不同压力CO_2气腹腹腔镜胆囊切除术对肩部疼痛ACTH、COR、PGE_2、NO/NOS及腹膜形态的影响
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摘要
1987年3月，法国医生Dr.Mouret成功的完成了世界医学史上首例腹腔镜胆囊切除术(laparoscopic cholecystectomy，LC)，这一手术的成功即引起了世界外科学界的轰动。我国的LC始于1991年2月，时至今日，已经普及到全国各地。LC作为一种新型的技术，已得到外科学界空前的赞同和支持，它开辟了现代高新科技与传统外科技术相结合的途径，既不违背现行的外科原则又能以最小的创伤完成传统的外科手术。然而，此类手术一般需在人工气腹下进行，借助于气体压力把腹前壁与腹内脏器分开，为术者提供一个良好的手术视野和一个易于操作的手术环境。当前国内外腹腔境技术普遍是依靠二氧化碳（carbon dioxide，CO2）气腹进行荷电操作，因此，LC有其特有的并发症，其中35-80％的病人主诉肩部疼痛，而且有时疼痛相当明显，其程度和持续时间上常常超过伤口疼痛，成为腹腔镜手术后病人最主要的不适主诉。目前采用术中更换气体、放置引流管、注射局麻药、术终吸净腹内气体、于术前术中术后经肌肉或静脉注射止痛药、联合麻醉等方法防治肩部疼痛，但这些方法都有其局限性。至今国内外有关LC后肩部疼痛的原因尚未阐明，这方面的文献报道极少，这就需要我们进一步研究LC后肩部疼痛的原因，以找到最佳的LC后肩部疼痛的防治方法。
腹腔镜手术的“微创”不仅体现在切口微小，而且对机体免疫、应激、代谢、呼吸、循环等多方面的影响小。我们在外科领域一直追求的目标是最大程度地维持机体内环境的稳定，而机体对手术的应激反应及免疫功能变化的程度是反映机体内环境稳定状态的重要组成部分。
本研究旨在通过观察不同压力CO2气腹LC对气腹存留时限、肩部疼痛、促肾上腺皮质激素（adrenocorticotropic hormone ，ACTH）、皮质醇（cortisol， COR）、前列腺素E2 （prostaglandin E2，PGE2）、一氧化氮（Nitric Oxide ，NO）、一氧化氮合酶（Nitric Oxide synthase，NOS）、诱导型一氧化氮合酶（inducible nitric oxide synthase，iNOS）、结构型一氧化氮合酶（constructive nitric oxide synthase，cNOS）及腹膜形态的影响，探讨LC后肩部疼痛发生的原因及防治方法，并阐述CO2气腹压力的变化对机体神经内分泌及免疫功能的影响。
一、不同压力CO2气腹LC后对气腹存留时限及肩部疼痛的影响
目的：观察不同压力CO2气腹LC后对气腹存留时限及肩部疼痛的影响，探讨LC后气腹存留时限的影响因素及肩部疼痛的原因。
方法：将69例行LC的病人随机分为A、B、C 3组，每组23例。气腹压力设定A组10mmHg，B组12mmHg，C组14mmHg。对69例LC患者术后进行连续胸部X线平片观察膈下游离气体，测量术后24小时两侧膈下游离气体的长、高并计算残气量。视觉模拟评分(Vision Analogue Score，VAS)观察3组术后1、3、6、12、24、48、72、96、120h肩部疼痛程度。
结果：
术后24h内气腹完全吸收37例，24h～3天内气腹完全吸收17例，3～5天内气腹完全吸收4例，5～6天内气腹完全吸收1例，LC后气腹存留时限平均为1.77±1.07天。
男女两组气腹存留时限比较无显著意义（H=0.013，P=0.911）。lg（气腹存留时限）与术后24小时膈下残气量呈正相关（r=0.616，p<0.001），与气腹时间呈负相关（r=-0.228，p=0.014），与年龄、体重、身高、手术时间及所用气体量无相关性。
3组组间比较，术中CO2用量（L）C组较A组多，差异有显著意义(q=11.724，P=0.046)，术后24小时膈下残气量及术后气腹存留时限差异无显著意义（p>0.05）。
69例患者中，术后有26例出现肩部疼痛。随A、B、C 3组气腹压力的增高，发生肩部疼痛患者的VAS明显增高(F=7.982, P<0.001)，术后24h肩部疼痛VAS与术后24小时右侧膈下残气量及气腹存留时限虽有相关性，但相关系数较小。
结论：
LC后气腹存留时限平均为1.77±1.07天，术毕尽量将腹腔内CO2气体排净可缩短术后残气吸收时间。
不同压力CO2气腹LC对术后残余的CO2气体量及气腹存留时限无明显影响。
LC后肩部疼痛程度随气腹压增高有明显加重趋势，与残余气腹虽有相关性，但相关系数较小，人工气腹引起膈肌的张力可能是造成肩部疼痛的重要原因。
观察LC后气腹存留时限对于术后诊断和鉴别诊断胆道损伤、消化道穿孔等疾病具有重要的临床指导意义。
二、不同压力CO2气腹LC对PaO2、PaCO2、pH值及肩部疼痛的影响
目的：研究不同压力CO2气腹对LC后PaO2、PaCO2、动脉血pH值及肩部疼痛的影响，探讨LC后肩部疼痛发生的原因、机理及防治方法。
方法: 将120例行LC的病人随机分为A、B、C 3组，每组40例。气腹压力设定A组10mmHg，B组12mmHg，C组14mmHg。在术前1d、术后1d抽取股动脉血1ml，行血气分析，观察3组术前、术后的PaO2、PaCO2、pH值，采用VAS观察术后1、3、6、12、24、48、72、96h肩部疼痛的发生率和程度。
结果:
3组患者手术时间无明显差异(P>0.05)。术中CO2用量C组较A组多，差异有显著意义(q=11.38，p=0.045)。
A、B、C 3组患者术后1天的PaO2均较术前减低，差异均有显著意义(A组：t=27.1，p=0.002；B组：t=13.5，p=0.005；C组：t=28.4，p=0.003)，而3组患者术后1天的PaCO2及pH值与术前相比无明显变化(P>0.05)。C组病人术?
