Bölke E, Jehle P M, Graf M, Baier A, Wiedeck H, Steinbach G, Storck M, Orth K
Departments of Surgery, University of Ulm, Germany.
Shock. 2001 Nov;16(5):334-9. doi: 10.1097/00024382-200116050-00002.
Several studies have been demonstrated that endotoxin is a potent stimulus of the acute inflammatory response following traumatic injury. Although numerous studies have indicated that the extent of surgical intervention correlates well with the inflammatory response, the potential role of endotoxin as a trigger under those conditions still remains unknown. Therefore, the aim of this study was to elucidate whether or not the up-regulated inflammatory mediators are paralleled by increased endotoxin plasma levels during and following surgery, and whether the extent of surgical intervention represents a crucial factor under those conditions. To study this, plasma was collected at various time points during and after surgery from 52 patients subjected to abdominal surgery (i.e., major surgery) and 25 patients subjected to thyroid surgery (i.e., minor surgery). Plasma was assessed for endotoxin, endotoxin neutralizing capacity (ENC), and inflammatory mediators (leucotriene-C4 [LTC4]-, 6-keto-prostaglandin-F-1-alpha [PGF]-, thromboxane-B2 [TxB2], interleukin-6 [IL-6], and C-reactive protein [CRP]). Furthermore, splanchnic blood circulation was measured by determination of the intraluminal pH of the stomach and sigma (pHi) by intraluminal tonometry. Mesenteric lymph nodes were also collected at the time point of organ mobilization in the major surgery group and were assessed for bacterial translocation. Among all parameters investigated, endotoxin showed the most rapid changes. A significant increase in plasma levels of endotoxin and a decrease of ENC were found in the major surgery groups following induction of anesthesia and in the minor surgery groups after skin incision. Moreover, the incidence of elevated endotoxin levels was significantly higher (89% with elevated endotoxin levels) than the incidence of bacterial translocation (35% with gram-negative bacteria) in mesenterial lymph nodes of the major surgery group. pHi decreased significantly in both groups after skin incision, but no difference was observed between the major and minor surgery groups. Plasma mediators of the arachidonic acid cascade (LTC4, PGF, and TxB2) were only elevated in individual patients during and following surgery in both groups. Conversely, the post-operative increase in the acute phase mediators was significantly different in the major and minor surgery groups. IL-6 plasma levels peaked higher and earlier after major surgery than after minor surgery and the delayed increase of CRP was significantly greater in the major surgery group. In conclusion, the results indicate that plasma levels of endotoxin significantly correlate with the severity of the surgical intervention and may play an important role in inducing mediators of the acute phase reaction under such conditions.
多项研究已证明，内毒素是创伤性损伤后急性炎症反应的有力刺激因素。尽管众多研究表明手术干预的程度与炎症反应密切相关，但在这些情况下内毒素作为触发因素的潜在作用仍不清楚。因此，本研究的目的是阐明手术期间及术后炎症介质上调是否与血浆内毒素水平升高平行，以及手术干预程度在这些情况下是否是一个关键因素。为了研究这一点，在手术期间及术后的不同时间点，从52例接受腹部手术（即大手术）的患者和25例接受甲状腺手术（即小手术）的患者中采集血浆。对血浆进行内毒素、内毒素中和能力（ENC）以及炎症介质（白三烯-C4 [LTC4]、6-酮-前列腺素-F-1-α [PGF]、血栓素-B2 [TxB2]、白细胞介素-6 [IL-6] 和C反应蛋白 [CRP]）的评估。此外，通过测定胃腔内pH值（pHi）并采用腔内张力测定法来测量内脏血液循环。在大手术组器官游离时也采集肠系膜淋巴结，并评估细菌移位情况。在所有研究参数中，内毒素变化最为迅速。在大手术组麻醉诱导后以及小手术组皮肤切开后，发现血浆内毒素水平显著升高，而ENC降低。此外，大手术组肠系膜淋巴结内毒素水平升高的发生率（89%内毒素水平升高）显著高于细菌移位的发生率（35%革兰氏阴性菌）。两组在皮肤切开后pHi均显著降低，但大手术组和小手术组之间未观察到差异。花生四烯酸级联反应的血浆介质（LTC4、PGF和TxB2）在两组手术期间及术后仅在个别患者中升高。相反，大手术组和小手术组术后急性期介质的升高存在显著差异。大手术后IL-6血浆水平达到峰值的时间比小手术后更高且更早，大手术组CRP的延迟升高也显著更大。总之，结果表明血浆内毒素水平与手术干预的严重程度显著相关，并且在这种情况下可能在诱导急性期反应介质方面发挥重要作用。
