二氧化碳气腹相关的肝肾损伤的研究进展
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摘要
腹腔镜手术的出现揭开了微创外科发展的序幕,但其所需的二氧化碳气腹会对患者的肝肾功能产生不良影响。二氧化碳气腹引起肝损伤的机制主要与气腹的直接压迫、肝动脉血流紊乱、高碳酸血症以及体位等相关,而肾损伤机制主要与气腹的直接压迫、神经内分泌反应以及缺血再灌注损伤等相关。通过降低气腹压力,使用麻醉药物、血管活性药物以及抗氧化剂,间歇式气动压力系统、支撑帐篷式非气腹装置以及预处理等可以减轻二氧化碳气腹对肝、肾功能的损伤。
The emergence of laparoscopic surgery has unveiled the development of minimally invasive surgery,but carbon dioxide pneumoperitoneum needed during surgery has adverse effects on liver and renal function. The mechanism of liver injury caused by carbon dioxide pneumoperitoneum is mainly related to direct compression of the pneumoperitoneum,hepatic artery blood flow disorder,hypercapnia and body position. The mechanism of renal injury is mainly related to direct compression of the pneumoperitoneum,neuroendocrine reaction and ischemia-reperfusion injury. The damage caused by carbon dioxide pneumoperitoneum to liver and kidney can be alleviated by reducing pneumoperitoneum pressure,using anesthetic drugs,vasoactive drugs,anti-oxidants,adopting intermittent pneumatic pressure system,support tent-type non-pneumoperitoneum device and pneumoperitoneum pretreatment.
The emergence of laparoscopic surgery has unveiled the development of minimally invasive surgery,but carbon dioxide pneumoperitoneum needed during surgery has adverse effects on liver and renal function. The mechanism of liver injury caused by carbon dioxide pneumoperitoneum is mainly related to direct compression of the pneumoperitoneum,hepatic artery blood flow disorder,hypercapnia and body position. The mechanism of renal injury is mainly related to direct compression of the pneumoperitoneum,neuroendocrine reaction and ischemia-reperfusion injury. The damage caused by carbon dioxide pneumoperitoneum to liver and kidney can be alleviated by reducing pneumoperitoneum pressure,using anesthetic drugs,vasoactive drugs,anti-oxidants,adopting intermittent pneumatic pressure system,support tent-type non-pneumoperitoneum device and pneumoperitoneum pretreatment.
引文
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[3] Sodha S,Nazarian S,Adshead JM,et al. Effect of pneumoperitoneumon on renal function and physiology in patients undergoing robotic renal surgery[J]. Curr Urol,2016,9(1):1-4.
[4] Dupont S, Schiffer ERC, White MJ, et al. Changes in hepatic blood flow and liver function during closed abdominal hyperthermic intraperitoneal chemotherapy following cytoreduction surgery[J].Gastroenterol Res Pract,2018,2018:8063097.
[5] Hoekstra LT, Ruys AT, Milstein DM, et al. Effects of prolonged pneumoperitoneumon on hepatic perfusion during laparoscopy[J].Ann Surg,2013,257(2):302-307.
[6] Liu Y, Cao W, Liu Y, et al. Changes in duration action of rocuronium following decrease in hepatic blood flow during pneumoperitoneumon for laparoscopic gynaecological surgery[J]. BMC Anesthesiol,2017,17(l):45.
[7] Antoniou EA,Kairi E,Margonis GA, et al. Effect of increased intra-abdominal pressure on liver histology and hemodynamics:An experimental study[J]. In Vivo,2018,32(1):85-91.
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[18] Bishara B, Karram T, Khatib S, et al. Impact of pneumoperitoneumon on renal perfusion and excretory function:Beneficial effects of nitroglycerine[J]. Surg Endosc,2009,23(3):568-576.
[19] Wauters J, Claus P, Brosens N, et al. Pathophysiology of renal hemodynamics and renal cortical microcirculation in a porcine model of elevated intra-abdominal pressure[J]. J Trauma,2009,66(3):713-719.
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[23] Sun LY, Wijeysundera DN,Tait GA,et al. Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery[J]. Anesthesiology,2015(123):515-523.
[24] Bruintjes MH,van Helden EV, Braat AE,et al. Deep neuromuscular block to optimize surgical space conditions during laparoscopic surgery:A systematic review and meta-analysis[J]. Br J Anaesth.2017,118(6):834-842.
