腹腔鏡胃癌術(shù)后CD4、CD8變化的研究

馮武國(guó) 王海濤 錢崇崴 劉志蘇

·論 著·(臨床研究)

腹腔鏡胃癌術(shù)后CD4、CD8變化的研究

馮武國(guó) 王海濤 錢崇崴 劉志蘇

目的 對(duì)比分析腹腔鏡與開腹胃癌根治術(shù)術(shù)后病人恢復(fù)情況及CD4、CD8的變化情況。方法 選取2013年3月至2015年3月66例經(jīng)胃鏡檢查和病理學(xué)診斷均為原發(fā)性胃癌的病人，其中32例行腹腔鏡胃癌根治術(shù)的病人作為腹腔鏡組，并選擇同期的34例行開腹胃癌根治術(shù)病人作為開腹組，比較兩組病人的手術(shù)時(shí)間、術(shù)中失血量、下床時(shí)間、術(shù)后排氣時(shí)間、首次進(jìn)食時(shí)間、術(shù)后平均住院日、術(shù)后并發(fā)癥；同時(shí)，檢測(cè)術(shù)前、術(shù)后1 d、術(shù)后3 d、術(shù)后7d病人外周血中白細(xì)胞(white blood cell,WBC)計(jì)數(shù)、C反應(yīng)蛋白(C-reactive protein,CRP)、CD4、CD8的水平。結(jié)果 兩組病人在年齡、性別和腫瘤的狀態(tài)方面差異均無(wú)明顯統(tǒng)計(jì)學(xué)意義(P>0.05)。腹腔鏡組的手術(shù)時(shí)間長(zhǎng)于開腹組，分別是(185.2±12.2) min和(173.7±12.0) min，P<0.05，但開腹組術(shù)中失血量明顯多于腹腔鏡組，分別是(297.5±48.3) ml和(162.4±31.6) ml，P<0.05；腹腔鏡組第一次下床時(shí)間為(1.3±0.7) d、術(shù)后排氣時(shí)間為(1.9±0.8) d、首次進(jìn)食時(shí)間為(4.3±1.1) d、術(shù)后平均住院天數(shù)為(10.7±2.4) d，均少于開腹組(P<0.05)。與開腹組相比手術(shù)前后WBC、CRP均較術(shù)前升高，但開腹組上升的程度明顯高于腹腔鏡組；而CD4、CD8術(shù)后均較術(shù)前減少，但腹腔鏡組下降的程度明顯低于開腹組，尤其是在術(shù)后3 d、7 d(P<0.05)。結(jié)論 與傳統(tǒng)開腹手術(shù)相比，腹腔鏡胃癌根治術(shù)具有手術(shù)創(chuàng)傷小、術(shù)后恢復(fù)快、住院時(shí)間短的優(yōu)點(diǎn)，且對(duì)機(jī)體CD4、CD8水平影響更小。

腹腔鏡； 胃癌； 免疫功能

胃癌是一種常見的惡性腫瘤，在我國(guó)消化道腫瘤中，其發(fā)病率和病死率占居首位[1]。根治性手術(shù)依然是治療胃癌的主要手段[2-3]，但手術(shù)創(chuàng)傷必然會(huì)引起機(jī)體免疫功能的改變，而術(shù)后機(jī)體的恢復(fù)與腫瘤的轉(zhuǎn)移、種植等在一定程度上與機(jī)體的免疫功能有關(guān)[4-5]。因此，本研究著重觀察開腹胃癌根治術(shù)與腹腔鏡胃癌根治術(shù)對(duì)機(jī)體CD4、CD8水平的影響。

