腹腔镜直肠癌根治术围手术期对机体应激、能量代谢及内脏蛋白的影响
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摘要
目的探讨腹腔镜与开腹直肠癌根治术围手术期C反应蛋白、能量代谢及血清内脏蛋白的差异。
方法将45例行直肠癌根治术患者按患者意愿分为腹腔镜组(n=20)和开腹组(n=25)，于术前、术后第1天、术后第2天、术后第3天晨检测血C反应蛋白(C-reactive protein，CRP)及内脏蛋白：白蛋白(Albumin，ALB)、前白蛋白(Prealbumin，PRE)、转铁蛋白(Transferrin，TRF)、视黄醇结合蛋白(Retinal-binding protein，RbP)的变化，同时应用间接能量测定仪测定静息能量消耗(Resting energy expenditure，REE)。
结果两组CRP在术后1、2、3 d均较术前明显升高(P＜0.01)，术后2 d达到峰值，腹腔镜组术后CRP明显低于开腹组(P＜0.01)。两组术后1、2、3 d REE亦较术前明显升高(P＜0.05，P＜0.01)，术后1、3 d腹腔镜组明显低于开腹组(P＜0.05)。ALB、PRE、TRF、RbP指标在两组术后均较术前有明显下降(P＜0.01)。术后1 d两组各指标无显著性差异(P＞0.05)；术后2 d腹腔镜组PRE明显高于开腹组(P＜0.05)；术后3 d腹腔镜组4种蛋白指标均明显高于开腹组(P＜0.01)。
结论腹腔镜直肠癌根治术较开腹手术创伤小，应激水平低，对机体能量代谢影响小，有利于机体能量代谢及血清内脏蛋白的恢复，但其同传统开腹手术均可导致术后早期血清内脏蛋白水平的显著下降。
Objective To compare the differences between laparoscopic-assisted and openresection of rectal carcinoma in respect of peri-operative levels of C-reactive protein(CRP)、rest energy expenditure (REE), and visceral proteins.
Methods According to patients' choice of operation, ether laparoscopic-assisted (n=20, Laparoscopic Group) or open (n=25, Open Group) resection of rectal carcinomawas performed. The levels of CRP and visceral proteins - including albumin(ALB),prealbumin(PRE), transferrin(TRF) and retinal-binding protein(RBP) - were assayedpreoperatively and on the 1st, 2nd and 3rd day postoperatively. The levels of REE werealso measured by indirect calorimetry in the morning.
Results Compared to the preoperative period, the CRP levels in both groups wereincreased significantly on the 1st, 2nd and 3rd day (P＜0.01) and peaked on the 2nd daypostoperatively. The postoperative CRP levels were significantly lower in theLaparoscopic Group than in the Open Group (P＜0.01). After operation, the REE levelswere significantly increased in both groups (P＜0.05, P＜0.01), with the responses in theLaparoscopic Group significantly lower than those in the Open Group on the 1st and 3rdday postoperatively (P＜0.05). The levels of ALB, PRE, TRF and RbP were significantlydecreased after operation in both groups (P＜0.01). There was no significant differencebetween the two groups in levels of ALB, PRE, TRF and RbP on the 1st postoperativeday (P＞0.05). The levels of PRE in the Laparoscopic group were significantly higher thanthose in the Open Group on the 2nd postoperative day (P＜0.05), and the levels of the fourproteins in the Laparoscopic Group were significantly higher than those in the OpenGroup on the 3rd postoperative day (P＜0.01).
Conclusions Laparoscopic-assisted resection of rectal carcinoma gives lower levelsof stress responses compared to open surgery, which benefits the restoration of energymetabolism and visceral proteins. However, both the laparoscopic and open operation can result in significant decrease in visceral proteins at early period postoperatively.