[25] Ge M,Chen H,Zhu Q,et al. Propofol post-conditioning alleviates hepatic ischaemia reperfusion injury via BRGl-mediated Nrf2/HO-1 transcriptional activation in human and mice[J]. J Cell Mol Med,2017,21(12):3693-3704.
[26] Xingwei X,Xin G,Peng Z,et al. Low-dose ketamine pretreatment reduces oxidative damage and inflammatory response following CO_2 pneumoperitoneum in rats[J]. Clin Invest Med,2014,37(3):E124.
[27]钟时,冯梅,蒋宗滨,等.长时间气腹下不同流量七氟烷对肾功能的影响[J].临床麻醉学杂志,2013,29(11):1082-1084.
[28] Kim ZG, Sanli E, Brinkmann L, et al. Impact of dopamine and endothelin-1 antagonism on portal venous blood flow during laparoscopic surgery[J]. Surg Endosc,2002,16(9):1292-1296.
[29] Agusti M, Elizalde Jl, Adalia R, et al. The effects of vasoactive drugs on hepatic blood flow changes induced by CO_2 laparoscopy:An animal study[J]. Anesth Analq,2001,93(5):1121-1126.
[30] Huh H, Kim NY, Park SJ, et al. Effect of nicardipine on renal function following robot-assisted laparoscopic radical prostatectomy in patients with pre-existing renal insufficiency[J]. J Int Med Res,2014,42(2):427-435.
[31] Ates E, Yilmaz S,Ihtiyar E,et al. Preconditioning-like amelioration of erythropoietin against laparoscopy-induced oxidative injury[J]. Surg Endose,2006,20(5):815-819.
[32] Cay A,Imamoglu M, Unsal MA,et al. Does anti-oxidant prophylaxis with melatonin prevent adverse outcomes related to increased oxidative stress caused by laparoscopy in experimental rat model?[J].J Surg Res,2006,135(1):2-8.
[33] Seguro AC,Polo de Figueiredo LF, Shimizu MH. N-acetylcysteine(NAC)protects against acute kidney injury(AKI)following prolonged pneumoperitoneumon in the rat[J]. J Surg Res, 2012,175(2):312-315.
[34] Bulbuloglu E, Yildiz H, Senoglu N, et al. Protective effects of zinc, pentoxifylline, and N-acetylcysteine in an animal model of laparoscopy induced ischemia/reperfusion injury of the small intestine[J]. J Laparoendosc Adv Surg Tech A,2011,21(10):947-951.
[35] Baltatzis M,Pavlidis TE, Ouroumidis O,et al. Aprotinin reduces oxidative stress induced by pneumoperitoneum in rats[J]. J Surg Res,2014,189(2):238-248.
[36] Chen M,Jiang L,Li Y, et al. Hydrogen protects against liver injury during CO_2 pneumoperitoneum in rats[J]. Oncotarget,2017,9(2):2631-2645.
[37] Al-Saeedi M, Nickkholgh A, Schultze D, et al. Glycine protects the liver from reperfusion injury following pneumoperitoneum[J].Eur Surg Res,2018,59(1/2):91-99.
[38] Bickel A,Loberant N, Bersudsky M, et al. Overcoming reduced hepatic and renal perfusion caused by positive-pressure pneumoperitoneumon[J]. Arch Surg,2007, 142(2):119-424.
[39] Veres TG,Takacs I, Nagy T,et al. Pneumoperitoneumon induced ischemia-reperfusi on injury of the peritoneum preconditioning may reduce the negative side-effects caused by carbon-dioxide pneumoperitoneumon-Pilot study[J]. Clin Hemorheol Microcirc,2018,69(4):481-488.
[40] Li SH,Deng J, Huang FT,et al. Impact of gasless laparoscopy on circulation, respiration, stress response, and other complications in gynecological geriatrics[J]. Int J Clin Exp Med,2014,7(9):2877-2882.
[2] Adam VN,Rasic Z, Mrsic V,et al. Effects of pneumoperitoneumon on liver function[J]. Lijec Vjesn,2010, 132(9/10):288-292.
[3] Sodha S,Nazarian S,Adshead JM,et al. Effect of pneumoperitoneumon on renal function and physiology in patients undergoing robotic renal surgery[J]. Curr Urol,2016,9(1):1-4.
