切开并缝合皮肤：骨折组应用自制双股骨骨折造模支架致双侧股骨干骨折；肝损伤组行剖腹血管夹夹闭肝蒂30分钟后再灌注造成肝缺血再灌注损伤；骨折+肝损伤组为多发骨折合并肝缺血再灌注损伤,模型制作完成后通过X线了解骨折类型、移位情况,于造模成功后1、24、48、72h处死大鼠取肝脏应用PCR方法检测肝组织中TNF-a、IL-6、IL-10mRNA表达,髓过氧化物酶(MPO)含量,取腹主动脉血检测ALT、血乳酸水平,并行组织学检查肝脏损伤情况。第二部分：将32只雄性SD大鼠随机分成4组(每组动物各8只)：骨折早手术(Fracture Early Surgery, FES)组、骨折晚手术(Fracture Later Surgery, FLS)组、骨折+肝损伤早手术(Fracture+Hepatic Injury Early Surgery,, F+HIES)组、骨折+肝损伤晚手术(Fracture+Hepatic Injury Later Surgery, F+HILS)组。早期手术为伤后1h内骨折髓内钉治疗,晚期手术为损伤后先用夹板固定骨折端72h后骨折髓内钉治疗。骨折治疗完成后6h应用PCR方法检测肝组织中TNF-a、IL-6、IL-10mRNA表达,检测髓过氧化物酶(MPO)含量,取腹主动脉血检测谷丙转氨酶(ALT)、血乳酸(LD),肝组织常规固定,HE染色后光镜检查。结果：第一部分：模型制作完成后行X线摄片证实双侧股骨干骨折均为闭合性中段横断骨折,骨折移位明显。骨折组、肝损伤组、骨折+肝损伤组大鼠血ALT、LD,肝脏MPO在1h升高,24h达到高峰,48h、72h下降,骨折+肝损伤组较骨折组、肝损伤组增高明显(P<0.05)。骨折组、肝损伤组、骨折+肝损伤组肝脏TNF-amRNA表达在1h升高,24h达到高峰,48h、72h下降；骨折+肝损伤组较骨折组、肝损伤组各个时间点均增高明显(P<0.05)；骨折组、肝损伤组、骨折+肝损伤组肝脏IL-6mRNA表达在1h、24h升高,48h达到高峰,72h下降。骨折+肝损伤组较骨折组、肝损伤组增高明显(P<0.05)；骨折组、肝损伤组、骨折+肝损伤组肝脏IL-10mRNA表达在1h、24h、48h升高,72h达到高峰。骨折+肝损伤组较骨折组、肝损伤组增高明显(P<0.05)三组大鼠肝脏病理切片显示肝窦充血、肝细胞肿胀、炎性细胞浸润,骨折+肝损伤组较其他两组肝细胞坏死、炎性细胞浸润显著。第二部分：骨折+肝损伤早手术组肝脏TNF-a、IL-6、IL-10mRNA表达含量、MPO含量、血ALT、血LD水平明显高于骨折早手术组、骨折晚手术组、骨折+肝损伤晚手术组(P<0.05)。骨折早手术组肝脏TNF-a、IL-6、IL-10mRNA表达含量、MPO含量、血ALT、血LD水平与骨折晚手术组比较差异较小。骨折+肝损伤早手术组肝脏充血、炎细胞浸润、细胞坏死等病理学改变显著。结论：多发骨折合并肝缺血再灌注损伤后肝脏炎性改变及细胞坏死的病理学早期(1h)改变明显,后期(72h)肝耐受性增加。手术时机对多发骨折后肝损害影响小,多发骨折合并肝缺血再灌注损伤后早期骨折治疗导致肝损害加重,损伤控制治疗能增加肝脏对于创伤的耐受性,降低肝损害程度。更多还原

【Abstract】 Objective:The managemengt of polytrauma frequently involves hepatic ischemia reperfusion injury。Hepatic ischemia tolerance and operation time selection after polytrauma are uncertain,the purpose of this experiment is to study that hepatic tolerance variation and deferent fracture management timing impact hepatic lesion after multiple fracture combining hepatic ischemia reperfusion injury。Methods:Animal study,partⅠ:establish the animal model of multiple fracture combining hepatic ischemia reperfusion injury.。Seventy-two SD rats were randomly divided into there groups(18 for each group):Fracture (F)group、Hepatic Injury(HI)group、Fracture+Hepatic Injury (F+HI)group。Contrast group is Sham Operation(Sham)group(6 for this group)。Sham group,only abdominal skin incision and skin closure; Bilateral femoral shaft fractures were caused by self-made device in Fracture group; Hepatic ischemia reperfusion injury was caused by Vascular liver pedicle clamping clip after 30 minutes to relax blood vessels in Hepatic Injury group; Fracture+Hepatic Injury group was fracture combining hepatic injury。Type and displacement of fracture were examed by X-ray after model completed, The expression of tumor necrosis factor-a (TNF-a)、interleukin-6(IL-6)、interleukin-10(IL-10) of hepatic tissue were detected by reverse transcription polymerase chain reaction(RT-PCR) after 1、24、48、72h of fracture management, hepatic myeloperoxidase (MPO) were detected, The contents of serum alanine aminotransferase(ALT)、lactic acid (LD) from abdominal aorta were detected. The morphological changes were observed by hematoxylin and eosin(HE)staining. PartⅡ:Thirty two SD rats were randomly divided into four groups(8 for each group):Fracture Early Surgery(FES)group、Fracture later Surgery(FLS)group、Fracture+Hepatic Injury Early Surgery(F+HIES)group、Fracture+Hepatic Injury Later Surgery,(F+HILS) group。