方法将45例行直肠癌根治术患者按患者意愿分为腹腔镜组(n=20)和开腹组(n=25)，于术前、术后第1天、术后第2天、术后第3天晨检测血C反应蛋白(C-reactive protein，CRP)及内脏蛋白：白蛋白(Albumin，ALB)、前白蛋白(Prealbumin，PRE)、转铁蛋白(Transferrin，TRF)、视黄醇结合蛋白(Retinal-binding protein，RbP)的变化，同时应用间接能量测定仪测定静息能量消耗(Resting energy expenditure，REE)。
结果两组CRP在术后1、2、3 d均较术前明显升高(P＜0.01)，术后2 d达到峰值，腹腔镜组术后CRP明显低于开腹组(P＜0.01)。两组术后1、2、3 d REE亦较术前明显升高(P＜0.05，P＜0.01)，术后1、3 d腹腔镜组明显低于开腹组(P＜0.05)。ALB、PRE、TRF、RbP指标在两组术后均较术前有明显下降(P＜0.01)。术后1 d两组各指标无显著性差异(P＞0.05)；术后2 d腹腔镜组PRE明显高于开腹组(P＜0.05)；术后3 d腹腔镜组4种蛋白指标均明显高于开腹组(P＜0.01)。
结论腹腔镜直肠癌根治术较开腹手术创伤小，应激水平低，对机体能量代谢影响小，有利于机体能量代谢及血清内脏蛋白的恢复，但其同传统开腹手术均可导致术后早期血清内脏蛋白水平的显著下降。
Objective To compare the differences between laparoscopic-assisted and openresection of rectal carcinoma in respect of peri-operative levels of C-reactive protein(CRP)、rest energy expenditure (REE), and visceral proteins.
Methods According to patients' choice of operation, ether laparoscopic-assisted (n=20, Laparoscopic Group) or open (n=25, Open Group) resection of rectal carcinomawas performed. The levels of CRP and visceral proteins - including albumin(ALB),prealbumin(PRE), transferrin(TRF) and retinal-binding protein(RBP) - were assayedpreoperatively and on the 1st, 2nd and 3rd day postoperatively. The levels of REE werealso measured by indirect calorimetry in the morning.
Results Compared to the preoperative period, the CRP levels in both groups wereincreased significantly on the 1st, 2nd and 3rd day (P＜0.01) and peaked on the 2nd daypostoperatively. The postoperative CRP levels were significantly lower in theLaparoscopic Group than in the Open Group (P＜0.01). After operation, the REE levelswere significantly increased in both groups (P＜0.05, P＜0.01), with the responses in theLaparoscopic Group significantly lower than those in the Open Group on the 1st and 3rdday postoperatively (P＜0.05). The levels of ALB, PRE, TRF and RbP were significantlydecreased after operation in both groups (P＜0.01). There was no significant differencebetween the two groups in levels of ALB, PRE, TRF and RbP on the 1st postoperativeday (P＞0.05). The levels of PRE in the Laparoscopic group were significantly higher thanthose in the Open Group on the 2nd postoperative day (P＜0.05), and the levels of the fourproteins in the Laparoscopic Group were significantly higher than those in the OpenGroup on the 3rd postoperative day (P＜0.01).
Conclusions Laparoscopic-assisted resection of rectal carcinoma gives lower levelsof stress responses compared to open surgery, which benefits the restoration of energymetabolism and visceral proteins. However, both the laparoscopic and open operation can result in significant decrease in visceral proteins at early period postoperatively.
引文
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34 Meierhenrich R, Gauss A, Vandenesch P, et al. The effects of intraabdominally insufflated carbon dioxide on hepatic blood flow during laparoscopic surgery assessed by transesophageal echocardiography. Anesth Analg. 2005 Feb; 100(2): 340-7.
35 Eleftheriadis E, Kotzampassi K, Papanotas K, et al. Gut ischemia, oxidative stress, and bacterial translocation in elevated abdominal pressure in rats. World J Surg. 1996 Jan; 20(1): 11-6.
36 Glerup H, Heindorff H, Flyvbjery A, et al. Elective laparoscopic cholecystectomy nearly abolished the postoperative hepatic catabolic stress response. Ann Surg, 1995, 221(3) : 214-221
37 Bistrian BR. A simple technique to estimate severity of stress. Surg Gynecol Obstet. 1979; 148(5): 675-8.
38 Cerra FB, Siegel JH, Border JR, et al. Correlations between metabolic and cardiopulmonary measurements in patients after trauma, general surgery, and sepsis. J Trauma. 1979;19(8) :621-9.
39 Birkhahn PH, Long CL, Fitkin D, et al. Effects of major skeletal trauma on whole body protein turnover in man measured by L-[1, 14C]-leucine. Surgery. 1980 Aug; 88 (2): 294-300.
