【摘要】：目的:在臨床和動(dòng)物實(shí)驗(yàn)的基礎(chǔ)上,觀察阻斷第一肝門對(duì)術(shù)后血清轉(zhuǎn)氨酶和淀粉酶的影響,并對(duì)其機(jī)制做進(jìn)一步的探討。方法:首先回顧性分析我院肝膽外科2013年1月至2015年6月采用阻斷第一肝門進(jìn)行肝切除的247例患者臨床資料,根據(jù)入組標(biāo)準(zhǔn):(1)肝功能Child-Pugh分級(jí)A級(jí)或B級(jí)經(jīng)短期治療改善至A級(jí);(2)術(shù)前血清淀粉酶正常(0~220 U/L),無胰腺炎病史、無膽石病患者;(3)阻斷肝臟血流方法為第一肝門(Pringle法),每次阻斷最長(zhǎng)時(shí)間為20min,間歇松開5min;(4)一般情況良好無明顯心、肺、腎等重要臟器的病變;(5)術(shù)后未行護(hù)肝、抑酶治療;(6)所有患者術(shù)前和術(shù)后的檢查資料完整。有87例患者符合入組要求,其中男68例,女19例,年齡18~69歲,平均48歲。術(shù)后病理:肝海綿狀血管瘤2例;膽管細(xì)胞癌3例;肝炎癥性壞死1例;肝細(xì)胞癌81例。對(duì)臨床數(shù)據(jù)做初步分析阻斷第一肝門對(duì)肝功能和術(shù)后淀粉酶的影響,然后設(shè)計(jì)動(dòng)物實(shí)驗(yàn)對(duì)臨床數(shù)據(jù)進(jìn)行驗(yàn)證和探討。選取70只雄性SD大鼠隨機(jī)分配為對(duì)照組(A)10只,持續(xù)阻斷組(B)30只,間歇阻斷組(C)30只。持續(xù)阻斷組大鼠持續(xù)阻斷肝門45分鐘;間歇阻斷組分次阻斷肝門,每次阻斷15分鐘,間歇5分鐘,共阻斷3次;對(duì)照組不做任何處理。分別在術(shù)后第一、二、三天從持續(xù)阻斷組和間歇阻斷組中每天各取10只(亞組,B1,B2,B3和C1,C2,C3,每組10只)抽取門靜脈血,測(cè)定血清淀粉酶和ALT、AST。同上,分別在各時(shí)段取大鼠肝中葉和胰腺組織,用甲醛固定制做HE染色切片,光鏡下觀察病理學(xué)變化。同時(shí)取部分胰腺組織,用戊二醛固定,電鏡下觀察組織細(xì)胞器水平變化。結(jié)果:臨床數(shù)據(jù)分析得出肝切除術(shù)后第一天轉(zhuǎn)氨酶較術(shù)前顯著升高,差異有統(tǒng)計(jì)學(xué)意義(P0.05);部分患者術(shù)后第一天出現(xiàn)高淀粉酶血癥,發(fā)生率為19.5%,且高淀粉酶血癥與阻斷第一肝門的次數(shù)有關(guān)(P0.05)。動(dòng)物實(shí)驗(yàn)血生化結(jié)果顯示,術(shù)后第一天血清淀粉酶水平持續(xù)阻斷組和間歇阻斷組較對(duì)照組顯著升高(持續(xù)阻斷組:2437.6±589.3 U/Lvs 909±221.9 U/L,P0.05,間歇阻斷組:1858.5±579.7 U/Lvs 909±221.9 U/L,P0.05),且持續(xù)阻斷組高于間歇阻斷組(2437.6±589.3 U/Lvs1858.5±579.7 U/L,P0.05);術(shù)后第一天血清ALT持續(xù)阻斷組和間歇阻斷組較對(duì)照組明顯升高(持續(xù)阻斷組:453.2±163.9 U/L vs65.4±13.1 U/L,P0.05;間歇阻斷組:199.4±80.5 U/L vs65.4±13.1 U/L,P0.05),同樣持續(xù)阻斷組高于間歇阻斷組(453.2±163.9 U/L vs199.4±80.5 U/L,P0.05);術(shù)后第一天血清AST持續(xù)阻斷組和間歇阻斷組較對(duì)照組顯著升高(持續(xù)阻斷組:628.4±69.2U/Lvs118.8±15.9 U/L,P0.05;間歇阻斷組:430.2±133.0 U/Lvs118.8±15.9U/L,P0.05),以持續(xù)阻斷組高于間歇阻斷組(628.4±69.2 U/Lvs430.2±133.0 U/L,P0.05)。在肝臟和胰腺組織MDA結(jié)果中:術(shù)后第一天肝臟組織MDA表達(dá)量持續(xù)阻斷組和間歇阻斷組顯著高于對(duì)照組(持續(xù)阻斷組:3.63±1.89 nmol/mgprotvs0.98±0.25 nmol/mgprot,P0.05;間歇阻斷組1.87±0.46 nmol/mgprotvs0.98±0.25 nmol/mgprot,P0.05),且持續(xù)阻斷高于間歇阻斷組(3.63±1.89 nmol/mgprotvs1.87±0.46 nmol/mgprot,P0.05);術(shù)后第二天持續(xù)阻斷組顯著高于間歇阻斷組(2.71±0.81 nmol/mgprotvs1.49±0.61nmol/mgprot,P0.05)。術(shù)后第一天胰腺組織MDA表達(dá)量持續(xù)阻斷組顯著高于對(duì)照組(1.23±0.75 mgprotvs0.58±0.31 mgprot,P0.05),且持續(xù)阻斷組高于間歇阻斷組(1.23±0.75 mgprotvs0.51±0.28 mgprot,P0.05);術(shù)后第二天持續(xù)阻斷組高于間歇阻斷組(0.99±0.31 mgprotvs0.71±0.26 mgprot,P0.05)。在肝臟和胰腺組織SOD結(jié)果中:術(shù)后第一天肝臟組織SOD表達(dá)量持續(xù)阻斷組和間歇阻斷組均顯著低于對(duì)照組(持續(xù)阻斷組:93.58±15.95 U/Lvs190.1±15.8 U/L,P0.05;間歇阻斷組:111.57±14.11U/L vs190.1±15.8 U/L,P0.05),且持續(xù)阻斷組顯著低于間歇阻斷組(93.58±15.95 U/Lvs111.57±14.11 U/L,P0.05);術(shù)后第二天和第三天SOD表達(dá)量持續(xù)阻斷組均顯著低于間歇阻斷組(術(shù)后第二天:102.7±22.89U/Lvs147.67±20.91 U/L,P0.05;術(shù)后第三天:116.77±32.4 U/Lvs146.77±27.4 U/L,P0.05);術(shù)后第一天胰腺組織SOD表達(dá)量持續(xù)阻斷組和間歇阻斷組較對(duì)照組明顯降低(持續(xù)阻斷組:85.4±38.1 U/Lvs 257.51±43.1U/L,P0.05;間歇阻斷組:145.5±75.1 U/Lvs 257.51±43.1 U/L,P0.05),且持續(xù)阻斷組顯著低于間歇阻斷組(85.4±38.1 U/Lvs145.5±75.1 U/L,P0.05),術(shù)后第二天持續(xù)阻斷組較間歇阻斷明顯降低(118.13±44.01 U/Lvs176.54±36.84 U/L,P0.05)。