| Part1The clinical contrast research of goal directed therapy in laparoscopic hepatectomyObjective To evaluate the clinical application value of the goal directed therapy for the patients undergoing laparoscopic hepatectomy prospectively comparing with the traditional fluid therapy.Methods From January2012to July2013, a total of44laparoscopic hepatectomy cases in the laparoscopic center of a hospital were prospectively adopted in our research and racdomly assigned to two groups by computer, in which21cases in the goal directed group(GDT) with CI2.5-4L/minxm2and SVV<13%, and23cases in the traditional fluid therapy group(CVP) with CVP5-12mmHg and MAP65-90mmHg. All the operations were done by the same surgeon team, and all the cases were introduced general anesthesia and trachea intubation. The purpose was to compare the clinical outcomes of the operative time, CO2pneumoperitomeum time, hepatectomy time, fluid volume, blood loss, urine output, transfusion, invasive artery pressure, heart rate, results of blood gas during operation, extubation time, postoperative passage of gas, time of resume diet, out-of-bed activity, surgical complication, postoperative hospital stay and hospitalization cost between the two groups. VAS score and analgesia within3days, vital signs, abdominal drainage and compilication, some lab data (CBC, biochemical examination and blood coagulation) within7days were also compared between group GDT and group CVP.Results A total of44cases were included in the research with3cases excluded for conversion to laparotomy. There were21cases in group GDT and23cases in group CVP. No difference was observed in age, gender, BMI, ASA, Child grade, type of diseases and surgery between these two groups, neither in operative time, CO2pneumoperitomeum time, hepatectomy time, blood loss, urine output and transfusion (P>0.05). Less colloid was needed in group GDT than group CVP (P<0.05). Group GDT had a higher PH during hepatectomy, a higher level of BE when establishing CO2pneumoperitomeum and reverse trendelenburg position, higher PaCO2during whole CO2pneumoperitomeum (P<0.05) compared with group CVP. There was no difference neither in vital signs and EtCO2, nor in the other results of blood gas during the operation (P>0.05). The patients in group GDT were extubated and pass gas earlier after operation than group CVP, together with less hospitalization cost (P<0.05). But there was no difference in terms of time of resuming diet, out-of-bed activity, surgical complication or postoperative hospital stay between the two groups (P>0.05). Group GDT had less drainage from3rd day to7th day after surgery comparing with group CVP (P<0.05), but with equal vital signs and analgesia condition (P>0.05). Group GDT had a lower level of WBC on3rd day, higher level of hemoglobin and shorter APTT on5th day, and higher level of fibrinogen on7th day after surgery (P<0.05). Group GDT also had lower level of ALT from3rd day to7th day after surger and lower level of AST on5th day after surgery(P<0.05).Conclusion Goal directed therapy help the patients undergoing laparoscopic hepatectomy maintain stable hemodynamic states with less colloid demand compared with traditional fluid therapy. GDT also had clinical advantages than traditional fluid therapy with better liver function and coagulation, mild inflammation, earlier recover of bowl function and less hospitalization cost. Part2The effect of goal directed therapy on the acute inflammatory stress of the patients undergoing laparoscopic hepatectomyObjective To compare the effect of goal directed therapy on the acute inflammatory stress of the patients undergoing laparoscopic hepatectomy with traditional fluid therapy.Methods From January2012to July2013, a total of44laparoscopic hepatectomy cases in the laparoscopic center of a hospital were prospectively adopted in our research. The details of grouping, anesthesia and surgery were seen in Part1. Comparing the number of WBC, NE%, level of cytokines (IL-6, IL-10, TNF-a) and acute phase reactive proteins (CRP, SAA, HSP70), cortisol and insulin of peripheral blood samples between the two groups within7days after surgery. Insulin resistance index (HI) and SIRS frequency were also compared between group GDT and group CVP during the same period.Results There was no statistical difference in the preoperative level of cortisol, insulin, blood glucose and HI between the two groups(P>0.05). Group GDT had an obvious lower level of cortisol at3hours and12hours after surgery (P<0.01), a lower level of blood glucose and insulin from12hours after surgery to3rd day (P<0.05), contributing to a lower HI within3days after surgery (P<0.05), comparing with group CVP. Group GDT had a lower mobidity of SIRS on the1st day after surgery than group CVP (42.86%vs73.91%, P<0.05). There was no difference in cytokines and acute phase reactive proteins before surgery between the tow groups (P>0.05). Group GDT had a lower level of IL-6in than group CVP (P<0.05for12h-3rd day postoperative and P<0.01for5th-7th day postoperative). Group GDT had a higher level of IL-10than group CVP within7days after surgery except the5th day (P<0.05), but a lower level of TNF-a (P<0.05, at12hours,1st day,3rd day and7th day after surgery) comparing with group CVP. The level of HSP70in group GDT was lower than that of group CVP from12hours to3rd day after surgery(p<0.05), and a lower level of SAA in group GDT within3days after surgery (P<0.05). Group GDT had a lower level of CRP than group CVP at12hours and24hours after surgery (P<0.05).Conclusion Goal directed therapy could reduce the level of stress-related hormone, inflammatory cytokines and acute phase reactive proteins of the patients undergoing laparoscopic hepatectomy, and could inhibit insulin resistance and SIRS after surgery comparing with traditional fluid therapy. That suggested goal directed therapy could alleviate postoperative inflammatory stress and help to accelerate the recovery. Part3The effect of goal directed therapy on immune system of the patients undergoing laparoscopic hepatectomyObjective To compare the effect of goal directed therapy on the immune system of the patients undergoing laparoscopic hepatectomy with traditional fluid therapy.Methods From January2012to July2013, a total of44laparoscopic hepatectomy cases in the laparoscopic center of a hospital were prospectively adopted in our research. The details of grouping, anesthesia and surgery were seen in Part1. Comparing the level of CD3/CD4/CD8+of T lymphocytes, NK cells and CD14/HLA-DR of monocyte in the peripheral blood between group GDT and group CVP both preoperative and postoperative (1st,3rd,5th,7th day after surgery). The level of IgA, IgM, IgG, C3and C4was also compared between the two groups both preoperative and postoperative (1st,3rd,5th,7th day after surgery).Results No statistical difference in the level of CD3+T cell was observed between group GDT and group CVP (P>0.05). Group GDT had a higher level of CD4+T cell and higher ratio of CD4/CD8+in group GDT during postoperative period compared with group CVP (P<0.05). Group GDT also had a higher level of NK cells on5th day and7th day after surgery compared with group CVP (P<0.05), together with a high level of CD14+/HLA-DR+on3rd,5th and7th day after surgery (P<0.05). The levels of IgA on3rd day, IgG and IgM on1st and3rd day and C4on1st day after surgery were higher in group GDT than in group CVP (P<0.05). There was no statistical difference in the targets at any other time between the two groups (P>0.05).Conclusion The immune function of the patients undergoing laparoscopic hepatectomy was slightly suppressed during early postoperative period. The level of immune cells and immunoglobulin of group GDT was higher than that of group CVP during early postoperative period as a whole, suggesting that GDT contribute to better protection of immune system compared with traditional fluid therapy after surgery. |