40 Birkhahn RH, Long CL, Fitkin D, et al. Whole-body protein metabolism due to trauma in man as estimated by L-[15N]alanine. Am J Physiol. 1981 Jul; 241(1): E64-71.
41 Clowes GH Jr, Randall HT, Cha CJ. Amino acid and energy metabolism in septic and traumatized patients. JPEN J Parenter Enteral Nutr. 1980 Mar-Apr; 4(2): 195-205.
42 Crane CW, Picou D, Smith R, et al. Protein turnover in patients before and after elective orthopaedic operations. Br J Surg. 1977 Feb; 64(2): 129-33.
43 Hill GL, Douglas RG, Schroeder D. Metabolic basis for the management of patients undergoing major surgery. World J Surg. 1993 Mar-Apr; 17(2): 146-53.
44 PerlmutterDH, Dinarello CA, Punsal PI, et al. Cachectin/tumor necrosis factor regulates hepatic acute-phase gene expression. J Clin Invest. 1986 Nov;78(5):1349-54.
45 秦环龙．外科严重创伤时的代谢改变及营养支持[J]．肠外与肠内营养，1999，6(1)：41～46．
46 唐爱华．营养状况评价的新指标．国外医学临床生物化学与检验学分册，1995，16(6)：272-273．
47 陈焕伟，甄作均，潘文松．血清前白蛋白和视黄醇结合蛋白在胃肠疾病患者在营养治疗评定中的临床研究[J]．中华胃肠外科杂志，2001，4(2)：122～123．
48 徐建海，文怡，桑剑峰．胃肠肿瘤患者化疗的营养评价指标研究．右江医学，2002，30(4)：323-324。
49 Essen P, Thorell A, McNurlan MA, et al. Laparoscopic cholecystectomy does not prevent the postoperative protein catabolic response in muscle. Ann Surg. 1995 Jul; 222(1): 36-42.
50 Targarona EM, Ports MJ, Balague C, et al. Acute phase is the only significantly reduced component of the injury response after laparoscopic cholecystectomy. World J Surg. 1996 Jun; 20(5):528-33; discussion 533-4.
51 Senagore AJ, Kilbride MJ, Luchtefeld MA, et al. Superior nitrogen balance after laparoscopic-assisted colectomy. Ann Surg. 1995;221(2):171-175.
52 Kaplan AS, Zemel BS, Neiswender KM, et al. Resting energy expenditure in clinical pediatrics: measured versus prediction equations. J Pediatr. 1995;127(2):200-5.
53 Bodamer OA, Hoffmann GF, Visser GH, et al. Assessment of energy expenditure in metabolic disorders. Eur J Pediatr. 1997;156 (Suppl 1): S24-8.
54 Flancbaum L, Choban PS, Sambucco S, et al. Comparison of indirect calorimetry, the Fick method, and prediction equations in estimating the energy requirements of critically ill patients. Am J Clin Nutr. 1999; 69(3): 461-6.
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28 Nguyen NT, Goldman CD, Ho HS, et al. Systemic stress response after laparoscopic and open gastric bypass. J Am Coll Surg. 2002 May;194(5):557-66; discussion 566-567.
29 Malik E, Buchweitz O, Muller-Steinhardt M, et al. Prospective evaluation of the systemic immune response following abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy. Surg Endosc. 2001 May;15(5):463-466.
30 Leung KL, Lai PB, Ho RL, et al. Systemic cytokine response after laparoscopic-assisted resection of rectosigmoid carcinoma:A prospective randomized trial. Ann Surg, 2000, 231(4):506-511.
31 Mehigan BJ, Hartley JE, Drew PJ, et al. Changes in T cell subsets, interleukin-6 and C-reactive protein after laparoscopic and open colorectal resection for malignancy. Surg Endosc, 2001, 15(11):1289-1293.
32 Kaplan AS, Zemel BS, Neiswender KM, et al. Resting energy expenditure in clinical pediatrics: measured versus prediction equations. J Pediatr. 1995;127(2):200-205.
33 Bodamer OA, Hoffmann GF, Visser GH, et al. Assessment of energy expenditure in metabolic disorders. Eur J Pediatr. 1997;156 (Suppl 1):S24-S28.
34 Flancbaum L, Choban PS, Sambucco S, et al. Comparison of indirect calorimetry, the Fick method, and prediction equations in estimating the energy requirements of critically ill patients. Am J Clin Nutr. 1999:69(3):461-466.
