腹腔镜下保留神经手术联合GnRH-a治疗深部浸润型子宫内膜异位症的疗效分析
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摘要
目的:探讨腹腔镜下保留神经手术联合促性腺释放激素激动剂(GnRH-a)治疗深部浸润型子宫内膜异位症(DIE)的临床疗效及机制。方法:将88例DIE患者随机分为观察组与对照组,每组44例。两组均行腹腔镜下保留神经手术治疗,观察组术后应用GnRH-a,对照组术后应用孕三烯酮。比较两组临床疗效、并发症、复发率及血清糖类抗原199(CA199)、基质金属蛋白酶-9 (MMP-9)、基质金属蛋白酶抑制剂-1(TIMP-1)和Th1/Th2细胞因子水平。结果 :术后6个月,观察组血清CA199、MMP-9、MMP-9/TIMP-1、白介素(IL)-4、IL-6、IL-10均显著低于对照组,TIMP-1、γ干扰素(IFN-γ)、IL-2均明显高于对照组(均P<0.05)。术后3个月、6个月、12个月,观察组疼痛视觉模拟量表(VAS)评分显著低于对照组(P<0.05)。两组治疗总有效率比较,差异无统计学意义(97.62%vs 90.24%,P>0.05),但观察组治愈率显著高于对照组(78.57%vs.53.66%,P<0.05)。观察组复发率显著低于对照组(4.88%vs.21.62%,P<0.05),妊娠率显著高于对照组(44.44%vs.20.00%,P<0.05)。结论:腹腔镜下保留神经手术联合GnRH-a治疗DIE安全、有效,能够降低复发率,其机制可能与调节Th1/Th2细胞平衡和MMP-9/TIMP-1平衡有关。
Objective:To investigate the clinical efficacy and mechanism of laparoscopic nervesparing surgery combined with GnRH-a for the treatment of deeply infiltrated endometriosis(DIE).Methods:A total of 88 patients with DIE were randomly divided into an observation group and a control group,with 44 cases in each group.All patients received laparoscopic nervesparing surgery.The patients in the observation group were treated with GnRH-a after surgery,and those in the control group were treated with gestrinone after surgery.The clinical efficacy,the incidence of complications and the recurrence rate were compared between the two groups.The serum CA199,TIMP-1,MMP-9 and Th1/Th2 cytokines levels were measured before and after surgery.Results:After 6 months of surgery,the serum levels of CA199,MMP-9,MMP-9/TIMP-1,IL-4,IL-6 and IL-10 in the observation group were significantly lower than those in the control group,while the levels of TIMP-1,IFN-γand IL-2 were significantly higher(P<0.05).3,6 and 12 months after surgery,the VAS score in the observation group was notably lower than that in the control group(P<0.05).There was no significant difference in the total effective rate between the two groups(97.62%vs.90.24%,P>0.05),but the cure rate was statistically significant(78.57%vs.53.66%,P<0.05).The recurrence rate in the observation group was significantly lower than that in the control group(4.88%vs.21.62%,P<0.05),and the pregnancy rate was significantly higher(44.44%vs.20.00%,P<0.05).Conclusion:Laparoscopic nerves paring surgery combined with GnRH-a was safe and effective for DIE,which could reduce the recurrence rate.The mechanism might be related to the regulation of Th1/Th2 and MMP-9/TIMP-1 balance.
Objective:To investigate the clinical efficacy and mechanism of laparoscopic nervesparing surgery combined with GnRH-a for the treatment of deeply infiltrated endometriosis(DIE).Methods:A total of 88 patients with DIE were randomly divided into an observation group and a control group,with 44 cases in each group.All patients received laparoscopic nervesparing surgery.The patients in the observation group were treated with GnRH-a after surgery,and those in the control group were treated with gestrinone after surgery.The clinical efficacy,the incidence of complications and the recurrence rate were compared between the two groups.The serum CA199,TIMP-1,MMP-9 and Th1/Th2 cytokines levels were measured before and after surgery.Results:After 6 months of surgery,the serum levels of CA199,MMP-9,MMP-9/TIMP-1,IL-4,IL-6 and IL-10 in the observation group were significantly lower than those in the control group,while the levels of TIMP-1,IFN-γand IL-2 were significantly higher(P<0.05).3,6 and 12 months after surgery,the VAS score in the observation group was notably lower than that in the control group(P<0.05).There was no significant difference in the total effective rate between the two groups(97.62%vs.90.24%,P>0.05),but the cure rate was statistically significant(78.57%vs.53.66%,P<0.05).The recurrence rate in the observation group was significantly lower than that in the control group(4.88%vs.21.62%,P<0.05),and the pregnancy rate was significantly higher(44.44%vs.20.00%,P<0.05).Conclusion:Laparoscopic nerves paring surgery combined with GnRH-a was safe and effective for DIE,which could reduce the recurrence rate.The mechanism might be related to the regulation of Th1/Th2 and MMP-9/TIMP-1 balance.
引文
[1]余贵媛,金平.深部浸润型子宫内膜异位症的治疗研究新进展[J].国际妇产科学杂志,2017,44(5):585-588.
[2] FERRERO S,ALESSANDRI F,RACCA A,et al.Treatment of pain associated with deep endometriosis:alternatives and evidence[J].Fertil Steril,2015,104(4):771-792.
[3]李莉.保留神经的腹腔镜手术治疗在深部浸润型子宫内膜异位症的临床应用[J].中国妇幼卫生杂志,2016,7(2):75-76,82.
