周健 高淳 唐学典



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腹腔镜胆囊切除术治疗老年急性坏疽性胆囊炎对机体免疫功能的影响

周健 高淳 唐学典

目的 探讨腹腔镜胆囊切除术和开腹胆囊切除术治疗老年急性坏疽性胆囊炎的疗效及其对机体免疫功能的影响。方法 选择就诊治疗的急性坏疽性胆囊炎的患者120例，按照随机数字法将患者分为观察组和对照组，每组60例。对照组予以开放胆囊切除术，观察组予以腹腔镜下胆囊切除术。观察2组治疗后的手术时间，术中出血量，肛门排气时间，住院时间，视觉模拟评分(VAS)，消化生存质量指数(GLQ)评分和并发症发生情况，比较2组治疗前后白介素(IL)-10、干扰素(INF)-γ、IL-2、IL-4、CD+3、CD+4、CD+8、CD+4/CD+8水平的变化。结果 观察组手术时间、术中出血量、肛门排气时间、住院时间、VAS评分和并发症明显短于或者少于对照组(P<0.01)，GLQ评分明显优于对照组(P<0.01)。2组治疗前IL-10、INF-γ、IL-2、IL-4、CD+3、CD+4、CD+8、CD+4/CD+8水平差异无统计学意义(P>0.05)，治疗后2组IL-10、IL-4、CD+3、CD+4和CD+4/CD+8水平较治疗前明显降低(P<0.01)，而INF-γ，IL-2 和CD+8水平较治疗前明显升高(P<0.01)，观察组治疗后IL-10、INF-γ、IL-2、IL-4、CD+3、CD+4、CD+8、CD+4/CD+8水平与对照组比较，差异有统计学意义(P<0.01)。结论 腹腔镜胆囊切除术治疗老年急性胆囊炎疗效确切，明显优于开胆囊切除术，对机体的炎症控制和缓解免疫漂移具有重要作用。

急性坏疽性胆囊炎；免疫功能；腹腔镜；疗效

急性坏疽性胆囊炎是肝胆外科的常见病，多发病，尤其老年患者有发病升高的趋势。老年的急性坏疽性胆囊炎具有发病快，常常合并糖尿病，心脏病和高血压等慢性疾病，治疗难度大，故传统的开腹手术往往具有手术时间长，术中出血量多和术后并发症多等特点，使患者的免疫功能下降，对患者生存质量造成严重的影响[1,2]。急性坏疽性胆囊炎患者机体出现免疫紊乱，主要表现细胞因子分泌紊乱和T细胞亚群的紊乱[3]。本组研究采用腹腔镜胆囊切除术治疗急性坏疽性胆囊炎，与传统开腹手术进行比较，观察对机体免疫功能的影响，报告如下。

1 资料与方法

1.1 一般资料 选择2012至2015年在上海市长宁区天山中医医院就诊治疗的急性坏疽性胆囊炎的患者120例，按照随机数字法将患者分为观察组和对照组，每组60例。观察组中，男32例，女28例；年龄60～85岁，平均年龄(72.36±9.35)岁；发病时间1～6 d，平均(2.36±0.19)d，合并高血压19例，糖尿病11例和慢性支气管炎6例。对照组中，男33例，女27例；年龄60～85岁，平均年龄(72.49±8.47)岁；发病时间1～6 d，平均(2.27±0.33)d；合并高血压22例，糖尿病9例和慢性支气管炎7例。2组患者均知情同意，排除患者有精神疾病；血液系统疾病；自身免疫性疾病；恶性肿瘤；肝炎，肺结核和肺炎等感染性疾病；心肝肾等重要脏器障碍。2组年龄、性别比、发病时间有可比性。

1.2 方法

1.2.1 治疗方法：对照组予以开放胆囊切除术，观察组予以腹腔镜下胆囊切除术。2组术前均予以控制基础性疾病，均予以禁食，禁水。腹腔镜胆囊切除术：在全麻下，取仰卧位，采用三孔法，建立二氧化碳气腹，压力为9～12 mm Hg，采用头高脚底位，左侧倾斜，充分暴露胆囊，先游离胃肠和大网膜与胆囊的粘连，显露胆囊。胆囊底部切开现予以减压，并予以钛夹夹闭，提起胆囊颈部，辨认Calot 三角，用电钩和吸引器分离Calot 三角，游离出胆囊颈管，胆囊动脉分别予以可吸收夹夹闭。对于胆囊颈管结石的患者，先将胆囊切开，充分冲洗胆囊颈管，将结石取出后再予以夹闭。对于解剖不清楚，难以完整切除胆囊的患者，将胆囊部分切除，在将胆囊黏膜予以烫除。确切止血和清除体内残留的胆汁，放置引流管一根。开腹胆囊切除术：采用右上腹小切口进腹，采用顺逆结合的方式切除胆囊。余腹腔镜胆囊切除术类似。

