Clinical Efficacy of Abdominal Ultrasound-guided Endoscopic Retrograde Appendicitis Therapy for Acute Uncomplicated Appendicitis
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摘要:
目的 利用倾向性评分匹配,评估腹部超声引导内镜下逆行阑尾炎治疗术(endoscopic retrograde appendicitis therapy,ERAT)与腹腔镜阑尾切除术(laparoscopic appendectomy,LA)2种手术方式治疗急性非复杂性阑尾炎的临床疗效。 方法 收集2020年03月至2023年04月云南省第三人民医院收治的441例急性非复杂性阑尾炎患者的病史资料。根据治疗方式差异,将病例分为ERAT组(n = 30)和LA组(n = 411)。采用倾向性评分匹配(propensity score matching,PSM)均衡组间协变量后,比较2组患者的临床疗效。 结果 经过PSM,2组共有30对患者匹配成功,且2组基线资料满足可比性要求。ERAT组术后24 h白细胞、中性粒细胞计数、C反应蛋白水平低于LA组,数据差异均有统计学意义(P < 0.05)。ERAT组手术时间及总有效率相较于LA组,差异无统计学意义(P > 0.05),但ERAT组术中失血量少于LA组,疼痛缓解时间短于LA组,2组之间差异具有统计学意义(P < 0.05)。 结论 腹部超声引导内镜下逆行阑尾炎治疗术效果显著、安全可行,可作为治疗急性阑尾炎切实可行的、有着良好发展前景的无创技术。 -
关键词:
- 腹部超声引导 /
- 内镜下逆行阑尾炎治疗术 /
- 急性非复杂性阑尾炎 /
- 倾向性评分匹配
Abstract:Objective To compare the clinical efficacy of abdominal ultrasound-guided endoscopic retrograde appendicitis therapy (ERAT) with laparoscopic appendectomy (LA) for acute uncomplicated appendicitis using propensity score matching. Methods The clinical data of 441 patients with acute uncomplicated appendicitis admitted to the Third People's Hospital of Yunnan Province from March 2020 to April 2023 were collected. The cases were classified based on the differences in surgical method and divided into the ERAT group (n = 30) and LA group (n = 411). The clinical efficacy of patients was compared between the two groups after reducing confounding bias by propensity score matching (PSM). Results After PSM, a total of 30 pairs of patients in the two groups were successfully matched, and the baseline data of the two groups met the requirements for comparability. At 24 hours after the operation, the ERAT group exhibited lower white blood cells, neutrophil counts, and C-reactive protein levels compared to the LA group, and these differences were statistically significant (P < 0.05). There was no significant difference in the operation time and total effective rate between the ERAT group and the LA group (P > 0.05). However, the ERAT group had lower intraoperative blood loss and shorter pain relief time compared to the LA group, and these differences were statistically significant (P < 0.05). Conclusion Abdominal ultrasound-guided endoscopic retrograde appendicitis treatment is an effective, safe, and feasible technique with good prospects for the treatment of acute uncomplicated appendicitis. -