[4]中华医学会妇产科学分会子宫内膜异位症协作组.子宫内膜异位症的诊断与治疗规范[J].中华妇产科杂志,2007,42(9):645-648.
[5]黄清.腹腔镜手术联合曲普瑞林治疗卵巢子宫内膜异位症88例[J].广西医科大学学报,2014,31(2):311-313.
[6] CAO Q,LU F,FENG W W,et al.Comparison of complete and incomplete excision of deep infiltrating endometriosis[J].Int J Clin Exp Med,2015,8(11):21497-21506.
[7] ANGIONI S,PONTIS A,DESSOLE M,et al.Pain control and quality of life after laparoscopic en-block resection of deep infiltrating endometriosis(DIE)vs Incomplete surgical treatment with or without GnRH-a administration after surgery[J].Arch Gynecol Obstet,2015,291(2):363-370.
[8]李抗旱,王云.腹腔镜手术分别联合GnRH-a与孕三烯酮治疗子宫内膜异位症的临床效果分析[J].中国计划生育学杂志,2015,23(4):261-263.
[9] TARJANNE S,NG C H,MANCONI F,et al.Use of hormonal therapy is associated with reduced nerve fiber density in deep infiltrating,rectovaginal endometriosis[J].Acta Obstet Gynecol Scand,2015,94(7):693-700.
[10]陈丹,张辉.促性腺激素释放激素激动剂对深部浸润型子宫内膜异位症患者生育功能的影响[J].中国妇幼保健,2018(1):145-147.
[11]张金风,蒋楠.Th亚群在子宫内膜异位症发病中的作用研究[J].中国妇幼保健,2016,31(15):3155-3157.
[12]DE ANDRADE V T,NACUL A P,DOS SANTOS B R,et al.Circulating and peritoneal fluid interleukin-6levels and gene expression in pelvic endometriosis[J].Exp Ther Med,2017,14(3):2317-2322.
[13]杨晓琼,杜小琴.腹腔镜手术联合戈舍瑞林治疗子宫内膜异位症合并不孕症的疗效及对血清MMP-9、TIMP-1水平的影响[J].中国妇幼保健,2017,32(18):4486-4489.
[14]范玉香.MMP及TIMP在子宫内膜异位症中的表达[J].贵州医科大学学报,2016,41(2):238-241.
[15]易旺军,贾玉芳.腹腔镜手术联合GnRH-a对子宫内膜异位症性不孕患者血清β-EP、TGF-β1、MMP、TIMP及Th1/Th2的影响[J].四川医学,2013,34(11):1711-1712.
[2] FERRERO S,ALESSANDRI F,RACCA A,et al.Treatment of pain associated with deep endometriosis:alternatives and evidence[J].Fertil Steril,2015,104(4):771-792.
[3]李莉.保留神经的腹腔镜手术治疗在深部浸润型子宫内膜异位症的临床应用[J].中国妇幼卫生杂志,2016,7(2):75-76,82.
[4]中华医学会妇产科学分会子宫内膜异位症协作组.子宫内膜异位症的诊断与治疗规范[J].中华妇产科杂志,2007,42(9):645-648.
[5]黄清.腹腔镜手术联合曲普瑞林治疗卵巢子宫内膜异位症88例[J].广西医科大学学报,2014,31(2):311-313.
[6] CAO Q,LU F,FENG W W,et al.Comparison of complete and incomplete excision of deep infiltrating endometriosis[J].Int J Clin Exp Med,2015,8(11):21497-21506.
[7] ANGIONI S,PONTIS A,DESSOLE M,et al.Pain control and quality of life after laparoscopic en-block resection of deep infiltrating endometriosis(DIE)vs Incomplete surgical treatment with or without GnRH-a administration after surgery[J].Arch Gynecol Obstet,2015,291(2):363-370.
[8]李抗旱,王云.腹腔镜手术分别联合GnRH-a与孕三烯酮治疗子宫内膜异位症的临床效果分析[J].中国计划生育学杂志,2015,23(4):261-263.
[9] TARJANNE S,NG C H,MANCONI F,et al.Use of hormonal therapy is associated with reduced nerve fiber density in deep infiltrating,rectovaginal endometriosis[J].Acta Obstet Gynecol Scand,2015,94(7):693-700.
[10]陈丹,张辉.促性腺激素释放激素激动剂对深部浸润型子宫内膜异位症患者生育功能的影响[J].中国妇幼保健,2018(1):145-147.
[11]张金风,蒋楠.Th亚群在子宫内膜异位症发病中的作用研究[J].中国妇幼保健,2016,31(15):3155-3157.
[12]DE ANDRADE V T,NACUL A P,DOS SANTOS B R,et al.Circulating and peritoneal fluid interleukin-6levels and gene expression in pelvic endometriosis[J].Exp Ther Med,2017,14(3):2317-2322.
[13]杨晓琼,杜小琴.腹腔镜手术联合戈舍瑞林治疗子宫内膜异位症合并不孕症的疗效及对血清MMP-9、TIMP-1水平的影响[J].中国妇幼保健,2017,32(18):4486-4489.
[14]范玉香.MMP及TIMP在子宫内膜异位症中的表达[J].贵州医科大学学报,2016,41(2):238-241.
[15]易旺军,贾玉芳.腹腔镜手术联合GnRH-a对子宫内膜异位症性不孕患者血清β-EP、TGF-β1、MMP、TIMP及Th1/Th2的影响[J].四川医学,2013,34(11):1711-1712.