In March 1987, Dr. Mouret successfully carried out the first laparoscopic cholecystectomy (LC) by means of electronic laparoscopy, which made a great stir in the surgical field all over the world. Since February 1991, this technique has been widely spreaded all over our country. As a new method with minimal surgical stress and without contravening conventional surgery principle, LC has combined new technique with conventional surgery and has been unparalleled generally approved by the field of surgery in surgical history. But pneumoperitoneum is needed to separate abdominal wall from abdominal organs to make LC performed easily and clearly. Nowadays, Carbon dioxide (CO2) is generally used in pneumoperitoneum for laparoscopy undergoing charging operation, while it might cause some specific complications after laparoscopy. Shoulder pain, which is frequently reported by 35%-80% of patients, is so severe sometimes that it preponderate over incision pain and becomes the main discomfort. It can be alleviated by changing the type of pneumoperitoneum, placing routine drainage, injecting local anesthetic, eliciting celiac gas, injecting analgesic via muscle or vein perioperative, combining anaethesia and so on, but all these methods have their limitations. The pathogenesis is still unknown and there are few literatures on it. Further studies should be introduced to clarify the cause of shoulder pain and to find the best way of preventing and managing the complication.
Laparoscopic operation is characteristic not only mild incision, but also less influence on body immunity, stress, metabolizability, respiration and circulation function. The conception of modern surgery is to maintain homoeostasis as possible as we can, while the stress to surgery and change of immunity functions can reflect homoeostasis.
This study is to investigate if the different CO2 pressure used in LC has any effects on the duration of pneumoperitoneum, the occurrence of postoperative shoulder pain, adrenocorticotropic hormone (ACTH), cortisol (COR), prostaglandin E2 (PGE2), nitric
oxide (NO), nitric oxide synthase (NOS), inducible nitric oxide synthase (iNOS), constructive nitric oxide synthase (cNOS) and peritoneal morphology, and to explore the cause of shoulder pain in search of best bet on preventing and managing of shoulder pain, to explicit if the CO2 pressure has any effects on the neuroendocrine response as well as immunity function.
1. The effects of different CO2 pneumoperitoneum pressure on duration of pneumoperitoneum and shoulder pain following LC
Objective: To define the duration of pneumoperitoneum and to identify factors which affect resolution time and shoulder pain.
Methods: Sixty-nine patients underwent LC were randomized into three groups (with 23 patients in each group): patients in group A underwent LC with 10 mmHg CO2, those in group B with 12 mmHg CO2, and those in group C with 14 mmHg CO2. Serial chest X ray were taken until all residual gas was resolved. The X ray’s results were analysed by a consultant radiologist. The volume of residual gas bubble under each hemi-diaphragm 24h afteer operation was calculated by making of length of arc and height of the gas. The intensity of shoulder pain was recorded on a visual analogue score (VAS) 1, 3, 6, 12, 24, 48, 72, 96, 120h after operation.