脑膜瘤是起源于脑膜的肿瘤,发病率高,约占颅内原发肿瘤的30%[1]。脑膜瘤以手术治疗为主,手术时间长、创伤大,导致免疫系统激活引起全身炎症反应,使体内炎症介质水平增高,导致术后严重的神经系统并发症[2]。
右美托嘧啶(dexmedetomidine,Dex)是现在术中常用的α2-肾上腺素受体激动剂[3-4],在围术期对多脏器都具有保护作用,改善患者预后[5]。在神经外科手术中应用,可稳定血流动力学,减轻炎症反应,抑制自由基的产生,从而起到脑保护的作用[6-8]。盐酸纳布啡是一种阿片类兴奋-拮抗剂,兴奋κ受体发挥镇静镇痛作用,部分拮抗μ受体。纳布啡在手术中可抑制炎症,使术中生命体征更平稳[9]。本研究通过联合应用Dex与纳布啡和单用Dex比较,探讨Dex联合纳布啡对脑膜瘤患者炎症及术后认知功能的影响。
1. 对象与方法
1.1 研究对象
本研究通过昆明医科大学第一附属医院伦理委员会审核,并取得患者及其家属的书面同意。纳入标准:年龄24~54岁,ASAⅠ~Ⅱ级,无其他系统疾病,无药物依赖史。排除标准:重要脏器失代偿者;对计划用药过敏者;无法完成简易精神状态检查表(MMSE)[10]或术前评分 < 24分的患者;围术期输血者;围术期应用影响免疫功能药物者;手术失败者。选取符合标准且于2018年7月至2019年3月昆明医科大学第一附属医院行择期脑膜瘤切除术治疗的患者共60例。采用随机数字表法将符合标准的患者分成两组:Dex联合纳布啡组(DN组)和Dex组(D组)。DN组男16例,女14例,平均(41.93±10.62)岁,平均手术时长(250±27.36) min。D组男17例,女13例,平均(40.33±8.56)岁,平均手术时长(257.20±29.13) min。两组患者年龄、性别构成、手术时长等一般资料比较,差异无统计学意义(P > 0.05)。
1.2 研究方法
1.2.1 麻醉方法
常规禁饮禁食,未使用麻醉前用药。入室后监测HR、MAP、ECG、SpO2、BIS。两组患者均予以相同的麻醉方案,采用麻醉机面罩吸氧FiO2 100%,氧流量3~4 L/min。麻醉诱导:依次静脉推注咪达唑仑2 mg,芬太尼3~4 µg/kg,丙泊酚1.5~2.5 mg/kg,罗库溴铵0.6~0.8 mg/kg诱导,诱导结束经口插入相应(ID 6.5~8.0)钢丝导管。插管后行右颈内静脉穿刺置管,测CVP。麻醉维持:瑞芬太尼0.25~2 µg/(kg·min)、丙泊酚4~12 mg/(kg·h)持续微量泵泵入,维持BIS值在40~60之间。DN组在切皮前5 min静脉注射盐酸纳布啡0.2 mg/kg,于诱导前30 min予Dex1 µg/kg泵注10 min后改为0.5 µg/(kg·h),持续泵注至缝合硬脑膜前。D组中Dex给予方案同前,不给纳布啡。
术中若MAP、HR平稳,BIS值超过50则调大丙泊酚泵注量;若BIS值40~50,MAP、HR升高则调大瑞芬太尼泵注量;若心动过缓(HR < 50次/min)静注阿托品0.3~0.5 mg,低血压(平均血压低于基础值的70%和(或)MAP < 60 mmHg)予麻黄碱6~12 mg。
1.2.2 观察指标
记录术前(T1),诱导插管时(T2),切皮时(T3),清醒拔管时(T4)的心率血压。于术前(t1),术后2 h (t2),术后6 h (t3),术后24 h (t4)采集中心静脉血液2 mL,用流式细胞仪检测炎症相关因子白介素6(IL-6)、白介素10 (IL-10)、肿瘤坏死因子α(TNF-α)浓度。在术前、术后6 h、术后24 h、术后3 d、术后6 d进行MMSE评分。MMSE评分 < 24分者,判定为术后认知功能障碍(postoperative cognitive dysfunction,POCD)。
1.3 统计学处理
采用SPSS统计软件分析实验结果。计量资料服从正态分布用均数±标准差描述,两组不同时间点比较采用重复测量的方差分析,如有差异两组间比较采用独立样本t检验。P < 0.05为差异有统计学意义(α = 0.05)。
2. 结果
2.1 两组心率、平均动脉压、住院时间比较
与D组相比,DN组拔管后HR、MAP均较低(P < 0.05)。与术前相比,DN组插管时、切皮时HR、MAP均明显降低(P < 0.05);D组插管时MAP明显下降(P < 0.05),切皮时、拔管时HR、MAP明显下降(P < 0.05)。DN组住院时间平均(11.37±1.72) d,D组住院时间平均(12.63±1.65) d,DN组住院时间明显缩短(P < 0.05),见表1。
表 1 两组术中HR、MAP和住院时间比较($\bar x \pm s$ )Table 1. Comparison of intraoperative HR,MAP and hospitalization time between the two groups ($\bar x \pm s$ )组别 观察指标 术前 插管时 切皮时 拔管时 DN组 HR (次/min) 82.23 ± 4.85 77.03 ± 7.99# 77.73 ± 7.58# 81.03 ± 5.91* MAP (mmHg) 82.4 ± 4.35 74.77 ± 3.98# 77.70 ± 3.46# 82.50 ± 4.54* D组 HR (次/min) 82.43 ± 4.57 78.97 ± 6.81 78.83 ± 7.95# 87.23 ± 7.66# MAP (mmHg) 81.83 ± 4.28 74.93 ± 4.71# 77.93 ± 4.43# 85.30 ± 5.23# 与D组比较,*P < 0.05;与同组术前比较,#P < 0.05; 2.2 两组炎症反应比较