[4] Dupont S, Schiffer ERC, White MJ, et al. Changes in hepatic blood flow and liver function during closed abdominal hyperthermic intraperitoneal chemotherapy following cytoreduction surgery[J].Gastroenterol Res Pract,2018,2018:8063097.
[5] Hoekstra LT, Ruys AT, Milstein DM, et al. Effects of prolonged pneumoperitoneumon on hepatic perfusion during laparoscopy[J].Ann Surg,2013,257(2):302-307.
[6] Liu Y, Cao W, Liu Y, et al. Changes in duration action of rocuronium following decrease in hepatic blood flow during pneumoperitoneumon for laparoscopic gynaecological surgery[J]. BMC Anesthesiol,2017,17(l):45.
[7] Antoniou EA,Kairi E,Margonis GA, et al. Effect of increased intra-abdominal pressure on liver histology and hemodynamics:An experimental study[J]. In Vivo,2018,32(1):85-91.
[8] Richter S,Olinger A,Hildebrandt U, et al. Loss of physiologic hepatic blood flow control("hepatic arterial buffer response")during CO_2 pneumoperitoneumon in the rat[J]. Anesth Analq,2001,93(4):872-877.
[9] Schafer M, Sagesser H, Reichen J, et al. Alterations in hemodynamics and hepatic and splanchnic circulation during laparoscopy in rats[J]. Surg Endosc,2001,15(10):1197-1201.
[10] Sala-Blanch X,Fontanals J, Martinez-Palli G,et al. Effects of carbon dioxide vs helium pneumoperitoneumon on hepatic blood flow[J].Surg Endosc, 1998,12(9):11214125.
[11] Shuto K, Kitano S, Yoshida T, et al. Hemodynamic and arterial blood gas change during carbon dioxide and helium pneumoperitoneumon in pigs[J]. Surg Endosc, 1995,9(11):11734178.
[12] Thomson IA, Fitch W, Hughes RL,et al. Effect of increased concentrations of carbon dioxide during halothane anaesthesia on liver blood flow and hepatic oxygen consumption[J]. Br J Anaesth,1983,55(12):1231-4237.
[13] Junghans T, Bohm B, Grundel K,et al. Does pneumoperitoneumon with different gases,body positions,and intraperitoneal pressures influence renal and hepatic blood flow[J]. Surgery,1997,121(2):206-211.
[14] Klopfenstein CE, Morel DR,Clergue F,et al. Effects of abdominal CO_2 insufflation and change of position on hepatic blood flow in anesthetized pigs[J]. Am J Physiol,1998,275(3 Pt 2):H900-905.
[15] Nickkholgh A, Barro-Bejarano M, Liang R,et al. Signs of reperfusion injury following CO_2 pneumoperitoneumon:an in vivo microscopy study[J]. Surg Endose,2008,22(1):1224 28.
[16] Kontoulis TM,Pissas DG,Pavlidis TE,et al. The oxidative effect of prolonged CO_2 pneumoperitoneumon:A comparative study in rats[J]. J Surg Res,2012,175(2):259-264.
[17] Goren 0, Matot I. Perioperative acute kidney injury[J]. Br J Anaesth,2015,115:ii3-ii14.
[18] Bishara B, Karram T, Khatib S, et al. Impact of pneumoperitoneumon on renal perfusion and excretory function:Beneficial effects of nitroglycerine[J]. Surg Endosc,2009,23(3):568-576.
[19] Wauters J, Claus P, Brosens N, et al. Pathophysiology of renal hemodynamics and renal cortical microcirculation in a porcine model of elevated intra-abdominal pressure[J]. J Trauma,2009,66(3):713-719.
[20] Wiesenthal JD,Fazio LM,Perks AE,et al. Effect of pneumoperitoneumon on renal tissue oxygenation and blood flow in a rat model[J].Urology,2011,77(6):1508.e9-45.
[21] Abassi Z, Bishara B, Karram T,et al. Adverse effects of pneumoperitoneumon on renal function:Involvement of the endothelin and nitric oxide systems[J]. Am J Physiol Requl Inteqr Comp Physiol,2008,294(3):R842-850.
[22] Khoury W, Weinbroum AA. Oxidants as important determinants of renal apoptosis during pneumoperitoneumon:A study in an isolated perfused rat kidney model[J]. Surg Endosc, 2012,26(5):1417-1424.
