【摘要】：PartⅠClinical Comparative analysis of laparoscopic versus conventional splenectomy
Background:Since the first technique has been reported of laparoscopic splenectomy by Delaitre in 1991, this developed rapidly due to its advantages of minimal incision, quick recovery and little complications. In many hospitals, LS has become the first choice of curing hematopathy, especially idiopathic thrombocytopenic purpura (ITP).
Objective:To evaluate the clinical situation and minimally invasive procedures (laproscopic) used in abdominal surgery. On the same period and underwent open splenectomy, Laparoscopic splenectomy were compared between two groups of patients,the saftey,efficacy and superiority of laparoscopic splenectomy in the clinical applications. Evaluation of minimally invasive surgery (laparoscopic surgery) in the clinical application status and value of exploring new surgical method.
Methods:From April 2009 to February 2011, patients received laparoscopic and open splenectomy at Huazhong University of Science and technology, Union Hospital, Tongji Medical College. We record the operative time, blood loss during operation, postoperative eating time, drainage time, postoperative hospital stay and hospitalization cost. Statistical analysis are made using SPSS 13.0 for windows.
Results:There are 65 cases enrolled, in which 35 cases are laparoscopic splenectomy,30 cased are open splenectomy.No complications were found. Two groups of patients in the gender and age is similar. LS operative time (157.31±40.20minutes) longer than the conventional splenectomy (135±24.45) p= 0.0102. Two groups's cases of blood loss are (189±83.88ml,54.57±21.47ml) for OS and LS respectively P.0001, postoperative eating time (4.33±0.61days,2.66±0.54days) for OS and LS respectively P.0001. Conventional splenectomy group postoperative hospital stay (11.57±2.16 days) longer than the LS group (8.57±1.14days) P.0001.In Laparoscopic splenectomy there were little Perioperative blood loss,fast postoperative recovery,blood cell number gradually recovering just after operation. And no complications.
Conclusion:Laparoscopic splenectomy is a feasible,effective and safe surgical procedure for patients with hematologic diseases or for patients who require splenectomy and have a normal to medium-sized enlarged spleen. Laparoscopic splenectomy is safe and effective to some splenic diseases which satisfy the indication.Though its operation time is longer than open splenectomy, there are significant differences in blood loss and postoperation eating time between the two operations. And the postoperative hospital stay of laparoscopic splenectomy is shorter than open splenectomy.
Part II Comparison between inflammatory responses after laparoscopic and conventional splenectomy
Objective:To compare the systemic and local inflammatory responses after laparoscopic and conventional splenectomy.
Methods:From April 2009 to February 2011, patients enrolled in this study received laparoscopic (n=35) and open splenectomy (n=30),the inflammatory responses were compared between the two groups. TNF-α、IL-6、IFN-γ、IL-4、IL-1βand CRP concentrations in serum and PDF were measured with ELISA kits.
Results:There were no significant differences in age,sex and preoperative levels of hemoglobin and albumin between the two groups(P0.05). Serum IL-6, TNF-alpha, IL-1β, IFN-y, IL-4 and CRP plasma levels were measured in 35 laparoscopic and 30 conventionally treated patients. PDF TNF-alpha and CRP too. Preoperative plasma levels of TNF-αIL-6、IFN-γ, IL-4、IL-1β,CRP,WBC and NE were not different between each group(P0.05). The plasma concentrations of TNF-α、IL-6、IFN-γ、IL-4、IL-1β,CRP increased postoperatively and remained above the preoperative plasma concentrations during the first postoperative week(P0.05). postoperative plasma levels of TNF-α、IL-6、IFN-γ、IL-4、IL-1β,CRP,WBC and NE were higher in the conventional than in the laparoscopic group(P0.05) were significantly lower in laparoscopic group than those in conventional group. peritoneal drainage fluid (PDF) TNF-a and CRP levels were significantly lower in laparoscopic group than that of conventional group(P0.05).
