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�� 【摘要】 目的 评估腹腔镜和开腹手术对异位妊娠患者机体应激及代谢的影响。方法 以非随机方式分为腹腔镜组、开腹手术组。分别检测术前24 h、术后24 h和术后72 h血清中皮质醇、甲状腺激素(FT3、FT4、TSH)及肝酶(ALT、AST)水平的变化。比较两组在手术前、后外周血中上述激素及因子变化。结果 ①手术作为创伤均可升高血皮质醇的水平,但开腹手术组术后24 h皮质醇变化较腹腔镜组更为显著,两组在术后72 h均能恢复至术前水平;②腹腔镜组手术前后甲状腺相关激素(FT3、FT4、TSH)反应较为轻微且恢复较为迅速,于术后72 h均能恢复术前的水平。开腹组则激素水平波动较大,于术后72 h FT3仍未能恢复术前水平;③腹腔镜组及开腹组对肝酶(ALT、AST)影响不明显;④两种术式的手术操作时间基本相似,但腹腔镜手术中患者的失血量明显少于开腹手术。结论 腹腔镜手术较开腹手术对机体的应激及代谢的影响小,腹腔镜手术是异位症患者有效安全损伤少的治疗方法。�
【关键词】 腹腔镜手术;开腹手术;应激;代谢
The study of effect of laparoscopic surgery on stress and metabolism for ectopic pregnancy patients
DAI Xiao-yun,LE Ai-wen,WANG Zhong-hai,et al.Department of Obstetric and Gynecology, Shenzhen Sixth People’s Hospital,Guangdong Medical College,Shenzhen 518052,China
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【Abstract】 Objective To evaluate laparoscopic surgery and open surgery approachs’effect on stress and metabolism of ectopic pregnancy patients.Methods With clinical diagnosis and permitting criterion,ectopic pregnancy patients were assigned to laparoscopic surgery and open surgery.Serum concentrations of cortisol、FT3、FT4、TSH 、ALT、AST were measured at preoperative 24 hours, postoperative 24 hours,postoperative 72 hours.We compared their change in two operative approachs.Results ①At postoperative 24 h,the level of cortisol increased more significantly in open surgery group than that in laparoscopic surgery group.The cortisol recovered at postoperative 72 h in both groups.But the degree of change in open surgery group was much greater than in laparoscopic surgery group.②the change of FT3、FT4 and TSH was gently and could reach the level of preoperative state at postoperative 72 h in laparoscopic surgery group.The change of FT3、FT4 and TSH was high,FT3 could not return at postoperative 72 h in open surgery group.③ALT and AST did not changed obviously in both groups.④There was no dramatically differences between two groups on operation time, but blood loss during surgery in laparoscopic group was lower than in open surgery.Conclusion The metabolic and stress response in laparoscopic surgery is lighter than in open surgery.The laparoscopic surgery is a kind of more efficient, secure and less injurious way to the ectopic pregnancy patients.�
【Key words】 Laparoscopic surgery; Open surgery; Stress; Metabolic
作者单位:518052广东医学院附属深圳市第六人民医院(南山医院)妇产科
自1987年3月Philipe Mouret完成了世界上首例腹腔镜胆囊切除术(LC)以来,腹腔镜手术通过近20年来在临床上的广泛应用,其技术日臻成熟。特别是近10年在妇科领域的发展十分迅速,使输卵管妊娠的治疗由创伤较大的开腹手术向微创的腹腔镜手术转化。腹腔镜手术具有创伤小,恢复快,美观等无法比拟的优点。但是随着在腹腔镜领域基础研究的不断深入,许多问题凸显出来,特别是腹腔镜手术对于机体应激和代谢的影响仍存有争议。为了进一步探讨腹腔镜手术在治疗异位妊娠时对机体的影响,本研究选取了甲状腺相关激素-FT3、FT4、TSH;应激相关激素-皮质醇;肝功能指标-肝酶(ALT、AST)等作为观察指标,探讨腹腔镜治疗异位妊娠对机体全身和腹腔脏器功能的影响。