[23] Sun LY, Wijeysundera DN,Tait GA,et al. Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery[J]. Anesthesiology,2015(123):515-523.
[24] Bruintjes MH,van Helden EV, Braat AE,et al. Deep neuromuscular block to optimize surgical space conditions during laparoscopic surgery:A systematic review and meta-analysis[J]. Br J Anaesth.2017,118(6):834-842.
[25] Ge M,Chen H,Zhu Q,et al. Propofol post-conditioning alleviates hepatic ischaemia reperfusion injury via BRGl-mediated Nrf2/HO-1 transcriptional activation in human and mice[J]. J Cell Mol Med,2017,21(12):3693-3704.
[26] Xingwei X,Xin G,Peng Z,et al. Low-dose ketamine pretreatment reduces oxidative damage and inflammatory response following CO_2 pneumoperitoneum in rats[J]. Clin Invest Med,2014,37(3):E124.
[27]钟时,冯梅,蒋宗滨,等.长时间气腹下不同流量七氟烷对肾功能的影响[J].临床麻醉学杂志,2013,29(11):1082-1084.
[28] Kim ZG, Sanli E, Brinkmann L, et al. Impact of dopamine and endothelin-1 antagonism on portal venous blood flow during laparoscopic surgery[J]. Surg Endosc,2002,16(9):1292-1296.
[29] Agusti M, Elizalde Jl, Adalia R, et al. The effects of vasoactive drugs on hepatic blood flow changes induced by CO_2 laparoscopy:An animal study[J]. Anesth Analq,2001,93(5):1121-1126.
[30] Huh H, Kim NY, Park SJ, et al. Effect of nicardipine on renal function following robot-assisted laparoscopic radical prostatectomy in patients with pre-existing renal insufficiency[J]. J Int Med Res,2014,42(2):427-435.
[31] Ates E, Yilmaz S,Ihtiyar E,et al. Preconditioning-like amelioration of erythropoietin against laparoscopy-induced oxidative injury[J]. Surg Endose,2006,20(5):815-819.
[32] Cay A,Imamoglu M, Unsal MA,et al. Does anti-oxidant prophylaxis with melatonin prevent adverse outcomes related to increased oxidative stress caused by laparoscopy in experimental rat model?[J].J Surg Res,2006,135(1):2-8.
[33] Seguro AC,Polo de Figueiredo LF, Shimizu MH. N-acetylcysteine(NAC)protects against acute kidney injury(AKI)following prolonged pneumoperitoneumon in the rat[J]. J Surg Res, 2012,175(2):312-315.
[34] Bulbuloglu E, Yildiz H, Senoglu N, et al. Protective effects of zinc, pentoxifylline, and N-acetylcysteine in an animal model of laparoscopy induced ischemia/reperfusion injury of the small intestine[J]. J Laparoendosc Adv Surg Tech A,2011,21(10):947-951.
[35] Baltatzis M,Pavlidis TE, Ouroumidis O,et al. Aprotinin reduces oxidative stress induced by pneumoperitoneum in rats[J]. J Surg Res,2014,189(2):238-248.
[36] Chen M,Jiang L,Li Y, et al. Hydrogen protects against liver injury during CO_2 pneumoperitoneum in rats[J]. Oncotarget,2017,9(2):2631-2645.
[37] Al-Saeedi M, Nickkholgh A, Schultze D, et al. Glycine protects the liver from reperfusion injury following pneumoperitoneum[J].Eur Surg Res,2018,59(1/2):91-99.
[38] Bickel A,Loberant N, Bersudsky M, et al. Overcoming reduced hepatic and renal perfusion caused by positive-pressure pneumoperitoneumon[J]. Arch Surg,2007, 142(2):119-424.
[39] Veres TG,Takacs I, Nagy T,et al. Pneumoperitoneumon induced ischemia-reperfusi on injury of the peritoneum preconditioning may reduce the negative side-effects caused by carbon-dioxide pneumoperitoneumon-Pilot study[J]. Clin Hemorheol Microcirc,2018,69(4):481-488.
[40] Li SH,Deng J, Huang FT,et al. Impact of gasless laparoscopy on circulation, respiration, stress response, and other complications in gynecological geriatrics[J]. Int J Clin Exp Med,2014,7(9):2877-2882.