Results:
Pneumooperitoneum disappeared within 24 h in 37patients, 3 to 5 days in 4 patients, 5 to 6 days in 1 patient. Mean resolution time for all patients was 1.77±1.07 days.
There was no apparent difference in resolution time between male and female;. Duration of the pneumoperitoneum was correlated with the volume under right hemi-diaphragm(r=0.616，p<0.001) and pneumoperitoneum time (r=-0.228，p=0.014), but was not correlated with gender, age, weight, duration of operation, volume of consumed CO2 .
The intraoperative CO2 consumption was significantly higher in group C (q=11.72, p=0.046) than that in group A. There was no apparent difference in resolution time and the volume under right hemi-diaphragm 24h afte operation b
腹腔镜手术的“微创”不仅体现在切口微小，而且对机体免疫、应激、代谢、呼吸、循环等多方面的影响小。我们在外科领域一直追求的目标是最大程度地维持机体内环境的稳定，而机体对手术的应激反应及免疫功能变化的程度是反映机体内环境稳定状态的重要组成部分。
本研究旨在通过观察不同压力CO2气腹LC对气腹存留时限、肩部疼痛、促肾上腺皮质激素（adrenocorticotropic hormone ，ACTH）、皮质醇（cortisol， COR）、前列腺素E2 （prostaglandin E2，PGE2）、一氧化氮（Nitric Oxide ，NO）、一氧化氮合酶（Nitric Oxide synthase，NOS）、诱导型一氧化氮合酶（inducible nitric oxide synthase，iNOS）、结构型一氧化氮合酶（constructive nitric oxide synthase，cNOS）及腹膜形态的影响，探讨LC后肩部疼痛发生的原因及防治方法，并阐述CO2气腹压力的变化对机体神经内分泌及免疫功能的影响。
一、不同压力CO2气腹LC后对气腹存留时限及肩部疼痛的影响
目的：观察不同压力CO2气腹LC后对气腹存留时限及肩部疼痛的影响，探讨LC后气腹存留时限的影响因素及肩部疼痛的原因。
方法：将69例行LC的病人随机分为A、B、C 3组，每组23例。气腹压力设定A组10mmHg，B组12mmHg，C组14mmHg。对69例LC患者术后进行连续胸部X线平片观察膈下游离气体，测量术后24小时两侧膈下游离气体的长、高并计算残气量。视觉模拟评分(Vision Analogue Score，VAS)观察3组术后1、3、6、12、24、48、72、96、120h肩部疼痛程度。
结果：
术后24h内气腹完全吸收37例，24h～3天内气腹完全吸收17例，3～5天内气腹完全吸收4例，5～6天内气腹完全吸收1例，LC后气腹存留时限平均为1.77±1.07天。
男女两组气腹存留时限比较无显著意义（H=0.013，P=0.911）。lg（气腹存留时限）与术后24小时膈下残气量呈正相关（r=0.616，p<0.001），与气腹时间呈负相关（r=-0.228，p=0.014），与年龄、体重、身高、手术时间及所用气体量无相关性。
3组组间比较，术中CO2用量（L）C组较A组多，差异有显著意义(q=11.724，P=0.046)，术后24小时膈下残气量及术后气腹存留时限差异无显著意义（p>0.05）。
69例患者中，术后有26例出现肩部疼痛。随A、B、C 3组气腹压力的增高，发生肩部疼痛患者的VAS明显增高(F=7.982, P<0.001)，术后24h肩部疼痛VAS与术后24小时右侧膈下残气量及气腹存留时限虽有相关性，但相关系数较小。
结论：
LC后气腹存留时限平均为1.77±1.07天，术毕尽量将腹腔内CO2气体排净可缩短术后残气吸收时间。
不同压力CO2气腹LC对术后残余的CO2气体量及气腹存留时限无明显影响。
LC后肩部疼痛程度随气腹压增高有明显加重趋势，与残余气腹虽有相关性，但相关系数较小，人工气腹引起膈肌的张力可能是造成肩部疼痛的重要原因。
观察LC后气腹存留时限对于术后诊断和鉴别诊断胆道损伤、消化道穿孔等疾病具有重要的临床指导意义。
二、不同压力CO2气腹LC对PaO2、PaCO2、pH值及肩部疼痛的影响
目的：研究不同压力CO2气腹对LC后PaO2、PaCO2、动脉血pH值及肩部疼痛的影响，探讨LC后肩部疼痛发生的原因、机理及防治方法。
方法: 将120例行LC的病人随机分为A、B、C 3组，每组40例。气腹压力设定A组10mmHg，B组12mmHg，C组14mmHg。在术前1d、术后1d抽取股动脉血1ml，行血气分析，观察3组术前、术后的PaO2、PaCO2、pH值，采用VAS观察术后1、3、6、12、24、48、72、96h肩部疼痛的发生率和程度。
结果:
3组患者手术时间无明显差异(P>0.05)。术中CO2用量C组较A组多，差异有显著意义(q=11.38，p=0.045)。
A、B、C 3组患者术后1天的PaO2均较术前减低，差异均有显著意义(A组：t=27.1，p=0.002；B组：t=13.5，p=0.005；C组：t=28.4，p=0.003)，而3组患者术后1天的PaCO2及pH值与术前相比无明显变化(P>0.05)。C组病人术?
