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1、腹腔镜下胃癌根治术对患者PT、INR和TNFa变化情况分析【摘要】目的：分析腹腔镜下胃癌根治术对患者的凝血酶原时间(PT)、凝血酶原国际标准化 值(INR)和肿瘤坏死因子(TNF-a )水平变化情况的影响。方法：选取来我院就诊胃癌患者 98例，其中选取50例进行腹腔镜下胃癌根治术作为观察组，选取48例进行开腹手术作为对 照组，分别检测两组患者手术前和手术后24h的血PT、INR和TNF-a结果，比较两组术前术 后上述三个指标的变化。结果:两组患者比较手术前PT值(12.680.73)s vs (12.330.71 )s 差异没有统计学意义(P0.05),而两组患者术后24h的PT值(11.29
2、0.62)s vs(11.480.61)s 均比手术前PT (12.680.73)s vs (12.330.71 )s明显缩短(p0.05 ),且腹腔镜组 (11.290.62)s与对照组(11.480.61)s比较具有统计学意义(p0.05),两组患者分别比较术前术后的INR数值差异也没有统计学意义(p0.05)o手 术前两组患者血清 TNF-a (189.5826.33)pg/mL vs (170.21 24.27)pg/mL水平无明显差异(p0.05),而术后 24h 两组患者的血清 TNF-a (248.27 25.26)pg/mL vs (341.2122.46)pg/mL 均较手术
3、前 TNF-a (189.5826.33)pg/mL vs (170.21 24.27)pg/mL明显增高(p0.05),且对 照组(341.2122.46)pg/mL 明显高于腹腔镜组(248.27 25.26)pg/mL (p0.05), while the PT values of the two groups at 24h after the operation (11.290.62)s vs (11.48 0.61 )s were both obviously shorter than that the PT values before the operation (12.680.7
4、3)s vs (12.330.71)s (p0.05). And there was an obvious difference of the value of PT between the subject group (11.290.62)s and the control group (11.480.61)s after the operation, (p0.05). For both of the two groups, the INR value had no obvious change before and 24h after the surgery (p0.05). There
5、was no significant value difference between the two groups of the serum level of the TNF-a (189.58 26.33) pg/mL vs (170.21 24.27) pg/mL before the surgery (p0.05). The TNF-a values of the two groups (248.27 25.26) pg/mL vs (341.21 22.46) pg/mL both increased obviously after the surgery (p0.05), whil
6、e the TNF-a values of laparoscopic group (248.27 25.26) pg/mL were obviously much lower than the values of laparotomy group (341.2122.46) pg/mL (p0.05).Conclusion: Both of the laparoscopic gastrecomy and the laparotomy had an obviously influence on the coagulation function of the patients, while the
7、 laparoscopic gastrecomy delivered a stronger influence on the coagulation function of the patients. Both of the laparoscopic gastrecomy and the laparotomy had an influence on the tumor necrosis factor-alpha in the serum of the patients, while the impact of the laparoscopy gastrecomy was weaker.Key
8、words: gastric cancer; laparoscopy; coagulation function;prothrombin time; prothrombin international normalized ratio; tumor necrosis factor-alpha.胃癌是一种临床较为常见的消化道恶性肿瘤。近年来，胃癌的发病率逐年增高。我国的胃 癌发病率在恶性肿瘤中仅次于肺癌居第二位，而发病死亡率位居肺癌及肝癌之后的第三位 随着诊断及治疗水平的提高，近些年胃癌的发病致死率有所降低对于处于胃癌早期的患者， 目前通过外科手术进行切除是主要采用的治疗手段叫自1994年首次报
