| Thyroid disease is a common disease,it can be seen more freqnently in young women.Traditional open thyroidectomy is a safe and effectinve method for thyroid disease,but a 5cm～8cm long surgical scar will be present in neck region after operation,it is hard to accept for modern young people,especially for young woman.With the quick update of laparoscopic instruments and development of endoscopic technic,the applications and indications of endoscopic surgery have been expanded gradually.Many surgical specialists attempted to perform endoscopic thyroidectomy and succeeded since the first endoscopic thyroidectomy in 1997.Presently,endoscopic thyroidectomy and parathyroidectomy have been carried out in many minimal invasive medical centres in the world.Although clinical datas have demonstrated that endoscopic thyroidectomy has an advantage in aspects of pain and functional recovery compared with open thyroidectomy,the trauma induced from endoscopic thyroidectomy is still shot of systematic and scientific evidence.Surgery,trauma-induced tissue trauma can cause the body produce a series of neuroendocrine changes in metabolism,that is,the stress response in order to adapt to environmental changes at a certain range,the greater the trauma,the more intense stress response,stress the extent of reaction and the size of surgical trauma.Traumatic stress can lead to,including the hypothalamus - pituitary - adrenal axis(hypothalamic-pitutiary-adrenalaxis,HPA) endocrine changes in the sympathetic nervous system and liver of the acute phase response(acute-phase-response,APR),including a series of conditioning system adaptability to change.TNF-αis a kind of be able to direct tumor cell death caused by cytokines.According to its origin and structure divided into two types, namely,TNF-αand TNF-β.The former is mainly produced by macrophages, T cells and NK cells in some under-stimulating factor can also secrete TNF-α;the latter mainly by activated T cells,T cells in the antigen, mitogen,such as stimulation can produce high levels of TNF-β.Human activity forms of TNF-αby the three elements 17ku trimer,TNF-αreceptor exists in almost all cell types,large doses of TNF-αcan cause cachexia,low concentrations of TNF - biological activity ofαis mainly expressed in anti-infection,causing inflammation and anti-tumor response.Surgical trauma stress may directly or indirectly caused by TNF-αsynthesis and release increase,TNF-αproduced substantial and into the blood can cause systemic reactions,such as for endogenous pyrogen caused fever,acting on monocytes and vascular endothelial cells, Stimulate IL-1 and IL-6 secretion,acting on the liver cells to increase the liver synthesis of acute phase proteins,also can directly stimulate the hypothalamic regulation of body temperature caused by central heating. Early post-traumatic emergence of TNF-αcan be used as tissue injury and cell-mediated immune response to the main effects of pathological material,are an indicator of stress response.IL-6 are stimulated by injury at surgery from monocytes and macrophages secreted.IL-6 can act on the body a wide range of target cells, tissue damage is not only an important marker,but also in the body after injury acute phase response plays an important role,Research has shown that it is first of all induced the production of acute-phase response, then stimulating the liver cells to produce C-reactive protein(CRP). Therefore consider IL-6 than the janitor's room Unification of CRP is more sensitive and more valuable,more accurately reflect the situation of body trauma.IL-6 are mediated stress the pathophysiological process of the most important one of inflammatory mediators,surgical trauma may be caused,directly or indirectly,IL-6 synthesis and release increase.IL-6 increased with the surgical stimulation and the extent of tissue injury and postoperative complications are closely related.Surgical stress lead to vascular endothelial dysfunction,decreased immunity,are the original heart,cerebrovascular diseases aggravated or serious complications occurred in the main mechanism.Ouchterlony,such as looking through epidemiological studies(1361 cases) found that the majority of intraoperative and postoperative adverse events happen with the degree of surgical stress were significantly correlated.IL-6 are mediated stress the pathophysiological process of the most important one of inflammatory mediators,surgical trauma may be caused,directly or indirectly,IL-6 synthesis and release increase.IL-6 increased with the surgical stimulation and the extent of tissue injury and postoperative complications is closely related,IL-6 levels than the early complications occurred 12 ~ 48h,before and after surgery in serum IL-6 levels contribute to determine the extent of surgical stress and indicate the occurrence of complications.Discovered Baigrie,such as IL-6 with or without complications in two groups of patients similar changes in the way,only those who have complications of IL-6 levels were elevated over, and the duration longer,a further indication of the level of IL-6 are reflect a sensitive index of tissue injury and surgical trauma itself, the level of IL-6 are the main reason for increased.IL-1 infection and inflammation are at state,from a variety of cells and has many biological functions of cytokines,their biological role is very broad,including participation in mediated inflammatory response, regulating immunity and metabolism.The results showed that,IL-1 in the stress response in a variety of physiological and pathological processes play a key role in stress occurs when the central IL-1 activity and hypothalamic IL-1 mRNA expression.Central injection of IL-1 and stress response is also very similar,have demonstrated for the sympathetic nervous system activity,the hypothalamus - pituitary - adrenal(HPA) axis activation,and abnormal behavior may occur.Surgical trauma stress reaction caused by the large number of IL-1 secretion,endocrine hormone into the blood flow exert the role of INF-αwith the same effect,such as caused by fever,induction of liver acute phase protein synthesis and catabolism caused by consumption.Therefore,it may be considered that IL-1 antagonist or IL-1 receptor blocker used to reduce the surgical stress response to trauma.Outside and inside of body,the experiment have been proved by monocytes, fibroblasts,lymphocytes and endothelial cells produced TNF-α,IL-6 and IL-1βis a multifunctional cytokine involved in the body's stress response and immune response,Post-traumatic acute phase,TNF-α,IL-6 and IL-1βare induced hepatocyte synthesis of acute reactive protein, the major cytokines,the body after surgery TNF-α,IL-6 and