資料與方法

一、一般資料

選取我院2013年3月至2015年3月66例經(jīng)胃鏡檢查和病理學(xué)診斷均為原發(fā)性胃癌的病人，其中32例行腹腔鏡胃癌根治術(shù)的病人作為腹腔鏡組， 34例行開腹胃癌根治術(shù)病人作為開腹組。腹腔鏡組與開腹組病人在性別、平均年齡、腫瘤部位、TNM分期及分化程度等方面比較，差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，具體資料見表1，其中排除病人中為胃癌Ⅳ期、復(fù)發(fā)性腫瘤、術(shù)前放化療、姑息性手術(shù)、圍手術(shù)期并發(fā)癥的病人。且糖尿病、類固醇類激素治療史或患有其他免疫系統(tǒng)疾病的病人也被排除在外，因?yàn)檫@些因素會(huì)影響病人術(shù)后的免疫功能[6-7]。所有的病人均簽署了手術(shù)知情同意書。

二、手術(shù)方法

腹腔鏡組手術(shù)與開腹手術(shù)所有手術(shù)病人均在全麻下進(jìn)行，且在麻醉藥物的應(yīng)用上無(wú)明顯差異。其中腹腔鏡組病人仰臥兩腿分開，呈“人”字位或改良截石位，臍下放置10 cm套管作為觀察孔，左側(cè)腋前線肋緣下1 cm放置12 mm套管作為主操作孔，左鎖骨中線平臍處放置5 mm套管作為輔助孔，在以上操作套管右側(cè)對(duì)稱位置分別放置兩個(gè)5 mm套管。將大網(wǎng)膜向頭側(cè)掀起，由橫結(jié)腸上緣無(wú)血管區(qū)分離胃結(jié)腸韌帶，向左至結(jié)腸脾曲，向右至結(jié)腸肝曲，依次分離結(jié)扎切斷胃網(wǎng)膜左動(dòng)靜脈、胃網(wǎng)膜右動(dòng)靜脈、胃左動(dòng)脈、胃右動(dòng)脈、并清掃相應(yīng)區(qū)域淋巴結(jié)，游離十二指腸球部至幽門下2 cm,用直線切割閉合器離斷十二指腸。提起橫結(jié)腸，用布帶捆扎距Treitz韌帶12 cm處空腸。做上腹部正中縱向切口5～6 cm，放置切口保護(hù)膜后，將胃及大小網(wǎng)膜拖出腹腔，切除腫瘤。將近端空腸于標(biāo)記處放置圓形吻合器釘砧頭，吻合器經(jīng)胃腔在胃后壁行胃空腸Billroth Ⅱ吻合，用直線切割閉合器在距吻合口2 cm以外閉合胃腔。常規(guī)放置引流管于手術(shù)創(chuàng)面，由左上套管孔引出。依上述相似方法完成全胃及近端胃切除。開腹組按傳統(tǒng)手術(shù)方法進(jìn)行手術(shù)。

三、觀察指標(biāo)

分別記錄兩組病人術(shù)中及術(shù)后情況包括手術(shù)時(shí)間、術(shù)中失血量、第一次下床時(shí)間、術(shù)后排氣時(shí)間、首次進(jìn)食時(shí)間、術(shù)后平均住院天數(shù)和術(shù)后并發(fā)癥例數(shù)。同時(shí)，利用流式細(xì)胞儀術(shù)檢測(cè)術(shù)前、術(shù)后1 d、術(shù)后4 d、術(shù)后7 d病人外周血中白細(xì)胞(WBC)計(jì)數(shù)、CD4、CD8水平，并運(yùn)用酶聯(lián)免疫吸附試驗(yàn)(ELISA)法檢測(cè)C反應(yīng)蛋白(C-reactive protein, CRP)水平。

四、統(tǒng)計(jì)學(xué)處理

結(jié) 果

一、兩組病人術(shù)時(shí)及術(shù)后恢復(fù)情況比較(表2)

