围术期胰岛素抵抗与肝胆胰手术创伤程度的关系
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摘要
目的探讨围术期胰岛素抵抗与手术创伤程度的关系。方法选取2014年1月-2015年12月于张北县医院实施肝胆胰手术治疗的186例患者作为研究对象,采用生理学和手术严重程度评分系统(POSSUM评分系统)对每位患者进行手术创伤程度评分。根据评分,将入组病例分为轻度创伤组(OSS≤7分),中度创伤组(OSS 8~10分)以及重度创伤组(OSS>10分)。比较3组间术前一般情况、体质量指数(body mass index,BMI)、PS评分及手术前后胰岛素敏感性(insulin sensitivity,IS)的差异。结果三组年龄、性别、BMI等术前一般资料差异无统计学意义(P>0.05);3组的手术创伤程度评分分别为(9.6±1.7)分、(12.4±2.3)分及(16.3±2.8)分,差异有统计学意义(P<0.01)。三组术后胰岛素敏感性均降低,并在术后24 h左右降到最低值,其中C组下降26.2%,显著高于A组、B组的13.4%、15.1%(P<0.01);此外,A组和B组的IS均于术后第7天恢复至术前水平,而C组IS在术后第7天仍未恢复到术前水平(P<0.01)。结论胰岛素抵抗一般在术后24 h左右达到高峰,随着患者的恢复逐渐至正常;随着手术创伤程度的增大,胰岛素抵抗的持续时间也随之延长。
Objective To explore the relationship between perioperative insulin resistance and hepatobiliary & pancreatic surgical trauma. Methods Total of 186 patients underwent hepatobiliary & pancreatic surgery in our department between January 2014 and December 2015 were enrolled and divided into 3 groups according to the POSSUM scoring system:mild trauma group(OSS≤7),moderate trauma group(OSS = 8-10) and severe trauma group(OSS>10). The patients' preoperative general characteristics,physiological scores and insulin sensitivity at different time points between three groups were analyzed and compared. Results No significant difference was found in patients' age,gender,BMI index and preoperative physiological scores between the three groups. The surgical trauma scores were 9.6±1.7 in mild trauma group,12.4±2.3 in moderate trauma group and 16.3±2.8 in severe trauma group,and the difference between each group was statistically significant(P <0.01,respectively). Insulin sensitivity decreased in three groups,and nadir occurred at 24 h after operation. It decreased by 26.2% in group C,which was significantly higher than 13.4% in group A and 15.1% in group B(P <0.01,respectively). In addition,the insulin sensitivity level returned to the preoperative level in group A and group B at 7th day after operation,while no same trend showed in group C,and the difference was statistically significant(P <0.01,respectively). Conclusion Insulin resistance degree is positively correlated with the surgical trauma severity. The insulin resistance peaks at 24 h after operation,then returns to normal with patients' recovery. The duration of insulin resistance extends with the increasing of surgical trauma severity.
Objective To explore the relationship between perioperative insulin resistance and hepatobiliary & pancreatic surgical trauma. Methods Total of 186 patients underwent hepatobiliary & pancreatic surgery in our department between January 2014 and December 2015 were enrolled and divided into 3 groups according to the POSSUM scoring system:mild trauma group(OSS≤7),moderate trauma group(OSS = 8-10) and severe trauma group(OSS>10). The patients' preoperative general characteristics,physiological scores and insulin sensitivity at different time points between three groups were analyzed and compared. Results No significant difference was found in patients' age,gender,BMI index and preoperative physiological scores between the three groups. The surgical trauma scores were 9.6±1.7 in mild trauma group,12.4±2.3 in moderate trauma group and 16.3±2.8 in severe trauma group,and the difference between each group was statistically significant(P <0.01,respectively). Insulin sensitivity decreased in three groups,and nadir occurred at 24 h after operation. It decreased by 26.2% in group C,which was significantly higher than 13.4% in group A and 15.1% in group B(P <0.01,respectively). In addition,the insulin sensitivity level returned to the preoperative level in group A and group B at 7th day after operation,while no same trend showed in group C,and the difference was statistically significant(P <0.01,respectively). Conclusion Insulin resistance degree is positively correlated with the surgical trauma severity. The insulin resistance peaks at 24 h after operation,then returns to normal with patients' recovery. The duration of insulin resistance extends with the increasing of surgical trauma severity.
引文
1陈俊勇,程黎阳.快速康复外科防治术后胰岛素抵抗的作用及机制[J].实用医学杂志,2013,29(1):12-14.
2 Awad S,Constantin-Teodosiu D,Constantin D,et al.Cellular mechanisms underlying the protective effects of preoperative feeding:a randomized study investigating muscle and liver glycogen content,mitochondrial function,gene and protein expression[J].Ann Surg,2010,252(2):247-253.
3 Mathur S,Plank LD,Mc Call JL,et al.Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery[J].Br J Surg,2010,97(4):485-494.
4 张迪,车向明,李海军,等.普通外科择期手术后胰岛素抵抗的临床研究[J].中国普外基础与临床杂志,2010,17(9):951-954.
5 陈宏,李非,贾建国,等.择期腹部手术后胰岛素抵抗相关因素研究[J].中国实用外科杂志,2009,(5):428-430.
6 萧丽军,缪珩,吴小梅,等.2型糖尿病患者胰岛素抵抗与体表测量指数的相关性分析[J].现代医学,2012,40(5):541-545.
7 汪晓东,方智,李姣,等.POSSUM评分系统在外科手术中的应用现状[J].重庆医学,2008,37(15):1747-1749.
