肝癌患者术后疼痛对细胞免疫功能及早期预后的影响

发布时间：2018-08-30 18:12

【摘要】：背景与目的原发性肝癌(Primary liver cancer,PLC)是目前世界范围内最常见恶性肿瘤之一。近年来虽然乙肝病毒感染患者的发病率明显下降,但原发性肝癌的总体新发病率及死亡率仍呈明显增长趋势,而原发性肝癌的总体生存率没有明显提高。手术切除是肝癌诊治的首选方式,但手术创伤大,疼痛是患者术后最主要的主诉之一,且术后几天内机体的免疫功能明显变差,早期预后差异较大。术后疼痛对机体免疫功能和早期预后有无影响尚不明确,本文收集了南方医院近2年肝癌术后病例,探讨术后疼痛与患者细胞免疫及早期预后的关系,为原发性肝癌术后快速康复模式选择提供依据。方法收集2014年6月至2016年10月90例在南方医院肝胆外科行肝癌切除术患者的临床病理资料。按照数字等级评分法对患者疼痛进行评分分组,将术后0—7天内NRS≤3(Numerical rating scal,数字等级评分)分为有效镇痛组(n=51例),NRS3分为无效镇痛组(n=39例).通过回顾性分析两组患者术前肝功能、血常规、手术切口长度、肿瘤部位、最大直径、术后肝功能及细胞免疫功能变化等临床病理资料并观察术后相关并发症、器官功能恢复等指标变化情况,对比分析两组患者各指标组间及组内差异性、预后情况及其临床意义。结果1.肝癌术后疼痛第1天最剧烈,第5天后程度减轻,有效镇痛治疗明显减轻疼痛程度。两组在年龄、体重指数等一般情况及术前血清丙氨酸氨基转移酶(alanine aminotransferase,ALT)、天门冬氨酸氨基转移酶(aspartate aminotransferase,AST)、血清总胆红素(total bilirubin,TB)、白蛋白(albumin,ALB)及凝血酶原时间(prothrombintime,PT)等肝功能参数及营养指标等方面均无显著差异性。2.两组患者在手术切口长度、肿瘤大小、手术时间、肿瘤位置,是否进行肝门阻断、肝断面缝扎、术中出血量、术中输血情况及麻醉方式、肿瘤病理类型、是否有淋巴结转移或门静脉或脉管癌栓、肿瘤TNM分期及病理分化程度等病理资料差异无显著差异。3.两组患者术前、术后ALT、AST、TBIL、PT、ALB水平相比具有显著差异(P0.05);且有效镇痛组ALT、AST、TBIL、PT上升或延长幅度均明显低于无效镇痛组。术后第5天ALB水平明显高于无效镇痛组,但术后第1天、第3天及第7天ALB水平及术后血红蛋白水平无显著差异(P0.05)。4.有效镇痛组术后总并发症发生率、肝功能恢复延迟、肺炎、肠梗阻、睡眠不良等并发症明显低于无效镇痛组,且术后首次肛门排气时间、首次下床活动时间)、首次进食时间、腹腔引流管放置时间、住院天数均少于无效镇痛组,差异具有统计学意义(p0.05)。5.两组患者静脉血CD3+T、CD4+T的表达及CD4+/CD8+比值显著低于正常值,而CD8+T细胞表达水平高于正常人,且两组患者术后血清CD3+T细胞、CD4+T细胞、CD8+T细胞及CD4+/CD8+比比比值与术前相比及术后同期相比,有效镇痛组免疫功能明显优于无效效镇痛组,差异均具有统计学意义(P0.05)。结论1.有效镇痛可显著减轻肝癌患者术后肝功能损害,促进肝功能尽快恢复。2.CD4+/CD8+比值反应患者免疫功能平衡状态的敏感指标,肝癌患者存在不同程度的免疫功能抑制,肝癌切除术进一步加重肝癌患者机体免疫功能损害,而有效镇痛治疗对免疫功能具有保护作用,镇痛效果越好,对免疫功能的保护作用越佳。3.持续有效镇痛治疗可加速各器官功能恢复、缩短住院时间及减少医疗费用,提高肝癌术后患者治疗疗效。4.我们可以通过术后有效镇痛治疗减轻患者应激反应程度及痛苦、减少术后并发症,加速患者快速康复而改善患者预后。
[Abstract]:BACKGROUND & OBJECTIVE Primary liver cancer (PLC) is one of the most common malignant tumors in the world at present. Although the incidence of hepatitis B virus infection has decreased significantly in recent years, the overall incidence and mortality of primary liver cancer are still increasing significantly, while the overall survival rate of primary liver cancer is not significantly improved. Surgical resection is the first choice for the diagnosis and treatment of hepatocellular carcinoma, but surgical trauma and pain is one of the main complaints of the patients after operation. The immune function of the body becomes worse within a few days after operation, and the early prognosis varies greatly. Objective To investigate the relationship between postoperative pain and cellular immunity and early prognosis of patients with primary hepatocellular carcinoma (PHC) and to provide evidence for choosing the mode of rapid postoperative rehabilitation. The patients were divided into effective analgesia group (n = 51 cases) and ineffective analgesia group (n = 39 cases). The preoperative liver function, blood routine, surgical incision length, tumor location, maximum diameter, postoperative liver function and cellular immune function were analyzed retrospectively. The clinical and pathological data, such as postoperative complications, organ function recovery and other indicators were observed, and the differences between the two groups were compared. The prognosis and clinical significance were analyzed. Results 1. The postoperative pain of hepatocellular carcinoma was the most severe on the first day, the degree of relief after the fifth day. Age, body mass index, preoperative serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum total bilirubin (TB), albumin (ALB), prothrombin time (PT) and other liver function parameters and nutrition There was no significant difference in the length of incision, tumor size, operation time, tumor location, hepatic portal obstruction, suture of hepatic section, intraoperative blood loss, intraoperative blood transfusion and anesthesia, pathological type of tumor, lymph node metastasis or portal vein or vascular tumor thrombus, TNM staging and pathology. The ALT, AST, TBIL, PT and ALB levels in the effective analgesia group were significantly lower than those in the ineffective analgesia group. There was no significant difference in ALB level and postoperative hemoglobin level (P 0.05). 4. The incidence of postoperative complications, delayed recovery of liver function, pneumonia, intestinal obstruction, poor sleep and other complications in the effective analgesia group were significantly lower than those in the ineffective analgesia group. The expression of CD3 + T, CD4 + T and the ratio of CD4 + / CD8 + in the venous blood of the two groups were significantly lower than the normal value, while the expression of CD8 + T cells was higher than that of the normal people, and the ratio of CD3 + T cells, CD4 + T cells, CD8 + T cells and CD4 + / CD8 + in the serum of the two groups was significantly lower than that of the preoperative patients. Compared with the same period after operation, the immune function of the effective analgesia group was significantly better than that of the ineffective analgesia group, the difference was statistically significant (P 0.05). Conclusion 1. Effective analgesia can significantly reduce the liver function damage and promote the recovery of liver function as soon as possible. 2. CD4 + / CD8 + ratio reflects the sensitive index of immune function balance in patients with liver cancer. Patients with liver cancer have different degrees of immunosuppression. Hepatectomy further aggravates the impairment of immune function in patients with liver cancer. Effective analgesic therapy has a protective effect on immune function. The better the analgesic effect, the better the protective effect on immune function. 3. Continuous and effective analgesic treatment can accelerate the recovery of organ function, shorten hospital stay and 4. We can reduce the degree of stress reaction and pain, reduce postoperative complications, accelerate the recovery of patients and improve the prognosis of patients by effective postoperative analgesia.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.7

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