在手術(shù)時(shí)間上腹腔鏡組長(zhǎng)于開腹組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05),但腹腔鏡組術(shù)中失血量明顯少于開腹組(P<0.05),同時(shí)在下床時(shí)間、術(shù)后排氣時(shí)間、術(shù)后住院日均也短于開腹組(P<0.05)。 腹腔鏡組中1例病人術(shù)后出現(xiàn)麻痹性腸梗阻，開腹組中3例病人出現(xiàn)術(shù)后傷口脂肪液化，2例病人出現(xiàn)術(shù)后吻合口出血，但經(jīng)相應(yīng)治療均恢復(fù)良好?？紤]到術(shù)后并發(fā)癥可能會(huì)影響到術(shù)后機(jī)體免疫系統(tǒng)的功能，故這6例病人被排除于此次研究之外。

二、兩組病人術(shù)前及術(shù)后免疫功能指標(biāo)變化情況比較(表3)

兩組病人術(shù)前WBC計(jì)數(shù)，CRP、CD4、CD8水平差異均無(wú)明顯統(tǒng)計(jì)學(xué)意義。術(shù)后WBC、CRP均較術(shù)前升高，但開腹組上升的程度明顯高于腹腔鏡組；而CD4、CD8術(shù)后均較術(shù)前減少，但腹腔鏡組下降的程度明顯低于開腹組，尤其是在術(shù)后3 d、7 d(P<0.05)。

表1 病人一般資料

注：P>0.05

表2 病人術(shù)時(shí)及術(shù)后基本情況比較

注：*P<0.05

組別例數(shù)WBC(×109/L)CRP(mg/L)術(shù)前術(shù)后1d術(shù)后3d術(shù)后7d術(shù)前術(shù)后1d術(shù)后3d術(shù)后7d腹腔鏡組315．9±1．610．7±2．37．5±1．86．8±1．39．8±12．856．2±31．433．2±22．120．9±14．4開腹組295．8±1．311．9±3．99．5±2．67．9±2．18．6±11．251．5±30．648．2±33．628．1±12．3t值0．3-1．5-3．6?-2．5?0．40．6-2．1?-2．2?組別例數(shù)CD4(%)CD8(%)術(shù)前術(shù)后1d術(shù)后3d術(shù)后7d術(shù)前術(shù)后1d術(shù)后3d術(shù)后7d腹腔鏡組3132．7±4．126．7±3．628．1±4．331．7±5．126．3±3．226．9±3．427．7±3．126．1±2．7開腹組2933．1±3．425．9±3．724．8±4．223．2±3．827．9±4．526．1±3．224．0±2．822．7±4．1t值-0．40．93．1?7．7?-1．71．05．1?4．0?

注：*P<0.05

討 論

胃癌是一種常見的惡性腫瘤，在我國(guó)各種惡性腫瘤中居首位。目前，外科手術(shù)依然是治療胃癌的主要方法。但胃癌早期病人大多無(wú)明顯癥狀，少數(shù)病人出現(xiàn)惡心、嘔吐或類似潰瘍病的上消化道癥狀，所以當(dāng)病人出現(xiàn)疼痛或體重減輕時(shí)，已經(jīng)多是進(jìn)展期[8]，故胃癌的預(yù)后不容樂(lè)觀，影響胃癌預(yù)后的因素有很多，其中手術(shù)應(yīng)激引起機(jī)體的免疫功能改變，在一定程度上影響著術(shù)后腫瘤的轉(zhuǎn)移、種植以及是否并發(fā)感染性疾病等，許多研究已經(jīng)證實(shí),腫瘤的預(yù)后與機(jī)體的免疫功能狀態(tài)有一定的相關(guān)性，同時(shí)手術(shù)的創(chuàng)傷程度與機(jī)體免疫功能的抑制也具有一定相關(guān)性[9-10]。因此，運(yùn)用有效的手段降低手術(shù)對(duì)機(jī)體免疫功能的抑制作用變得尤為重要。