Early surgery defined as the intramedullary nail treatment of fracture after injury 1h, later surgery defined as splint fracture after injury and the intramedullary nail treatment of fracture after injury 72h。The expression of tumor necrosis factor-a (TNF-a)、interleukin-6(IL-6)、interleukin-10(IL-10) of hepatic tissue were detected by reverse transcription polymerase chain reaction(RT-PCR) after 6h of fracture management, hepatic myeloperoxidase (MPO) were detected, The contents of serum alanine aminotransferase(ALT)、lactic acid (LD) from abdominal aorta were detected。The morphological changes were observed by hematoxylin and eosin(HE)staining。Result:PartⅠ:X-ray shows that bilateral femoral fractures were closed fractures and significant shaft after model completed。Serum ALT、LD、MPO of three groups elevated in 1h,reached a peak in 24h,down in 48h、72h,The contents of Serum ALT、LD、MPO were significantly higher of Fracture+Hepatic Injury group than Fracture group or Hepatic Injury group (P<0.05)。The expression of tumor necrosis factor-a (TNF-a)of fracture group、hepatic injury group and fracture+hepatic injury group elevated in 1h, reached a peak in 24h,down in 48h、72h, the expression of tumor necrosis factor-a (TNF-a) of Fracture+Hepatic Injury group group was significantly higher than Fracture group or Hepatic Injury group (P<0.05); The expression of interleukin-6(IL-6) of fracture group、hepatic injury group and fracture+hepatic injury group elevated in 1h, reached a peak in 24h,down in 48h、72h, the expression of interleukin-6(IL-6) of Fracture+Hepatic Injury group was significantly higher than Fracture group or Hepatic Injury group(P<0.05); The expression of interleukin-10(IL-10) of fracture group、hepatic injury group and fracture+hepatic injury group elevated in 1h、24h、48h, reached a peak in 72h, the expression of interleukin-10(IL-10) of Fracture+Hepatic Injury group was significantly higher than Fracture group or Hepatic Injury group (P<0.05)。Rat liver biopsy in three groups shows Sinusoidal congestion、liver cell swelling,、inflammatory cell infiltration, Liver cell necrosis, inflammatory cell infiltration significantly in Fracture+Hepatic Injury group。PartⅡ:The expression of tumor necrosis factor-a (TNF-a)、interleukin-6(IL-6)、interleukin-10(IL-10)and the contents of hepatic myeloperoxidase (MPO)、serum ALT、serum LD in F+HIES group were higher than FES group or FLS group or F+HILS group (P<0.05)。The expression of tumor necrosis factor-a (TNF-a)、interleukin-6(IL-6)、interleukin-10(IL-10) and the contents of hepatic myeloperoxidase (MPO)、serum ALT、serum LD in FES group were similar with FLS group。F+HIES group of liver congestion, inflammatory cell infiltration, cell necrosis and other pathological changes significant.Conclusion:Liver cell necrosis, inflammatory changes、pathological changes and hepatic tolerence declining of the early stage (1h)was significantly after Multiple fractures complicated with hepatic ischemia-reperfusion injury. However, hepatic tolerance enhanced in later stage (72h)。Timing of surgery effect on liver lesion after multiple fractures is small, the early fracture treatment of multiple fractures complicated with hepatic ischemia-reperfusion injury can lead to that liver lesion aggravate, treatment of damage control can increase the hepatic tolerance for the trauma and decrease liver lesion。更多还原