9、道了使用腹腔镜辅助 胃部分切除术来治疗早期胃癌，腹腔镜辅助胃癌切除手术逐渐得到了广泛的关注。随着人们 对外科手术微创性的需求的增加，微创技术逐渐在各个外科应用的逐渐成熟，腹腔镜胃癌根治 手术得到了广泛的应用，尤其是针对早期胃癌的治疗Di。1o腹腔镜胃癌根治术在广泛运用的过程当中也在逐渐完善，腹腔镜手术技术也逐渐成熟。在 近年来，胃癌微创外科手术治疗领域，腹腔镜胃癌根治术被公认具有：创伤小，腹盆腔干扰小， 视野放大而清晰，可多角度观察周围解剖结构，出血少，恢复快，操作空间大，组织间隙更易 识别等优点。上述优点使腹腔镜胃癌根治术具有传统内镜手术和开腹手术所不具备的微创优 势，这使得其应用前景广阔，
10、可以用来解决原有传统开腹手术解决不了的问题。然而，任何一 种手术导致的应急反应又必然会引起机体免疫功能的改变，并且术后可能出现血栓形成致肺栓 塞等严重并发症而危及患者生命。目前，临床对腹腔镜手术的安全性存在争议，国内外学者针 对腹腔镜手术的安全性进行了大量的研究。针对上述问题，本文回顾性的分析来我院经过 胃癌手术的98例患者的术前术后的凝血功能：凝血酶原时间(PT)和凝血酶原国际标准化比 值(INR)的影响，以及对肿瘤坏死因子(TNF-a )的影响，旨在为腹腔镜胃癌根治手术的安 全性和可行性的探讨提供理论参考依据。1资料与方法一般资料选取2013年6月到2016年1月来我院就诊经过胃镜检查确诊
11、为胃癌并接受手术治疗的患 者共98例，分为腹腔镜组50例，对照组48例。年龄40岁-70岁，平均年龄为60.44.6岁， 其中包括男69例，女29例。本研究中的患者纳入标准如下T)所有患者经胃镜检查和病理 检查确诊为胃癌2)无手术禁忌症3)所有患者手术前未进行放疗和化疗等4)影像学检查未 见患者有远处转移。根据术前患者及家属所述情况，排除严重的原发性疾病患者，排除浅表静 脉血栓病史患者，肺栓塞病史患者，具有下肢深静脉血栓症状或体征者，凝血功能异常患者， 在手术前使用了影响凝血功能药物者，以及具有其他手术禁忌症的患者。本研究中所选患者均 通过术前检查，均未出现合并感染；为排除实验人员不同给实验结
12、果带来的不确定性，本研究 中入选患者的手术均为同一组医生行胃癌根治术。1.1 手术方式腹腔镜组50例，行远端胃切除术28例、近端胃切除术14例、全胃切除术8例，对照组 48例，行远端胃切除术24例、近端胃切除术15例、全胃切除术9例，切除范围等同于腹腔 镜组。两组患者淋巴结清扫均按日本第13版胃癌处理规约的胃癌分期方法行&根治术，所有 患者术中均严格遵循无瘤原则。1.2 观察指标所有患者采清晨空腹静脉血,检测两组患者术前和手术后24h的凝血项包括凝血酶原时间 (PT),并计算凝血酶原国际标准化数值(INR)。静脉血经离心处理分离血浆后采用双抗体夹 心酶联免疫吸附试验(ELISA)定量检测两组患
13、者手术前和手术后24h的血清中TNF-a的含 量。1.3 统计学处理采用SPSS13.0软件进行统计学分析，计量资料采用Xs表示，分析采用检验；以尸0.05)o而术后24小时与术前比较，两组患者PT均明显 缩短，差异具有统计学意义(P0.05),并且腹腔镜组缩短的更明显(p0.05)。 2.2两组患者术前术后的TNF-a比较如表2所示，手术前两组患者血清TNF-a水平无明显差异(p0.05),而术后24h两组患 者的血清TNF-a均较手术前明显增高(p0.05),且对照组增高较明显(p 0.05341.21 22.46*p 0.05本研究结果表明：腹腔镜和开腹胃癌根治手术都会使胃癌患者的PT时
14、间明显缩短，两种 手术均会明显影响患者的凝血功能。已有学者完成了相关研究，证实腹腔镜胃癌根治术与胃癌 患者手术后血栓形成存在密切关系。本研究发现，腹腔镜胃癌根治术较开腹手术对凝血功 能有更明显的影响，导致术后患者血液更易处于高凝状态，这增加了术后血栓形成的危险。根 据相关研究工作及报道，患者术后凝血功能受影响可能与CO2气腹压力有关因此，在 进行腹腔镜胃癌根治手术之前，应该积极采取措施防范术后血栓的形成再进行手术更为安全。 3.2两组手术对胃癌患者血清TNF-a的影响TNF-a在体内主要由单核巨噬细胞产生，它是一种具有多重生物活性的细胞因子，在组 织的损伤早期比较常见，该坏死因子能够触发炎性反
15、应2。-2文本研究发现：腹腔镜胃癌根治术 较开腹手术对TNF-a的影响更小，对机体损伤也相对较轻，机体产生的应激反应也相对较弱, 上述研究结果与近年来国内外报道的结果相吻合侬-26。本研究旨在通过临床实验研究腹腔镜胃癌根治手术对患者的凝血功能及肿瘤坏死因子的 影响，以为腹腔镜手术的应用及其安全性提供参考。本研究的实验结果表明：腹腔镜胃癌根治 手术能有效降低手术创伤，降低患者手术应激反应，在手术前采取措施防范术后血栓的形成下 仍为较安全可行的治疗方式，值得在临床上推广应用。表1两组手术对胃癌患者凝血功能的影响PT(s)INR组另IJ 术前术后24h术前术后24h腹腔镜组12.680.7311.2
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