隨著腹腔鏡技術(shù)的發(fā)展，在治療良性和惡性腫瘤方面有了重大的進(jìn)展,尤其是大大減小了手術(shù)的創(chuàng)傷[11-12]。腹腔鏡術(shù)后，病人通常可以較快的恢復(fù)至術(shù)前水平，顯著縮短住院治療時(shí)間[13-14]。

本研究中腹腔鏡組手術(shù)時(shí)間與開腹組組手術(shù)時(shí)間分別為(185.2±12.2) min和(173.7±12.0) min，腹腔鏡組手術(shù)時(shí)間長(zhǎng)于開腹組(P<0.05),Kim等[15]也報(bào)道了同樣的結(jié)果。在術(shù)中失血量方面，腹腔鏡組和開腹組分別為(162.4±31.6) ml與(297.5±48.3) ml，腹腔鏡組明顯較開腹組少，Kinoshita等[16]研究結(jié)果與本研究相似，腹腔鏡術(shù)后病人能獲得更早的恢復(fù)腸功能、飲食時(shí)間以及更短平均住院時(shí)間。Siani等[17]也證實(shí)我們的研究。由以上研究結(jié)果顯示腹腔鏡組與開腹組相比在短期療效及術(shù)后恢復(fù)方面，具有更大的優(yōu)勢(shì)。

Mila?ienè等[18]報(bào)道CD4+T細(xì)胞、CD8+T細(xì)胞和NK細(xì)胞與胃癌病人長(zhǎng)期的總體生存率直接相關(guān)。當(dāng)腫瘤細(xì)胞的抗原被抗原提呈細(xì)胞(antigen presenting cell, APC)識(shí)別后,被處理成免疫原性多肽，這些被APC激活的肽類作為第一和第二信號(hào)激活CD4細(xì)胞和CD8細(xì)胞。當(dāng)CD4細(xì)胞和CD8細(xì)胞接受到這些刺激，分別分化成Th0細(xì)胞以及pCTL。當(dāng)Th0細(xì)胞接受不同的同種異體信號(hào)，可又分化為Th1和Th2細(xì)胞，Th2細(xì)胞表達(dá)的IL-4激活B淋巴細(xì)胞，激活的B淋巴細(xì)胞分泌大量的腫瘤特異性抗體，通過(guò)補(bǔ)體依賴細(xì)胞毒性(CDC)和抗體依賴細(xì)胞介導(dǎo)細(xì)胞毒性作用(ADCC)殺死腫瘤細(xì)胞[19]。Th1則表達(dá)IL-2或IFN-γ激活pCTL細(xì)胞，激活CTL可以直接殺死腫瘤細(xì)胞，同時(shí)也可以增強(qiáng)NK細(xì)胞活性。本研究顯示術(shù)后CD4細(xì)胞、CD8細(xì)胞均較術(shù)前降低，但開腹組術(shù)后CD4細(xì)胞、CD8細(xì)胞比例明顯少于腹腔鏡組，此結(jié)果顯示出腹腔鏡組病人對(duì)機(jī)體的免疫系統(tǒng)影響與開腹組相比更小，特別是手術(shù)3 d以后。Hiki等[20]報(bào)道,腹腔鏡手術(shù)比開腹手術(shù)更大的減輕了機(jī)體的炎癥反應(yīng)。我們研究也顯示出腹腔鏡手術(shù)具有較小的手術(shù)創(chuàng)傷和更小的促炎反應(yīng)。CRP[21-22]是一種能與肺炎鏈球菌C多糖體反應(yīng)形成復(fù)合物的急性時(shí)相反應(yīng)蛋白。當(dāng)機(jī)體組織受到損傷時(shí)，其在血漿中含量急劇上升，CRP可以激活補(bǔ)體和加強(qiáng)吞噬細(xì)胞的吞噬而起調(diào)理作用，從而清除損傷、壞死、凋亡的組織細(xì)胞，在機(jī)體的應(yīng)激過(guò)程中發(fā)揮重要的保護(hù)作用。CRP與WBC存在正相關(guān)，在應(yīng)激反應(yīng)中起著積極作用,使人體具有非特異性抵抗力[23]。本研究中CRP和白細(xì)胞水平術(shù)后較術(shù)前均有所升高，但開腹組明顯高于腹腔鏡組。Jung等[24]的研究也顯示出腔鏡手術(shù)對(duì)CRP的影響小于開腹手術(shù)。