与D组相比,DN组IL-6、IL-10、TNF-α浓度在T1、T2、T3、T4时刻浓度较低(P < 0.05);与同组术前IL-6、IL-10、TNF-α浓度相比较,除T4时刻TNF-α浓度差异无统计学意义(P > 0.05),差异有统计学意义(P < 0.05)。DN组IL-6、IL-10、TNF-α浓度上升较D组小,见表2。
表 2 两组相同时间点炎症因子水平比较[($ {\bar{{x}}} \pm s$ ),pg/mL]Table 2. Comparison of inflammatory factor levels between the two groups at the same time point [($ {\bar{{x}}} \pm s$ ),pg/mL]组别 术前 2 h 6 h 24 h IL-6 IL-10 TNF-α IL-6 IL-10 TNF-α IL-6 IL-10 TNF-α IL-6 IL-10 TNF-α DN组 1.85±0.28 1.74±0.16 0.40±0.20 10.04±1.84*# 24.12±1.41*# 0.16±0.11*# 25.76±1.25*# 2.55±0.85*# 0.27±0.07*# 22.30±5.48*# 2.43±0.36*# 0.39±0.09* D组 1.94±0.38 1.75±0.15 0.38±0.17 18.26±2.34# 38.01±1.97# 0.60±0.08# 35.72±6.10# 11.59±1.34# 0.71±0.12# 49.58±5.51# 5.41±0.34# 0.79±0.11# 与D组比较,*P < 0.05;与同组术前比较,#P < 0.05。 2.3 两组术后认知功能比较
与D组相比,DN组术后6 h、24 h MMSE简易智力状态检查量表评分明显较高(P < 0.05);与术前相比,DN组6 h MMSE评分明显较低(P < 0.05),D组6 h、24 h MMSE评分明显较低(P < 0.05),见表3。
表 3 两组术后认知功能MMSE评分比较[(${\bar{{x}}}\pm s$ ),分]Table 3. Comparison of MMSE scores of postoperative cognitive function between the two groups [(${\bar{{x}}}\pm s$ ),scores]组别 术前 术后6 h 术后24 h 术后3 d 术后6 d DN组 27.37 ± 1.73 25.93 ± 2.18*# 26.33 ± 2.37* 26.77 ± 1.52 26.97 ± 1.71 D组 26.5 ± 1.93 24.80 ± 1.67# 25.10 ± 1.81# 27.33 ± 2.09 27.10 ± 1.79 与D组比较,*P < 0.05;与同组术前比较,#P < 0.05。 3. 讨论
脑膜瘤是起源于脑膜及脑膜间隙的肿瘤,多为良性,呈膨胀性生长。根据肿瘤位置不同,可以出现头痛、癫痫,视力、视野、嗅觉或听觉障碍及肢体运动障碍等[11]。手术切除是脑膜瘤最有效的治疗手段。
Dex与大脑蓝斑受体作用发挥镇静作用[12];同时,Dex通过结合脊髓后角α2受体抑制疼痛冲动向中枢传递,有一定的镇痛作用[13]。Ye Cai等[14]的研究表明α2受体激动剂可改善缺血性脑损伤的预后。纳布啡属吗啡喃类,是一种激动–拮抗镇痛药,结构上类似于阿片受体拮抗剂纳洛酮和强效阿片类镇痛药羟吗啡酮,镇痛效价与吗啡类似,但副作用较少[15]。研究发现,使用纳布啡可更有效的缓解神经外科手术后的疼痛[16]。本研究中,笔者对比Dex联合纳布啡和单独用于脑膜瘤手术中,发现联合用药组术中生命体征更稳定,术后生命体征与术前差异更小,住院时间缩短。保持稳定的生命体征有利于维持患者器官灌注稳定,减少不良预后,说明联合用药更有利于维持生命体征稳定。
颅内病变或手术可激活蓝斑去甲肾上腺素轴和下丘脑-垂体-肾上腺轴以及刺激免疫系统,导致激素和促炎细胞因子分泌增加[17]。TNF-α,IL-6是中枢神经系统神经炎症的主要介质,并且首先在缺血性脑损伤的急性期引发[18]。适当释放炎症介质与神经保护有关但过度炎症反应可能导致神经细胞肿胀和坏死。Dex可通过Nrf2信号通路减轻创伤性脑损伤后神经炎症,显着下调炎症反应因子TNF-α,IL-1β和NF-κB以及IL-6[19]。纳布啡用于老年胸科手术中可使患者血清中TNF-α和IL-6浓度降低[20]。笔者发现与D组相比,DN组在相同时刻IL-6、IL-10、TNF-α浓度较低,与同组术前比较,DN组IL-6、IL-10、TNF-α浓度上升较D组小。
术后认知功能障碍(postoperative cognitive dysfunction,POCD)是指术后出现的人格、社交能力及认知能力和技巧的变化,表现为精神错乱、焦虑、人格的改变以及记忆受损等[21-22]。研究发现,在老年髋关节手术中,右美托咪定镇静的患者术后谵妄和术后认知功能障碍的发生率都较丙泊酚更低较低,出院时间更短[23]。笔者发现,两组在术后24 h内MMSE评分均较术前降低,但联合用药较单用Dex MMSE评分较高,术后认知功能恢复较快。说明联合用药更有利于患者术后认知功能恢复。
