野战条件下闭合性肝损伤救治新策略—腹腔镜探查联合射频辅助止血的应用研究

发布时间：2018-06-01 20:21

本文选题：腹腔镜 + 肝外伤　；参考：《福建医科大学》2013年硕士论文

【摘要】：【目的】 1、探讨腹腔镜下射频消融固化止血治疗在肝外伤救治中的应用，有望得出一种可应用于临床和战时的安全、有效、简便、易于推广的肝外伤止血治疗手段。从而实现在伤情的早期判断和全面评估的基础上，尽可能的避免不必要的剖腹手术和器官切除手术，尽可能地实现微创的、个体化的、安全有效的治疗。 2、通过实验分析该技术应用于肝外伤救治的适应证、疗效、安全性。 3、将当前肝胆外科的新技术、新观念前伸并应用到战时和非战争军事行动条件下的肝外伤的救治中，探索野战条件下肝损伤救治的新途径、新策略。【方法】将进入实验的20只动物随机分为两组，采用自制小型生物撞击器致伤后，依据美国创伤外科学会(AAST)器官伤分类委员会，1989年提出经1994年修改的肝脏损伤程度分级标准对伤情进行评估。A组于伤后30-60min内行腹腔镜探查，进一步判断、评估伤情。在腹腔镜直视下，结合B超，对出血部位施行经皮射频消融固化止血治疗。治疗失败者或合并其他脏器损伤者，根据伤情，行开腹手术（包括肝叶切除、脾切除术等）。B组经B超检查后确定肝损伤等级后，予以非手术治疗（包括采取液体复苏、监测血流动力学等）。所有动物均按阶段采集血常规、生化指标、影像学复查等。对于血流动力学不稳定，影像学提示持续出血的严重肝损伤者，择机开腹探查，手术止血。治疗过程中死亡动物，立即尸检。第28天处死动物，，尸检，完整切取肝脏，探查腹腔、胸腔，记录发生的并发症。标本脱水处理后石蜡包埋，常规HE染色，光镜分析，采集组织学资料。【结果】 1.止血时间及失血量方面腹腔镜探查联合射频消融治疗组与非手术组在止血时间、失血量上除I级肝外伤外均有明显差异（P0.05）。 2.血糖、胰岛素、胰高血糖素两组动物伤前血糖、INS、GLU比较均无显著差异(P0.05)。术后即刻、术后1天、术后2天，两组动物血糖较伤前均有明显升高(P0.05)。术后第2天，手术组血糖高于非手术组，差异有统计学意义(P0.05)。术后第4天手术组血糖恢复至正常水平(P0.05)，术后第10天非手术组血糖恢复至正常水平，两组比较差异有统计学意义(P0.05)。两组动物INS在术后即刻明显下降，较致伤前比较差异有统计学意义(P0.05)。术后第1、2天，两组INS均显著升高，较致伤前比较有差异性(P0.05)。术后第4天，手术组INS有所下降，与致伤前比较无明显差异(P0.05)，而非手术组仍显著高于伤前水平，与伤前和手术组比较差异均有统计学意义(P0.05)。非手术组INS于术后第7天恢复术前水平(P0.05)。两组动物术后GLU均呈上升趋势，术后第1天达最高值。两组动物GLU术后即刻、术后第1、2天与术前比较，差异有统计学意义(P0.05)。术后第4天，手术组恢复至伤前水平，非手术组第7天GLU逐渐恢复至伤前水平(P0.05)，但组间无差异(P0.05)。 3.ALT、AST、Tbil、Dbil 两组动物伤前ALT、AST比较均无显著差异(P0.05)。术后即刻、术后第1天、第2天、第4天，两组动物ALT明显升高，较伤前比较差异有显著性(P0.05)。其中，手术组在术后第1天达最高值，非手术组在术后第4天达最高值，非手术组ALT在术后第4天显著高于手术组(P0.05)。术后第7天两组ALT接近伤前水平(P0.05)。术后即刻至术后第4天，两组AST均显著升高，较伤前比较差异有显著性(P0.05)，两组都在术后第1天达最高值。手术组AST在术后第7天接近术前水平(P0.05)，而非手术组AST虽然有所下降，但较伤前和手术组比较，仍有统计学差异(P0.05)。伤后两组Tbil、Dbil开始缓慢上升，均在术后第2天达高峰，其中非手术组仅Dbil在术后第1、2天较伤前比较差异有统计学意义(P0.05)，术后第4天降至正常。手术组Tbil、Dbil在术后第1、2天较伤前比较，差异有显著性(P0.05)，术后第7天恢复至正常水平。两组之间比较均没有统计学意义(P0.05)。【结论】 1.腹腔镜探查联合射频消融固化止血治疗技术较之传统保守治疗，止血时间明显缩短，失血量明显减少，并发症发生率低，适用于不同伤情的肝外伤的救治，值得推广。 2.腹腔镜探查联合射频消融固化止血治疗肝外伤具有创伤小、恢复快、并发症少等特点；机体应激反应轻、肝功能影响小。 3.腹腔镜探查联合射频消融有以下技术优势：1、有利于早期全面的伤情判断，防止遗漏多发脏器损伤的诊断；2、直视下穿刺射频针，定位准确，简便易行，技术难度小而可靠，适用于战时的特殊要求。
[Abstract]:[Objective]
1, the application of laparoscopic radiofrequency ablation and hemostasis treatment in the treatment of liver trauma is expected to be a safe, effective, simple and easy to be used for the treatment of liver trauma, which can be used to avoid unnecessary laparotomy on the basis of early judgement and comprehensive assessment of the injury. And organ resection to achieve minimally invasive, individualized, safe and effective treatment as far as possible.
2, we analyzed the indications, efficacy and safety of the technology in the treatment of liver trauma through experiments.
3, to explore new ways and strategies for the treatment of liver injury under the condition of field warfare, the new technology of the current Department of hepatobiliary surgery, new ideas are extended and applied to the treatment of liver trauma under the conditions of wartime and non war military operations.
[method]
20 animals who entered the experiment were randomly divided into two groups. After the injury caused by a self-made small biological impactor, according to the American Society for trauma surgery (AAST) organ injury classification Committee, in 1989, the evaluation of the degree of liver injury revised in 1994 was evaluated for the evaluation of the injury in the group of 30-60min. Under the direct vision of the laparoscope, combined with B-ultrasound, percutaneous radiofrequency ablation and hemostasis was performed on the bleeding site. In the treatment of the losers or those with other organs injury, the.B group was treated after the B-ultrasound examination to determine the grade of liver injury after the B-ultrasound examination. Resuscitation, monitoring hemodynamics, etc. all animals were collected by stage of blood routine, biochemical index, imaging review and so on. For hemodynamic instability, patients with severe liver injury with continuous bleeding, selective laparotomy, surgical hemostasis, and immediate autopsy in the course of treatment. Animals, autopsy and complete removal were executed twenty-eighth days. The liver, the abdominal cavity and the chest cavity were recorded, and complications were recorded. Specimens were dehydrated and paraffin embedded, stained with conventional HE, analyzed by light microscopy, and histologic data were collected.
[results]
1. the time of hemostasis and the amount of blood loss
Laparoscopy combined with radiofrequency ablation group and non operation group had significant difference in hemostasis time and blood loss except I grade liver trauma (P0.05).
2. blood glucose, insulin, glucagon