Conclusion:In early stage after operation, intra-peritoneal inflammatory response and systemic inflammatory response caused by laparoscopic surgery is slightly lower than that of conventional splenectomy
PartⅢThe Influence of Laparoscopic and conventional splenectomy On Immune function
Immune function is a defensive ability of resisting infection, including immunologic defence, immunologic homeostasis and immunologic surveillance. Immunoglobulin and complements are having the effect of resisting bacteria and viruses in the body. As immunocompetent cell, T lymphocyte has the effect of immunologic surveillance. Immunoreaction of T lymphocyte has important effect in resisting infections, NK cell is a lymphocyte, It has killer ability and play role in immunologic surveillance. It had recently been discovered that wounds of surgical operation could influence immune function. Laparoscopic operations were rapidly developed because it has a little wound and pain.Several abroad studies had reported about the Influence of laparoscopic splenectomy on immune system.
Investigation and comparison values of laparoscopic splenectomy and conventional splenectomy are variable on the immunoglobulins, complements and T lymphocyte.
To study the Influence of laparoscopic splenectomy and conventional splenectomy on immune system.
We selected 65 ITP patients. Laparoscopic splenectomy 35 patient and conventional splenectomy 30 patients were enrolled in the study.the Immune function responses were compared between the two groups.There was no significant difference of sex and age between two groups (P0.05). Blood samples were obtained at study entry preoperative and at day 1、5 postoperatively. Samples were collected in plastic tubes. Serum was prepared to examine immunoglobulin (IgG,,IgA,IgE,IgM),complement(C3、C4) and T lymphocyte(CD3,CD4,CD8,CD(16+56),CD 19). The examination of immunoglobulin and complements selected reagent and instrument from the American DER Lin Company, applying immunoradiometric assay. The examination of lymphocyte selected reagent and instrument from the American Kurete company and selected reagent from German company (IgG1-FITC/IgG1-PE, CD3-EITC/CD4-PE CD3-FITC/CD8-PE, CD3-FITC/CD (16+56)-PE, IgGI-PE, IgG2a-FITC, CD10-PE, CD3-PE, CD8-PE).
Postoperative levels of serum immunoglobulin and complements of laparoscopic splenectomy and conventional splenectomy were lower than preoperative levels. The difference was not statistically significant (p0.05). But the level of serum C3 was significantly decreased after conventional splenectomy, from 2.19±0.26g/L to 0.97±0.24g/L and 1.12±0.23g/L; the difference was statistically significant(p0.05 or p0.01). The level of serum IgG was significantly decreased after conventional splenectomy, from 13.09±1.96g/Lto 11.45±2.24 g/L and 11.93±3.05g/L, the difference was statistically significant(p0.05 or p0.01). But the levels of serum C3 and IgG after conventional splenectomy decreased more significantly than laparoscopic splenectomy, the difference was statistically significant (p0.05 or p0.01). Postoperative levels of serum CD8, CD(16+56) and CD19 of conventional splenectomy were slightly decreased than preoperation, the difference was not statistically significant(p0.05). The level of serum CD3 decreased significantly in conventional splenectomy, from 57.88±2.97%to 55.98±4.08%and 51.03±4.02%, the difference was statistically significant(p0.05 or p0.01). The level of serum CD4 was significantly decreased after conventional splenectomy, from
37.31±2.96%to 36.14±3.49%and 30.49±3.93%, the difference was statistically significant(p0.05 or p0.01).The level of CD4/CD8 was significantly decreased after conventional splenectomy, from 1.37±0.72 to 1.54±0.69 and 1.25±0.87, the difference was statistically significant(p0.05). But postoperative levels of serum CD3, CD4, CD8, CD(16+56), CD 19 and CD4/CD8 of laparoscopic splenectomy were slightly decreased than preoperation, and recovered normally to the basal line 5 days after operation, the difference is not statistically significant(p0.05). The differences of two groups were statistically significant (p0.01).Both laparoscopic splenectomy and conventional splenectomy could cause a certain degree suppresion of immune function in the earlier postoperative period. But laparoscopic splenectomy caused less suppression of immune function than conventional splenectomy did and recovery of the immunosuppression in laparoscopic splenectomy was faster than in conventional splenectomy. That is to say, laparoscopy procedure was less traumatic.