35 任建安，黎介寿，刘放南，等．能量代谢监测指导外科病人合理营养支持的研究．肠外与肠内营养，1994，1(1)：26-30．
36 Aliprandi G, Bissolotti L, Turla D, et al. The use of REE determination in a clinical setting applied to respiratory disease. Acta Diabetol. 2001; 38(1): 27-30.
37 Reid CL. Nutritional requirements of surgical and critically-ill patients: do we really know what they need? Proc Nutr Soc. 2004 Aug;63(3):467-472.
38 施章时。中等手术创伤对能量代谢的影响．肠外与肠内营养，1997，4(3)：141-143
39 黄德骧，欧军海，吴国豪．我国健康人和外科住院患者的静息能量消耗[J]。中国临床营养杂志，1994，2(1)：3-6。
40 叶古祥，汤昊，曾和平，围手术期静息能量消耗测定的意义[J]。中国临床营养杂志，1997，5(3)：134-136。
41 罗开，黎介寿，李令堂，等．腹腔镜胆囊切除围手术期应激、酸碱平衡和能量代谢．中华外科杂志，2002，40(12)：923-926．
42 李康华，刘文和，王斌，等．膝关节微创外科围手术期应激反应．医师进修杂志．2005：28(1)：12-14．
43 刘文和，李康华，陈立科，等．腰椎间盘微创外科围手术期应激反应．湘南学院学报(自然科学版)，2004；6(3)：1-3．
44 Bistrian BR. A simple technique to estimate severity of stress. Surg Gynecol Obstet. 1979; 148(5): 675-678.
45 Cerra FB, Siegel JH, Border JR, et al. Correlations between metabolic and cardiopulmonary measurements in patients after trauma, general surgery, and sepsis. J Trauma. 1979;19(8):621-629.
46 Birkhahn RH, Long CL, Fitkin D, et al. Effects of major skeletal trauma on whole body protein turnover in man measured by g-[1,14C]-leucine. Surgery. 1980 Aug;88(2):294-300.
47 Birkhahn RH, Long CL, Fitkin D, et al. Whole-body protein metabolism due to trauma in man as estimated by L-[15N]alanine. Am J Physiol. 1981 Jul; 241(1): E64-E71.
48 Clowes GH Jr, Randall HT, Cha CJ. Amino acid and energy metabolism in septic and traumatized patients. JPEN J Parenter Enteral Nutr. 1980 Mar-Apr;4(2):195-205.
49 Crane CW, Picou D, Smith R, et al. Protein turnover in patients before and after elective orthopaedic operations. Br J Surg. 1977 Feb;64(2):129-133.
50 Hill GL, Douglas RG, Schroeder D. Metabolic basis for the management of patients undergoing major surgery. World J Surg. 1993 Mar-Apr;17(2):146-153.
51 Perlmutter OH, Dinarello CA, Punsal PI, et al. Cachectin/tumor necrosis factor regulates hepatic acute-phase gene expression. J Clin Invest. 1986 Nov: 78(5):1349-1354.
52 秦环龙．外科严重创伤时的代谢改变及营养支持[J]．肠外与肠内营养，1999，6(1)：41-46．
53 吴国豪，刘中华，郑烈伟，等．普外科住院患者营养状况评价及预后分析．中华外科杂志，2005，43(11)：693-696．
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55 陈焕伟，甄作均，潘文松．血清前白蛋白和视黄醇结合蛋白在胃肠疾病患者在营养治疗评定中的临床研究[J]．中华胃肠外科杂志，2001，4(2)：122-123．
56 徐建海，文怡，桑剑峰．胃肠肿瘤患者化疗的营养评价指标研究．右江医学，2002，30(4)：323-324．
57 Essen P, Thorell A, McNurlan MA, et al. Laparoscopic cholecystectomy does not prevent the postoperative protein catabolic response in muscle. Ann Surg. 1995 Jul; 222(1): 36-42.
58 Nguyen NT, Braley S, Fleming NW, et al. Comparison of postoperative hepatic function after laparoscopic versus open gastric bypass. Am J Surg. 2003 Jul; 186(1): 40-44.
59 Targarona EM, Pons MJ, Balague C, et al. Acute phase is the only significantly reduced component of the injury response after laparoscopic cholecystectomy. World J Surg. 1996 Jun;20(5):528-33; discussion 533-534.