联合用药可降低患者血清中TNF-α,IL-6和IL-10水平,减轻患者全身炎症反应。研究发现,目前认为术后认知功能障碍可能的机制与炎症密切相关,炎性因子以直接通过血脑屏障破坏或激活多种信号通路等方式引发中枢系统炎症[24]。炎症因子直接或间接影响方患者的认知功能,引发POCD[25]。所以,笔者认为患者MMSE评分差异与联合应用右Dex及纳布啡降低患者全身炎症反应有关。
综上所述,在脑膜瘤术中,联合应有Dex和纳布啡较单独应用Dex可降低患者全身炎症反应,更有利于维持术中术后生命体征平稳,患者术后苏醒更快,住院时间更短,是更有利的麻醉用药方式。
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表 1 倾向性评分匹配前后两组患者基线特征 [n(%)/M(Q1,Q3)]
Table 1. The baseline characteristics of the two groups before and after PSM [n(%)/M(Q1,Q3)]
变量 PSM前 PSM后 ERAT组
(n = 30)LA组
(n = 411)χ2/Z P ERAT组
(n = 30)LA组
(n = 30)χ2/Z P 年龄[M(Q1,Q3)岁] 54(33,61) 32(25,49) −3.628 <0.001* 54(33,61) 38(26,24) −0.628 0.534 性别[n(%)] 0.002 0.961 0.000 1.000 男 13(43.3) 180(43.8) 13(43.3) 13(43.3) 女 17(56.7) 231(56.2) 17(56.7) 17(56.7) 合并症[n(%)] 高血压 5(16.7) 31(7.5) 3.105 0.078 5(16.7) 2(6.7) 1.456 0.228 糖尿病 2(6.7) 12(2.9) 1.277 0.258 2(6.7) 2(6.7) 0.000 1.000 冠心病 0(0) 2(0.5) 0.147 0.702 0 0 生活习惯[n(%)] 吸烟 6(20) 68(16.5) 0.239 0.625 6(20) 4(13.3) 0.480 0.488 饮酒 3(10) 36(8.8) 0.053 0.817 3(10) 2(6.7) 0.218 0.640 *P < 0.05。 表 2 手术前及术后24 h炎性指标水平比较 [M(Q1,Q3)]
Table 2. Comparison of inflammatory marker levels before and 24 hours after operation [M(Q1,Q3)]
组别 WBC(×109/L) 中性粒细胞计数(×109/L) CRP(mg/L) 手术前 术后24 h 手术前 术后24 h 手术前 术后24 h LA组
(n = 30)9.78
(6.55,13.97)7.01
(5.23,8.12)7.61
(3.98,11.71)4.30
(3.32,6.47)8.30
(4.69,72.21)4.81
(0.80,29.51)ERAT组
(n = 30)10.29
(7.66,14.56)10.13
(8.98,12.08)8.09
(5.06,12.79)8.30
(6.56,10.25)7.29
(1.77,24.46)18.27
(6.92,50.68)Z −1.079 −4.243 −1.109 −4.421 −1.124 −2.575 P 0.280 <0.001* 0.267 <0.001* 0.267 0.010* *P < 0.05。 表 3 术中情况及手术前后疼痛度比较 [M(Q1,Q3)]
Table 3. Comparison of intraoperative conditions and pain level before and after surgery [M(Q1,Q3)]
组别 ERAT组(n = 30) LA组(n = 30) Z P 手术时间(min) 37(27,62) 50(45,60) 1.863 0.062 术中失血量(mL) 0.0(0.0,0.0) 5.0(5.0,5.0) 5.744 <0.001* VAS 评分 术前 8.0(8.0,9.0) 8.0(8.0,9.0) −0.362 0.696 术后6 h 3.0(2.0,4.0) 6.0(5.0,7.0) 6.490 <0.001* 术后24 h 0.0(0.0,0.0) 2.0(1.0,2.0) 6.047 <0.001* *P < 0.05。 表 4 2组患者术后第3天手术疗效对比 [n(%)]
Table 4. Comparison of surgical efficacy between the two groups on the third day after operation [n(%)]
组别 n 显效 有效 无效 总有效率(%) ERAT组 30 21(70.0) 9(30.0) 0(0) 100.0 LA组 30 14(46.7) 15(50.0) 1(3.3%) 96.7 χ2 1.017 P 1.000 -
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