IL-1βlevels and the size of surgical trauma was positively correlated reflects the extent of tissue damage the most sensitive indicators.In this study,the traditional thyroidectomy(traditional thyroidectomy,TT) as a control,through the detection of patients with preoperative and postoperative 6h,24h,72h in serum and wound cavity drainage fluid cytokine TNF-α,IL-6 and IL-1βlevels to compare the levels of cytokines inter-group differences,analysis of traditional thyroid surgery with areola approach Endoscopic Thyroidectomy on the body and systemic effects of local trauma to explore the areola approach of minimally invasive endoscopic thyroidectomy significance,guiding clinical adopting measures to prevent the stress response is too intense or adjust the imbalance to reduce the stress brought about the harm to the body,so that patients with minimally invasive access to beauty and the dual effect.Objective:To investigate the degree of trauma to the body of endoscopic thyroidectomy through prospective,non-randomized controlled clinical trial,and to evaluate the minimal invasive significance of endoscopic thyroidectomy.Methods:20 patients that received endoscopic thyroidectomy by anterior chest breast areola approach formed the experimental group, while 20 patients that received kopen thyroidectomy formed the controlled group.Serum values of tumor necrosis factor-alpha(TNF-a), interleukin-6(IL-6),interleukin-1β(IL-1β),white blood(cell) count(WBC) and body temperature(BT) were measured at time points of 1 day before operation,6hours,24 hours and 72 hours after operation.To compare the degrees of related stress responses to the body,and to compare the changes in preoperative and postoperative body temperature,operation time,blood loss during operation,hospital stay,visual analogue scales and postoperative analgesic usage between the two groups.Results:40patients completed the experiment successfully and no complication occurred.1.There was no significant differences between experimental and control group on cases(male/female),age,body weight,tumor size and pathologic diagnosis.On this condition,The operation time of experimental group was singnificantly loger than that of control group(87.24±18.3min and 57.85±12.3min,respectively)(P＜0.01).The blood loss during the operation of endoscopic thyroidectomy group was significant less than that of open thyroidectomy group(45.32±8.25ml and 57.63±9.18ml,respectively)(P＜0.01).The hospital stay after endoscopic thyroidectomy was significantly shoter than after open thyroidectomy(4.21±0.86d and 5.32±1.05 d,respectively)(P＜0.05);Test group of patients with post-operative analgesic drug consumption(strong pain will be 0.1mg / support) for 0.1±0.15 and 0.1±0.2 in control group showed no significant difference(p＞0.05);surgical incision after surgery in patients with the beauty of the evaluation results show test group of patients satisfied with the cosmetic score 9.3±0.8 higher than 8.4±1.0,(p＜0.05).2.Two groups of patients 6 h after surgery in patients with serum and wound cavity drainage fluid TNF-αconcentration reached a peak after 6 h in patients with wound cavity drainage fluid TNF-αconcentration in the control group was significantly higher than the experimental group, there is statistical difference between the two groups significance(p＜0.05);Group Comparison of the experimental group after 72 h of serum TNF-αconcentrations have dropped to pre-operative level(p＞0.05), while the control group 72 h after surgery in patients with serum concentrations of TNF-αlevel was still higher than before surgery(p＜0.05);The control group each time point after surgery in patients with serum and wound cavity drainage fluid TNF-αconcentrations were higher than the experimental group.3.Two groups of patients 6 h after surgery in patients with serum and wound cavity drainage fluid IL-6 concentrations reached a peak,after 6 h of serum and wound cavity drainage fluid IL-6 concentration in the control group was significantly higher than the experimental group,two sets of differences have statistical significance(p＜0.05);Group Comparison of the experimental group after 72 h of serum IL-6 concentrations have dropped to pre-operative level(p＞0.05),while the control group 72 h after surgery in patients with serum IL-6 concentration was still higher than pre-operative level(p＜0.05);The control group each time point after surgery in patients with serum and wound cavity drainage fluid IL-6 concentrations were higher than the experimental group.4.Two groups of patients 6 h after surgery in patients with serum and wound cavity drainage fluid concentrations of IL-1βreached a peak after 6 h of serum and wound cavity drainage fluid IL-1βconcentration in the control group was significantly higher than the experimental group,the two Group differences were significant(p＜0.05);Group Comparison of the experimental group after 72 h of serum IL-1βconcentrations have dropped to pre-operative level(p＞0.05),while the control group 72 h after surgery in patients with serum IL-1βconcentration was still higher than pre-operative level(p＜0.05);the control group each time point after surgery in patients with serum and wound cavity drainage fluid IL-1 concentrations were high in the experimental group.5.Two groups of patients with body temperature are at 6h after the operation began to increase(p＜0.05),at a peak 24h after surgery(p＜0.01),then gradually decreased,72h after the operation down to the level before surgery(p＞0.05);Comparison between the two groups after the operation temperature of the various de facto standards,with the exception of the test group 24h after surgery was significantly lower than the control group(p＜0.05),the other point in time there was no significant difference(p＞0.05).6.Two groups of patients with WBC at 6h after the operation has increased, reached a peak 24h after surgery and then gradually decreased 72h after the operation was still higher than the level before surgery(p＜0.05); comparison group after the operation each time point WBC levels,the experimental group were significantly lower than the control group(p＜0.05). 7.Two groups of patients in post-operative VAS score reached a peak 6h after surgery and then gradually declined to compare groups in all post-operative VAS score point level,after the operation 6h,24h test group were significantly lower than the control group(p＜0.05)Conclusion:The level of body's stress response to surgical trauma in endoscopic thyroidectomy is less than that in the traditional open thyroidectomy;endoscopic thyroidectomy has better cosmetic results and higher patient satisfaction. |
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