In March 1987, Dr. Mouret successfully carried out the first laparoscopic cholecystectomy (LC) by means of electronic laparoscopy, which made a great stir in the surgical field all over the world. Since February 1991, this technique has been widely spreaded all over our country. As a new method with minimal surgical stress and without contravening conventional surgery principle, LC has combined new technique with conventional surgery and has been unparalleled generally approved by the field of surgery in surgical history. But pneumoperitoneum is needed to separate abdominal wall from abdominal organs to make LC performed easily and clearly. Nowadays, Carbon dioxide (CO2) is generally used in pneumoperitoneum for laparoscopy undergoing charging operation, while it might cause some specific complications after laparoscopy. Shoulder pain, which is frequently reported by 35%-80% of patients, is so severe sometimes that it preponderate over incision pain and becomes the main discomfort. It can be alleviated by changing the type of pneumoperitoneum, placing routine drainage, injecting local anesthetic, eliciting celiac gas, injecting analgesic via muscle or vein perioperative, combining anaethesia and so on, but all these methods have their limitations. The pathogenesis is still unknown and there are few literatures on it. Further studies should be introduced to clarify the cause of shoulder pain and to find the best way of preventing and managing the complication.
Laparoscopic operation is characteristic not only mild incision, but also less influence on body immunity, stress, metabolizability, respiration and circulation function. The conception of modern surgery is to maintain homoeostasis as possible as we can, while the stress to surgery and change of immunity functions can reflect homoeostasis.
This study is to investigate if the different CO2 pressure used in LC has any effects on the duration of pneumoperitoneum, the occurrence of postoperative shoulder pain, adrenocorticotropic hormone (ACTH), cortisol (COR), prostaglandin E2 (PGE2), nitric
oxide (NO), nitric oxide synthase (NOS), inducible nitric oxide synthase (iNOS), constructive nitric oxide synthase (cNOS) and peritoneal morphology, and to explore the cause of shoulder pain in search of best bet on preventing and managing of shoulder pain, to explicit if the CO2 pressure has any effects on the neuroendocrine response as well as immunity function.
1. The effects of different CO2 pneumoperitoneum pressure on duration of pneumoperitoneum and shoulder pain following LC
Objective: To define the duration of pneumoperitoneum and to identify factors which affect resolution time and shoulder pain.
Methods: Sixty-nine patients underwent LC were randomized into three groups (with 23 patients in each group): patients in group A underwent LC with 10 mmHg CO2, those in group B with 12 mmHg CO2, and those in group C with 14 mmHg CO2. Serial chest X ray were taken until all residual gas was resolved. The X ray’s results were analysed by a consultant radiologist. The volume of residual gas bubble under each hemi-diaphragm 24h afteer operation was calculated by making of length of arc and height of the gas. The intensity of shoulder pain was recorded on a visual analogue score (VAS) 1, 3, 6, 12, 24, 48, 72, 96, 120h after operation.
Results:
Pneumooperitoneum disappeared within 24 h in 37patients, 3 to 5 days in 4 patients, 5 to 6 days in 1 patient. Mean resolution time for all patients was 1.77±1.07 days.