胰腺組織HE染色,對(duì)照組胰腺組織內(nèi)分泌腺、外分泌腺細(xì)胞排列正常,無病理改變。持續(xù)阻斷組和間歇阻斷組都有明顯的病理學(xué)變化,且在術(shù)后第一天最為嚴(yán)重。光鏡下看到有少量胰腺細(xì)胞壞死,腫脹,空泡狀改變,并有炎癥細(xì)胞浸潤(rùn)和少量的出血,以持續(xù)阻斷肝門后最重。肝臟組織經(jīng)HE染色后,光鏡下觀察對(duì)照組無明顯的病理學(xué)改變。持續(xù)阻斷組肝細(xì)胞出現(xiàn)大量適應(yīng)性改變(包括細(xì)胞萎縮、增生和凝結(jié)),不同類型的變性、壞死,炎性細(xì)胞浸潤(rùn),并且同樣以術(shù)后第一天最重,間歇阻斷組病理性改變較輕。術(shù)后第三天可見到再生的肝細(xì)胞和纖維化。電鏡下發(fā)現(xiàn)持續(xù)阻斷組胰腺的外分泌腺細(xì)胞的內(nèi)質(zhì)網(wǎng)和線粒體輕度腫脹,間歇阻斷組沒發(fā)現(xiàn)明顯病理改變。結(jié)論:(1)阻斷第一肝門后血清轉(zhuǎn)氨酶和淀粉酶升高,可能與肝臟缺血在灌注損傷和胰腺的淤血損傷有關(guān)。(2)間歇阻斷肝門比持續(xù)阻斷肝門對(duì)肝臟和胰腺的損傷有較好的耐受性。
[Abstract]:Objective:To observe the effect of blocking the first hepatic porta on serum aminotransferase and amylase after hepatectomy on the basis of clinical and animal experiments,and to further explore the mechanism.Methods:The clinical data of 247 patients who underwent hepatectomy by blocking the first hepatic porta from January 2013 to June 2015 in the Department of Hepatobiliary Surgery of our hospital were retrospectively analyzed. Group criteria: (1) Child-Pugh grade A or B liver function improved to grade A after short-term treatment; (2) preoperative serum amylase normal (0-220 U/L), no history of pancreatitis, no gallstone disease; (3) blockade of liver blood flow method for the first porta hepatis (Pringle method), each blockade for 20 minutes, intermittent relaxation for 5 minutes; (4) in general good without obvious heart, Lung, kidney and other important organs lesions; (5) postoperative liver protection, inhibition of enzyme treatment; (6) all patients before and after the examination data integrity. 87 patients met the inclusion requirements, including 68 males, 19 females, age 18-69 years, average 48 years. Postoperative pathology: hepatic cavernous hemangioma 2 cases; cholangiocarcinoma 3 cases; hepatic inflammatory necrosis 1 case; hepatocellular carcinoma 81 cases. Seventy male SD rats were randomly divided into control group (A), continuous blockade group (B), intermittent blockade group (C) and continuous blockade group (B), respectively. The control group did not receive any treatment. Ten portal vein blood samples (subgroups, B1, B2, B3 and C1, C2, C3, 10 in each group) were taken daily from the continuous occlusion group and the intermittent occlusion group on the first, second and third days after operation, respectively. Serum amylase and ALT, AST. At the same time, some pancreatic tissues were fixed with glutaraldehyde, and the level of organelles was observed under electron microscope. Results: The transaminase level in the first day after hepatectomy was significantly higher than that before hepatectomy. The incidence of hyperamylasemia was 19.5% in some patients on the first day after operation, and hyperamylasemia was related to the times of blocking the first