60 Senagore AJ, Kitbride MJ, Luchtefeld MA, et al. Superior nitrogen balance after laparoscopic-assisted colectomy. Ann Surg, 1995,221(2): 171-175.
61 Kasparek MS, Muller MH, Glatzle J, et al. Postoperative colonic motility in patients following laparoscopic-assisted and open sigmoid colectomy. J gastrointest Surg, 2003,7(8):1073-1081.
62 高羽，张连阳，刘宝华，等。腹腔镜结直肠癌根治术后胃肠运动与血清胃肠激素的变化．第三军医大学学报，2006，28(6)：598-600．
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3 Demirer S, Karadayi K, Simsek S, et al. Comparison of postoperative acute-phase reactants in patients who underwent laparoscopic v open cholecystectomy: a randomized study. J Laparoendosc Adv Surg Tech A. 2000 Oct;10(5):249-52.
4 SchietromaM, Carlei F, Lezoche E, et al. Evaluation of immune response in patients after open or laparoscopic cbolecystectomy. Hepatogastroenterology. 2001 May-Jun;48(39):642-6.
5 Janicki K, Bicki J, Radzikowska E, et al. C-reactive protein (CRP) as a response to postoperative stress in laparoscopic cholecystectomy using the abdominal wall lift, with performed pneumoperitoneum (CO2), and in open cholecystectomy. Ann Univ Mariae Curie Sklodowska [Med]. 2001;56:397-402.
6 Grande M, Tucci GF, Adorisio O, et al. Systemic acute-phase response after laparoscopic and open cholecystectomy. Surg Endosc. 2002 Feb;16(2):313-6.
7 Nguyen NT, Goldman CD, Ho HS, et al. Systemic stress response after laparoscopic and open gastric bypass. J Am Coll Surg. 2002 May;194(5):557-66; discussion 566-7.
8 Malik E, Buchweitz O, Muller-Steinhardt M, et al. Prospective evaluation of the systemic immune response following abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy. Surg Endosc. 2001 May;15(5):463-6.
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32 Gutt CN, Schmedt CG, Schmandra T, et al. Insufflation profile and body position influance portal venous blood flow during pneumoperitoneum. Surg Endosc. 2003 Dec; 17 (12): 1951-7.
33 Diebel LN, Wilson RF, Dulchavsky SA, et al. Effect of increased intra-abdominal pressure on hepatic arterial, portal venous, and hepatic microcirculatory blood flow. J Trauma. 1992 Aug;33(2):279-82; discussion 282-3.
34 Meierhenrich R, Gauss A, Vandenesch P, et al. The effects of intraabdominally insufflated carbon dioxide on hepatic blood flow during laparoscopic surgery assessed by transesophageal echocardiography. Anesth Analg. 2005 Feb; 100(2): 340-7.
35 Eleftheriadis E, Kotzampassi K, Papanotas K, et al. Gut ischemia, oxidative stress, and bacterial translocation in elevated abdominal pressure in rats. World J Surg. 1996 Jan; 20(1): 11-6.
36 Glerup H, Heindorff H, Flyvbjery A, et al. Elective laparoscopic cholecystectomy nearly abolished the postoperative hepatic catabolic stress response. Ann Surg, 1995, 221(3) : 214-221
37 Bistrian BR. A simple technique to estimate severity of stress. Surg Gynecol Obstet. 1979; 148(5): 675-8.
38 Cerra FB, Siegel JH, Border JR, et al. Correlations between metabolic and cardiopulmonary measurements in patients after trauma, general surgery, and sepsis. J Trauma. 1979;19(8) :621-9.
39 Birkhahn PH, Long CL, Fitkin D, et al. Effects of major skeletal trauma on whole body protein turnover in man measured by L-[1, 14C]-leucine. Surgery. 1980 Aug; 88 (2): 294-300.
40 Birkhahn RH, Long CL, Fitkin D, et al. Whole-body protein metabolism due to trauma in man as estimated by L-[15N]alanine. Am J Physiol. 1981 Jul; 241(1): E64-71.
41 Clowes GH Jr, Randall HT, Cha CJ. Amino acid and energy metabolism in septic and traumatized patients. JPEN J Parenter Enteral Nutr. 1980 Mar-Apr; 4(2): 195-205.
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