There was no apparent difference in resolution time between male and female;. Duration of the pneumoperitoneum was correlated with the volume under right hemi-diaphragm(r=0.616，p<0.001) and pneumoperitoneum time (r=-0.228，p=0.014), but was not correlated with gender, age, weight, duration of operation, volume of consumed CO2 .
The intraoperative CO2 consumption was significantly higher in group C (q=11.72, p=0.046) than that in group A. There was no apparent difference in resolution time and the volume under right hemi-diaphragm 24h afte operation b
引文
Reidel HH, Semm K.The post-laparoscopic pain syndrome. Geburtshilfe Frauenheikd, 1980,40:635～643
Carroll BJ, Birth M, Phillips EH.Common bile duct injuries during laparoscopic cholecystectomy that result in litigation. Surg Endosc,1998,12:310～314
Brian Fredman, MB, Fredman B, Jedeikin R, et al. Residual pneumoperitoneum: a cause of postoperative pain after laparoscopic cholecystectomy. Anesth Analg, 1994,79(1):152～154
Aitola P, Airo I, Kaukinen S, Ylitalo P, et al. Comparison of N2O and CO2 pneumoperitoneums during laparoscopic cholecystectomy with special reference to postoperative pain. Surg Laparosc Endosc, 1998,8:140～144
Di Massa A, Avella R, Gentili C. Respiratory dysfunction related to diaphragmatic shoulder pain after abdominal and pelvic Laparoscopy. Minerva Anestesiol, 1996,62(5):171～176
Sarli R, Costi G, Sansebastiano M, et al. Prospective randomized trial of low-pressure pneumoperitoneums for reduction of shoulder-tip pain following laparoscopy. Br J Surgery,2000,87:1161～1165
Jackson SA, Laurence AS, Hill JC. Does post-laparoscopy pain relate to residual carbon dioxide? Anaesthesia, 1996,51(5):485～487
Draper K, Jefson R, Jongeward R, et al. Duration of postlaparoscopic pneumoperitoneum. Surg Endosc, 1997,11:809～811
嵇武，徐梅，陈训如等. 腹腔镜与开腹胆囊切除术后气腹存留时限的X线观察。中华消化内镜杂志，1999，5(16):287～289
Tang CL, Yeong KY, Nyam DC, et al. Postoperative intra-abdominal free gas after open colorectal resection. Dis Colon Rectum 2000,43(8):1116～1120
陈训如，主编。腹腔镜手术的并发症与对策。第1版，昆明：云南科技出版社，1997，86～91
蔡恒生。剖腹术后气腹期限X线观察。甘肃中医学院学报，1997，14:48
Carroll BJ, Birth M, Phillips EH.Common bile duct injuries during laparoscopic cholecystectomy that result in litigation. Surg Endosc,1998,12:310～314
Brian Fredman, MB, Fredman B, Jedeikin R, et al. Residual pneumoperitoneum: a cause of postoperative pain after laparoscopic cholecystectomy. Anesth Analg, 1994,79(1):152～154
Aitola P, Airo I, Kaukinen S, Ylitalo P, et al. Comparison of N2O and CO2 pneumoperitoneums during laparoscopic cholecystectomy with special reference to postoperative pain. Surg Laparosc Endosc, 1998,8:140～144
Di Massa A, Avella R, Gentili C. Respiratory dysfunction related to diaphragmatic shoulder pain after abdominal and pelvic Laparoscopy. Minerva Anestesiol, 1996,62(5):171～176
Sarli R, Costi G, Sansebastiano M, et al. Prospective randomized trial of low-pressure pneumoperitoneums for reduction of shoulder-tip pain following laparoscopy. Br J Surgery,2000,87:1161～1165
Jackson SA, Laurence AS, Hill JC. Does post-laparoscopy pain relate to residual carbon dioxide? Anaesthesia, 1996,51(5):485～487
Draper K, Jefson R, Jongeward R, et al. Duration of postlaparoscopic pneumoperitoneum. Surg Endosc, 1997,11:809～811
嵇武，徐梅，陈训如等. 腹腔镜与开腹胆囊切除术后气腹存留时限的X线观察。中华消化内镜杂志，1999，5(16):287～289
Tang CL, Yeong KY, Nyam DC, et al. Postoperative intra-abdominal free gas after open colorectal resection. Dis Colon Rectum 2000,43(8):1116～1120
陈训如，主编。腹腔镜手术的并发症与对策。第1版，昆明：云南科技出版社，1997，86～91
蔡恒生。剖腹术后气腹期限X线观察。甘肃中医学院学报，1997，14:48