綜上所述，通過(guò)對(duì)兩組手術(shù)術(shù)中及術(shù)后恢復(fù)情況的比較，腹腔鏡胃癌根治術(shù)具有術(shù)中出血少、術(shù)后恢復(fù)快、住院時(shí)間短等優(yōu)勢(shì)[25-26]。同時(shí)分析兩組手術(shù)前后WBC、CRP、CD4、CD8水平，可以得出腹腔鏡胃癌根治術(shù)能夠更好地降低術(shù)后機(jī)體的炎癥反應(yīng)，對(duì)機(jī)體CD4、CD8的影響更小。

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Change of CD4 and CD8 after laparoscopy gastric cancer radical surgery

FengWuguo*,WangHaitao,QianChongwei,LiuZhisu.

*DepartmentofGeneralSurgery,LuotianCountyWanMiZhaiHospital,Luotian438600,China

LiuZhisu,Email:liuzs53@sina.com

Objective To compare the recovery and immunologic function after laparoscopic vs. open radical gastrectomy for gastric cancer.Methods Thirty-two cases of gastric cancer were subjected to laparoscopic surgery as laparoscopic group, and 34 cases of gastric cancer at the same period were given open radical gastrectomy as laparotomy group. The blood loss in operation, operative time, the first time of getting out of bed, postoperative exhaust time, practical eating time, mean postoperative hospital stay, and postoperative complications were prospectively analyzed and evaluated in two groups. Meanwhile, the white blood cells, C-reactive protein, CD4(%), and CD8(%) were also detected before and at 1st, 3rd, and 7th day after the surgery.Results There was no significant difference in the age, gender and tumor status between the two groups. Operating time in the laparoscopic group [(185.2±12.2) min] was longer than in laparotomy group [(173.7±12.0) min], and the blood loss in laparotomy group [(297.5±48.3) mL] was more than that in laparoscopic group [(162.4±31.6) mL] (P<0.05). The first time of getting out of bed [(1.3±0.7) days], postoperative exhaust time [(1.9±0.8) days], practical eating time [(4.3±1.1) days], and mean postoperative hospital stay [(10.7±2.4) days] were significantly shorter in laparoscopic group than in laparotomy group (P<0.05 for all). The number of WBC, and CRP levels were elevated after the surgery, and those in laparotomy group were increased more significantly than in laparoscopic group (P<0.05). CD4(%) and CD8(%) were significantly lower after surgery than before surgery (P<0.05), and those in laparoscopic group were decreased more significantly than in laparotomy group, especially at the 3rd and 7th day after surgery (P<0.05).Conclusions Compared with the traditional open operation, laparoscopic surgery is an option for radical treatment of gastric cancer with less trauma, quicker rehabilitation, and shorter hospital stay, and it has a smaller influence on CD4 and CD8 levels.

Laparoscope; Gastric cancer; Immune function

438600 湖北羅田，羅田縣萬(wàn)密齋醫(yī)院普外科(馮武國(guó))；武漢大學(xué)中南醫(yī)院普外科(王海濤、錢崇崴、劉志蘇)

劉志蘇，Email：liuzs53@sina.com

R735.2

A [DOI] 10.3969/j.issn.1003-5591.2016.02.018

?品,胡祥.胃癌腹腔鏡手術(shù)近遠(yuǎn)期療效的循證醫(yī)學(xué)評(píng)價(jià).腹部外科,2015,1:65-67.

10.3969/j.issn.1003-5591.2015.01.019.

2015-06-15)