8 曹相原,王晓红,马少林,等.应激性高糖血症与胰岛素抵抗的相关因素研究[J].中国危重病急救医学,2006,18(12):751-754.
9 Wang ZG,Wang Q,Wang WJ,et al.Randomized clinical trial to compare the effects of preoperative oral carbohydrate versus placebo on insulin resistance after colorectal surgery[J].Br J Surg,2010,97(3):317-327.
10 刘伟,苏跃,田鸣,等.不同麻醉和镇痛方法对胸科手术胰岛素抵抗及相关因素影响的研究[J].国际麻醉学与复苏杂志,2011,32(1):32-35.
11 卢冠铭,李天资.创伤应激反应与胰岛素抵抗关系的研究进展[J].中西医结合心脑血管病杂志,2013,11(2):213-214.
12 黄勇,朱宣进,刘建伟.腹腔镜与开腹结直肠癌根治术对患者围手术期胰岛素抵抗的影响[J].实用医学杂志,2015,(9):1508-1510.
13 王健,王晓晖,邸墅,等.危重症患者发生应激性高血糖症的相关因素及其对患者预后的影响[J].临床荟萃,2012,27(3):238-239.
14 De Fronzo RA,Tobin JD,Andres R.Glucose clamp technique:a method for quantifying insulin secretion and resistance[J].Am J Physiol,1979,237(3):E214-E223.
15 孟涛,王飞,张茜,等.POSSUM评分系统预测高龄食管胃结合部腺癌术后并发症风险的临床应用研究[J].中国全科医学,2012,15(23):2626-2628.
16 Pratt W,Joseph S,Callery MP,et al.POSSUM accurately predicts morbidity for pancreatic resection[J].Surgery,2008,143(1):8-19.
17 田伯乐,张肇达,刘续宝,等.POSSUM评分系统预测胰十二指肠切除术手术风险的价值[J].中华外科杂志,2009,47(11):814-817.
18 Monzillo LU,Hamdy O.Evaluation of insulin sensitivity in clinical practice and in research settings[J].Nutr Rev,2003,61(12):397-412.
19 Carlson GL.Insulin resistance in sepsis[J].Br J Surg,2003,90(3):259-260.
2 Awad S,Constantin-Teodosiu D,Constantin D,et al.Cellular mechanisms underlying the protective effects of preoperative feeding:a randomized study investigating muscle and liver glycogen content,mitochondrial function,gene and protein expression[J].Ann Surg,2010,252(2):247-253.
3 Mathur S,Plank LD,Mc Call JL,et al.Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery[J].Br J Surg,2010,97(4):485-494.
4 张迪,车向明,李海军,等.普通外科择期手术后胰岛素抵抗的临床研究[J].中国普外基础与临床杂志,2010,17(9):951-954.
5 陈宏,李非,贾建国,等.择期腹部手术后胰岛素抵抗相关因素研究[J].中国实用外科杂志,2009,(5):428-430.
6 萧丽军,缪珩,吴小梅,等.2型糖尿病患者胰岛素抵抗与体表测量指数的相关性分析[J].现代医学,2012,40(5):541-545.
7 汪晓东,方智,李姣,等.POSSUM评分系统在外科手术中的应用现状[J].重庆医学,2008,37(15):1747-1749.
8 曹相原,王晓红,马少林,等.应激性高糖血症与胰岛素抵抗的相关因素研究[J].中国危重病急救医学,2006,18(12):751-754.
9 Wang ZG,Wang Q,Wang WJ,et al.Randomized clinical trial to compare the effects of preoperative oral carbohydrate versus placebo on insulin resistance after colorectal surgery[J].Br J Surg,2010,97(3):317-327.
10 刘伟,苏跃,田鸣,等.不同麻醉和镇痛方法对胸科手术胰岛素抵抗及相关因素影响的研究[J].国际麻醉学与复苏杂志,2011,32(1):32-35.
11 卢冠铭,李天资.创伤应激反应与胰岛素抵抗关系的研究进展[J].中西医结合心脑血管病杂志,2013,11(2):213-214.
12 黄勇,朱宣进,刘建伟.腹腔镜与开腹结直肠癌根治术对患者围手术期胰岛素抵抗的影响[J].实用医学杂志,2015,(9):1508-1510.
13 王健,王晓晖,邸墅,等.危重症患者发生应激性高血糖症的相关因素及其对患者预后的影响[J].临床荟萃,2012,27(3):238-239.
14 De Fronzo RA,Tobin JD,Andres R.Glucose clamp technique:a method for quantifying insulin secretion and resistance[J].Am J Physiol,1979,237(3):E214-E223.
15 孟涛,王飞,张茜,等.POSSUM评分系统预测高龄食管胃结合部腺癌术后并发症风险的临床应用研究[J].中国全科医学,2012,15(23):2626-2628.
16 Pratt W,Joseph S,Callery MP,et al.POSSUM accurately predicts morbidity for pancreatic resection[J].Surgery,2008,143(1):8-19.
17 田伯乐,张肇达,刘续宝,等.POSSUM评分系统预测胰十二指肠切除术手术风险的价值[J].中华外科杂志,2009,47(11):814-817.
18 Monzillo LU,Hamdy O.Evaluation of insulin sensitivity in clinical practice and in research settings[J].Nutr Rev,2003,61(12):397-412.
19 Carlson GL.Insulin resistance in sepsis[J].Br J Surg,2003,90(3):259-260.