1 资料与方法
1.1 一般资料 本研究对象来自2007年10月至2009年10月,本院妇产科住院的异位妊娠患者。根据纳入标准筛选出符合条件的研究对象,其中腹腔镜手术组36例,开腹手术组30例。
1.2 对象选择
1.2.1 纳入标准 年龄在20～45岁;术前根据病史、症状和体征能够初步诊断为异位妊娠;术后病理确诊为异位妊娠不合并重要脏器的器质性疾病,能够耐受手术的患者;术前1个月内没有服用过影响机体代谢和内分泌的药物。
1.2.2 分组标准 ①术前检查输卵管包快直径>3 cm;②β-hCG>2000U/L;③输卵管妊娠发生流产或破裂有严重腹痛;④有腹腔内出血或伴有失血性休克症状者。有两项或两项以上符合上述指标的归入开腹手术组;少于两项上述指标且生命体征较平稳,或自身要求腹腔镜手术的归入腹腔镜手术组。
1.2.3 排除标准 术后诊断与术前不相符的患者;加用抗代谢的药物;患者依从性不好,中途退出或不能配合完成实验标本采集的患者。
1.3 分组及指标观测
1.3.1 指标监测 皮质醇、甲状腺相关激素(FT4、FT3、TSH),肝脏转氨酶(ALT、AST)等。
1.3.1.1 手术前后皮质醇和甲状腺相关激素(FT4、FT3、TSH)的测定 测定方法:采用放射免疫分析方法。以标准品浓度为横坐标,Bi/B0为纵坐标,绘制标准曲线,根据待测标本Bi/B0即可从标准曲线查出相应的浓度。
1.3.2 手术前后肝脏转氨酶的测定 送生化实验室,日立7600自动生化检测仪连续检测。
1.4 统计学处理 计量资料用均数士标准差(x±s)表示,利用SPSS 13.0软件进行统计分析,组间均数比较采用t检验,组内不同时点间比较采用配对t检验,计数采用χ�2检验。以P 从术中出血和手术时间看,腹腔镜又充分显示了作为微创手术的优势,对于异位妊娠患者来说,大多数患者在术前就有出血和贫血的情况下,手术过程中尽量缩短手术时间和减少医源性出血对于患者病情的恢复至关重要。�
腹腔镜技术作为一项新兴的手术方式,有其优势同时也有一定的弊端。本研究只是对于腹腔镜手术对机体代谢中的几项有代表性的激素进行了研究,下一步拟多层次、多角度、全方位的探讨腹腔镜手术对机体的应激及代谢的影响,比较两种术式及保守治疗的远期治疗效果。
参 考 文 献
[1] Haque Z,Rahaman IL,Siddique A,et al.Metabolic and stress responses of the body to trauma:produced by the laparoscopic and open cholecystectomy.Mymensingh Med. J,2004,13(1):48-52.
[2] Marana E,Scambia q,Maussier ML,et al.Neuroendocrine stress response in patients undering benign ovarian cyst surgery by laparoscopy,minilaparotomy,and laparotomy.J Am Assoc Gynecol Laparosc,2003,10(2):159-165.
[3] Matsumoto ED,Margulis V,Tunc L,et al.Cytokine response to surgical stress:comparison of pure laparoscopic,hand-assisted laparoscopic,and open nephrectomy.J Endourol,2005,19(9):1140-1145.
[4] Hague Z,Rahman M,Siddique MA,et al.Metabolic and stress responses of the body to trauma:produced by the laparoscopic and open cholecystectomy.Mymensingh Med J,2004,13(1):48-52.
[5] Junghans T,Modersohn D,Dorner F,et al.Systematic evaluation of different approaches for minimizing hemodynamic changes during pneumoperitoneum.Surg Endosc,2006,20(5):763-769.
[6] Klopfenstein CE,More DR,Clergue F,et al.Effects of abdominal C02 insufflation and Changes of position on hepatic blood flow in anesthetized pigs.Am J Physiol,1998,275(3 Pt 2):900-905.
[7] Blobner M,Bogdanski R,Kochs E,et al.Effects of intraabdomunally insufflated carbondioxide and elevated intraabdominal pressure on splanchnic circulation.Anesthesiology,1998,89(2):475-482.
[8] Jakimowicz J,Stultiens G,Smulders F.Laparoscopic insufflation of the abdomen reduces portal venous flow.Sure Endosc,1998,12(2):129-132.
[9] Sato K,Kawamura T,Wakusawa R.Hepatic blood flow and function in elderly patients under going laparoscopic cholecystecomy.Anesth Analg,2000,90(5):1198-1202.
