Clinical And Basic Comparative Analysis Of Laparoscopic Versus Conventional Splenectomy

PartⅠClinical Comparative analysis of laparoscopic versus conventional splenectomyBackground: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. PartⅡComparison between inflammatory responses after laparoscopic and conventional splenectomyObjective: 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(P>0.05) . Serum IL-6, TNF-alpha, IL-1β, IFN-γ, 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-α,IL- 6,IFN-γ,IL-4,IL-1β,CRP,WBC and NE were not different between each group(P>0.05). 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(P<0.05). 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(P<0.05) were significantly lower in laparoscopic group than those in conventional group. peritoneal drainage fluid (PDF) TNF-αand CRP levels were significantly lower in laparoscopic group than that of conventional group(P<0.05).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 functionBecause of its advantages such as small incision, fast recovery and less pain, laparoscopic operation has been quickly popularized and widely used all over the world. According to recent study, the stress response caused by the surgical operation more or less affects the immune function of the body. To which extent the immune function is suppressed is related to the occurrence of infection or sepsis.Immune Function which refers to defense capability of the body against infection includes immunological defense, immunological homeostasis and immunological surveillance. In the immunoglobulin, the IgG antibody activates complement system through its combination with the complement. Because of its affinity to Fc receptors on the cell surface, it activates phagocytosis'and macrophages'neutrophils and the killing function of cytotoxicity K cells to target cells so as to neutralize or deal with the antigens. IgM is the major antibody of primary immune response, and IgA comes from the alimental and respiratory tract mucosa, fending off infection to mucosa. The operation wound can bring down complement activation component and serum complement level to an extent in proportion to the seriousness of wound. As immune competent cells serving the function of immunological surveillance, T lymphocytes can be divided into CD3 (total T lymphocytes), CD4( helper/inductor T cells), CD8(suppressor / cytotoxic T cells), CD(16+56)(NK cell) and total B lymphocytes(CD19). Under normal circumstances, CD4/CD8 can maintain dynamic stability, reflect and respond to changes in the immune state of the body. The lymphokines released by activated t lymphocytes can suppress or kill pathogenic microorganism directly or indirectly and immune against re-infection of pathogenic microorganisms. Therefore, immunoglobulin, complement and T lymphocytes are significant to resisting bacteria and toxic infection.Although, at home and abroad, there are some results of researches on the influence and scope of influence of laparoscope technology on immune function, nothing has been mentioned about the splenectomy. Therefore, we have conducted a forward-looking comparison research, and investigated the changes of serum immunoglobulin, complements and T lymphocytes after laparoscope and open Splenectomy respectively so as to explore the relations between Laparoscope and Open Splenectomy on the one hand and their influences to immune function of the body on the other and expound on the privilege of the laparoscopic operation.Fasting plasma glucose on patients is carried out on the second day after their hospitalization, the first day and fifth morning after the operation. Serum are separated and tested within 2 hours.2.1 Test of Immunoglobulin and complement: BN-II Automatic Specific Protein Analyzer and original reagent of Dade Behring Company are utilized to adopt the detection of immune nephelometry2.2 Test of lymphocyte Subsets: With the assistance of flow cytometry and SYSTEM TM II SOFTYWARE V 3.0 provided by Coulter, USA and monoclonal antibody reagents (including IgG 1-FITC/IgG 1-PE, CD3-EITC/CD4-PE, CD3-FITC/CD8-PE, CD3-FITC/CD(16+56)-PE, IgG1-PE, IgG2a-FITC, CD10-PE, CD3-PE, CD4-PE, CD8-PE ), the test is conducted through phenotype notation and flow cytometry analysis.Patients of the two groups have a sound recovery, without any post-operation complications. Both LS and OS group Immunoglobulin level and complement level are lower those before the operation. The difference between two groups is insignificant ( p>0.05). The comparison between pre and post operation in LS group indicates no difference(p>0.05 ) But serum C3 on the first and the fifth day after operation were 0.97±0.24g/L and 1.12±0.23g/L respectively, noticeably lower than 2.19±0.26g/L, the pre-operation level. Serum IgG were 11.45±2.24g/L and 11.93±3.05g/L respectively on the first and the fifth day after operation, significantly lower than 13.09±1.96g/l which was the pre-operation level, with an obvious difference(p<0.05 or p<0.01). Compared to LS group ,the decline range in OS group is more evident(p<0.05 or p<0.01). Moreover, in the OS group, CD8(suppressor / cytotoxic T cells), CD(16+56)(NK cell) and total B lymphocytes(CD19) decrease slightly after the operation with an insignificant difference(p>0.05) In OS group, CD3(total T lymphocytes) level on the first and the fifth day after operation was 55.98±4.08% and 51.03±4.02% respectively, falling significantly compared to 57.88±2.97%, the pre-operation level, with a clear difference(p<0.05 ). CD4( helper/ inductor T cells) in the OS group was 1.54±0.69 and 1.25±0.87, lower than 1.37±0.72, the pre-operation level, with an obvious difference(p<0.05 ). But in LS group, CD3(total T lymphocytes), CD4( helper/inductor T cells), CD8(suppressor / cytotoxic T cells), CD(16+56)(NK cell) , total B lymphocytes(CD19) and CD4/CD8 level only dropped a little on the first day after the operation and restored the pre-operation level on the fifth day after the operation, with an insignificant difference(p>0.05 ). The comparison between groups demonstrated obvious differences.