1.2.3 视觉模拟评分(VAS)和生存质量指数(GLQ):VAS，无痛为0分，剧痛为10分，分数越高，疼痛越重。GLQ评价患者的生存质量，包括主观症状、生理状态、心理状态、日常生活状态及社会活动状态。共36项目，每个项目0～4分，总分0～144分，分值越高，健康状态越好。

2 结果

2.1 2组手术情况和术后恢复比较 观察组的手术时间、术中出血量、肛门排气时间、住院时间和VAS评分明显短于或者少于对照组(P<0.01)，GLQ评分明显优于对照组(P<0.01)。观察组术后胆管损伤1例，恶心呕吐2，胆漏1例，其并发症发生率为6.67%(4/60)；对照组切口感染2例，胆漏2例，恶心呕吐3例，其并发症发生率11.67%(7/60)，观察组与对照组的并发症发生率差异无统计学意义(P>0.05)。见表1。

表1 2组手术情况和术后恢复比较

组别手术时间(min)术中出血量(ml)肛门排气时间(h)住院时间(d)VAS评分(分)GLQ评分(分)并发症[例(%)]观察组61.65±13.5965.18±10.7922.34±8.673.94±0.853.75±1.06117.36±12.344(6.67)对照组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组治疗前后IL-10、INF-γ、IL-2和IL-4水平的变化 2组治疗前的IL-10、INF-γ、IL-2和IL-4水平差异无统计学意义(P>0.05)，治疗后2组IL-10和IL-4水平较治疗前明显降低(P<0.01)，而INF-γ和IL-2水平较治疗前明显升高(P<0.01)，观察组的降低或者升高水平更为明显(P<0.01)。见表2。

表2 2组治疗前后IL-10，INF-γ，IL-2和IL-4水平的变化

组别IL-10(pg/ml)治疗前治疗后INF-γ(pg/ml)治疗前治疗后IL-2(pg/ml)治疗前治疗后IL-4(pg/ml)治疗前治疗后观察组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*对照组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：与治疗前比较，*P<0.01

组别CD+3(%)治疗前治疗后CD+4(%)治疗前治疗后CD+8(%)治疗前治疗后CD+4/CD+8治疗前治疗后观察组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*对照组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：与治疗前比较，*P<0.01

3 讨论

本组研究表明腹腔镜胆囊切除术治疗老年急性坏疽性胆囊炎的疗效明显优于开腹胆囊切除术，主要表现手术时间短，出血量少，术后疼痛程度轻，术后肠道功能恢复快和术后胃肠生存质量明显提高，可能与腹腔镜胆囊切除术更有利于肝脏功能的恢复，避免了疼痛给患者带来痛苦。本组研究还发现腹腔镜胆囊切除术胃肠生存质量明显优于开腹手术治疗老年急性坏疽性胆囊炎，说明腹腔镜胆囊切除术在提高患者术后生存质量方面具有重要意义。腹腔镜胆囊切除术较开腹手术具有以下优势[4-8]：由于创口较小手术无瘢痕，患者易于接受微创的概念；术中术野更为清晰，解剖更为精细，清除炎性组织更为彻底，术后恢复更快；手术时间短，术中出血少；术后患者恢复快，术后住院时间短。当然术中应注意[9]：术中对Calot 三角区的解剖特别重要，由于急性坏疽性胆囊炎炎症极为严重，三角区的解剖常常不清楚，常常需要从胆囊床往胆囊颈部解剖，需要钝性分离，避免盲目地使用电凝。对于三角区很致密的水肿和粘连，可行逆行胆囊切除术，或者做部分胆囊切除，残余胆囊壁粘连烫除。

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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 上海市长宁区天山中医医院外二科(周健、唐学典)；上海市交通大学医学院附属同仁医院普外科(高淳)

唐学典，200051 上海市长宁区天山中医医院外二科；

E-mail：zhjian2003@163.com

R 575.61

A

1002-7386(2016)23-3561-04

2016-03-31)