There was no significant difference in blood sugar, INS, GLU before injury in the two groups (P0.05). Immediately after operation, 1 days after operation, 2 days after operation, the blood sugar of two groups were significantly higher than before injury (P0.05). The blood sugar of the operation group was higher than that of non operation group at second days after operation. The difference was statistically significant (P0.05). The blood sugar recovered to normal level (P0.05) in the operation group fourth days after operation (P0.05), first after operation, first after operation. The blood glucose of the non operative group recovered to the normal level in the 0 day, and the difference between the two groups was statistically significant (P0.05). The difference between the two groups of animals was significantly lower than that before the injury (P0.05). The two groups of INS were significantly higher after the postoperative day 1,2, compared with the prior injury (P0.05). Fourth days after the operation, the operation group INS decreased. There was no significant difference between before and before injury (P0.05), but the non operative group was still significantly higher than the pre injury level, and there was significant difference between the pre injury and the operation group (P0.05). The INS in the non operation group recovered before the operation (P0.05) seventh days after the operation. The GLU of the two groups of animals showed a rising trend after operation, and the highest value in first Tianda after the operation. Two groups of animals were immediately after the operation, The difference was statistically significant (P0.05) after 1,2 day after operation (P0.05). The operation group recovered to the level of pre injury fourth days after operation, and the GLU of the non operation group gradually recovered to the pre injury level (P0.05), but there was no difference between the groups (P0.05).
3.ALT, AST, Tbil, Dbil
There was no significant difference in ALT and AST between the two groups before injury (P0.05). Immediately after operation, first days, second days and fourth days after operation, the two groups of animals were significantly higher than before injury (P0.05). Among them, the highest value of the operation group in first Tianda, the highest value of the non operative group in fourth Tianda after the operation, and the ALT in the non operation group was significantly higher than that in the fourth day after the operation. The operation group (P0.05). Seventh days after the operation, two groups of ALT were close to the pre injury level (P0.05). The two groups of AST were significantly increased after the operation and fourth days after the operation. The difference was significant compared with that before the injury (P0.05). The two groups were the highest in first Tianda after the operation. The operation group was close to the preoperative level (P0.05) on the seventh day after the operation, while the AST in the non operative group decreased, but the injury was more severe. Compared with the operation group, there were still statistical differences (P0.05). The two groups of Tbil and Dbil began to rise slowly after the injury, all of which were in the peak of second Tianda after the operation. The difference between the non operative group and the postoperative 1,2 days was statistically significant (P0.05), and the fourth day after the operation was reduced to the normal. The operative group Tbil, Dbil compared with the injury before the operation, the difference was compared with the injury before the operation. The difference was the difference between the operation group and the postoperative day before the injury. Significance (P0.05) returned to normal level seventh days after operation. There was no significant difference between the two groups (P0.05).
[Conclusion]
1. laparoscopy combined with radiofrequency ablation curing hemostasis treatment technology is better than traditional conservative treatment. The time of hemostasis is shortened obviously, the amount of blood loss is reduced obviously, and the incidence of complications is low. It is worth popularizing for the treatment of liver trauma with different injuries.
2. laparoscopy combined with radiofrequency ablation and hemostasis for the treatment of liver trauma has the characteristics of small trauma, quick recovery, less complications, light stress reaction and small effect of liver function.
3. laparoscopy combined with radiofrequency ablation has the following technical advantages: 1, it is beneficial to the early and comprehensive assessment of the injury, to prevent the diagnosis of omission of multiple organ damage; 2, the puncture radiofrequency needle under direct vision is accurate, simple and easy to be used, and the technical difficulty is small and reliable. It is suitable for the special requirements of wartime.
【学位授予单位】：福建医科大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R82

【参考文献】