hepatic hilum (P 0.05). Continuous block group: 2437.6 65 The levels of serum AST in the intermittent blockade group were significantly higher than those in the intermittent blockade group (628.4+692 U/Lvs118.8) on the first day after operation. The expression of MDA in liver and pancreas tissues on the first day after operation was significantly higher than that in the control group (628.4 +69.2 U/Lvs 430.2 +133.0 U/L, P 0.05). Group: 3.63 + 1.89nmol / mgprotvs 0.98 + 0.25 nmol / mgprotv 0.98 [/mgprotv 0.98 + 0.25 nmol / mgprotv 0.98 + 0.25 nmol / mgprotv 0.98 [/mgprotv 0.98 [/mgprotv 0.25 nmol / mgprot, P 0.05, P 0.05, 3.63 + 1.89nmol / mgprotvs 1.98 [/mgprotvs 1.87 + 0.87 + 0.46 nmol / mgprotv 1.46 nmol / mgprotv 0.05, P 0.05, 0.05, 0.05, 1.87 [/mgprotv 0.87 [/mgprotv 0.In the meantime, it is necessary to study the relationship between the two. The expression of MDA in pancreatic tissue was significantly higher in the first day after operation than in the control group (1.23.75 mgprotvs 0.58.31 mgprot, P 0.05), and higher in the continuous block group than in the intermittent block group (1.23.75 mgprotvs 0.51.28 mgprot, P 0.05), and higher in the second day after operation than in the intermittent block group (0.99.31 mgprot, P 0.05). Rotvs 0.71 (+ 0.26 mgprot, P 0.05). In the results of SOD in liver and pancreas tissues, the expression of SOD in the first day after operation was significantly lower than that in the control group (93.58 (+ 15.95 U / Lvs 190.1 (+ 15.8 U / L, P 0.05); and in the intermittent blocking group, 111.57 (+ 14.11 U / Lvs 190.1 (+ 15.8 U / L), P 0.05). The expression of SOD in the two groups was significantly lower than that in the intermittent group (93.58 Compared with the control group, the expression level in the continuous block group and the intermittent block group was significantly lower (85.4 65507 HE staining of pancreatic tissue showed that the endocrine glands and exocrine gland cells in the control group were normal without pathological changes. Cell necrosis, swelling, vacuolar changes, inflammatory cell infiltration and a small amount of hemorrhage were the most serious after continuous blockade of the hepatic hilum. Necrosis, infiltration of inflammatory cells, and also the most severe on the first day after surgery, the pathological changes were mild in the intermittent blocking group. Regenerated hepatocytes and fibrosis were seen on the third day after surgery. (1) The elevation of serum aminotransferase and amylase after hepatic portal occlusion may be related to hepatic ischemia perfusion injury and pancreatic congestion injury. (2) Intermittent hepatic portal occlusion is more tolerant to hepatic and pancreatic injury than continuous hepatic portal occlusion.
【學(xué)位授予單位】：廣西醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R657.3

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