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Article(id=1322210900975669536, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322210840242139234, articleNumber=null, orderNo=null, doi=10.16016/j.2097-0927.202410091, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1729612800000, receivedDateStr=2024-10-23, revisedDate=1739721600000, revisedDateStr=2025-02-17, acceptedDate=null, acceptedDateStr=null, onlineDate=1793169244283, onlineDateStr=2026-10-28, pubDate=1744646400000, pubDateStr=2025-04-15, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793169244283, onlineIssueDateStr=2026-10-28, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793169244283, creator=13701087609, updateTime=1793169244283, updator=13701087609, issue=Issue{id=1322210840242139234, tenantId=1146029695717560320, journalId=1319373162502258839, year='2025', volume='47', issue='7', pageStart='629', pageEnd='748', issueExtLink='null', onlineDate='null', pubDate='1744646400000', pubDateStr='2025-04-15', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1793169229803, creator='13701087609', updateTime=1793325214855, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext={EN=IssueExt(id=1322865089049383299, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322210840242139234, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1322865089049383300, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322210840242139234, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null, downloadFileDto=null}, startPage=720, endPage=727, ext={EN=ArticleExt(id=1322210903051850017, articleId=1322210900975669536, tenantId=1146029695717560320, journalId=1319373162502258839, language=EN, title=Protective effect of paravertebral nerve block combined with general anesthesia on postoperative liver injury in patients undergoing laparoscopic hepatectomy, columnId=1320435174995772212, journalTitle=Journal of Army Medical University, columnName=Clinical Medicine, runingTitle=null, highlight=null, articleAbstract=

To investigate the protective effect of paravertebral nerve block combined with general anesthesia on liver injury after laparoscopic hepatectomy (LH).

‍A randomized controlled trial was conducted on 51 patients undergoing LH in our hospital between April and August 2024. They were randomly divided into control group (n=25, general anesthesia) and paravertebral block group (n=26, paravertebral nerve block before general anesthesia induction). Beside anesthesia, they received same other medical treatment. The following indicators were compared between the 2 groups, that is, serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL) and albumin (ALB), and systemic-immune inflammation (SII) index within 7 d before and on the 1st and 2nd days after surgery; heart rate and mean arterial pressure (MAP) before anesthesia induction (T1), before pneumoperitoneum establishment (T2), pneumoperitoneum establishment (T3), and at the first hilar occlusion (T4); usages of intraoperative norepinephrine, sevoflurane, and analgesic drugs 24 h postoperatively; as well as operation time, extubation time, and lengths of postanesthesia care unit (PACU) stay and hospital stay.

The paravertebral block group had significantly lower ALT on the 1st day after surgery [178.40 (126.55, 325.86) vs 292.20 (197.20, 468.95) U/L], SII on the 2nd day after surgery [704.13 (486.61, 1 078.59) vs 1 075.09 (753.80, 1 614.38)], and amount of analgesic drugs in 24 h after surgery [29.70 (27.37, 32.07) vs 31.99 (28.92, 40.81) mg], and decreased MAP level at T3 and T4, early extubation, and shorter lengths of PACU stay and hospital stay when compared with the control group (all P<0.05).

Paravertebral nerve block combined with general anesthesia can reduce inflammatory responses, relieve postoperative pain, stabilize hemodynamics for patients undergoing LH, and thereby alleviate postoperative liver injury in them.

, authors=Yuxi SONG, Xiao XU, Xian GAO, Jiaxiang DUAN, Jing WEN, Jiaolin NING, authorsList=Yuxi SONG, Xiao XU, Xian GAO, Jiaxiang DUAN, Jing WEN, Jiaolin NING, authorCompany=null, correspAuthors=Jiaolin NING, authorNote=null, correspAuthorsNote=null, copyrightStatement=© 2025 Journal of Army Medical University, copyrightOwner=Editorial Office of Journal of Army Medical University, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1322210903798436130, articleId=1322210900975669536, tenantId=1146029695717560320, journalId=1319373162502258839, language=CN, title=椎旁神经阻滞复合全身麻醉对腹腔镜下肝切除术后肝损伤的保护作用, columnId=1322185541475488183, journalTitle=陆军军医大学学报, columnName=临床医学, runingTitle=null, highlight=null, articleAbstract=
目的

探究椎旁神经阻滞复合全身麻醉对腹腔镜下肝切除（laparoscopic hepatectomy，LH）术后肝损伤的保护作用。

方法

本研究为随机对照研究，纳入2024年4-8月陆军军医大学第一附属医院肝胆外科收治的51例接受LH的患者作为研究对象，采用随机数表法将入组患者随机分为对照组（n=25）和椎旁阻滞组（n=26）。对照组采用全身麻醉，椎旁阻滞组在全麻诱导前进行椎旁神经阻滞，其余医疗处置相同。比较2组患者：术前7 d内、术后第1、2天谷丙转氨酶（alanine aminotransferase，ALT）、谷草转氨酶（aspartate aminotransferase，AST）、胆红素（total bilirubin，TBIL）、白蛋白（albumin，ALB）、全身免疫炎症指数（systemic-immune inflammation index，SII）水平，麻醉诱导前（T1）、建立气腹前5 min（T2）、建立气腹时（T3）、第1次肝门阻断时（T4）心率和平均动脉压（mean arterial pressure，MAP），术中去甲肾上腺素、七氟烷、术后24 h镇痛药物使用量以及2组患者手术时间、拔管时间、麻醉复苏室（postanesthesia care unit，PACU）停留时间、住院时间。

结果

椎旁阻滞组患者术后第1天ALT［178.40（126.55，325.86）vs 292.20（197.20，468.95）U/L］、术后第2天SII［704.13（486.61，1 078.59） vs 1 075.09（753.80，1 614.38）］、术后24 h镇痛药使用量［29.70（27.37，32.07）vs 31.99（28.92，40.81）mg］均较对照组降低（P<0.05）；椎旁阻滞组T3、T4时MAP、拔管时间、PACU停留时间及住院时间均较对照组显著下降（P<0.05）。

结论

椎旁神经阻滞复合全身麻醉可在一定程度上减轻患者LH术后炎症反应和疼痛，维持血流动力学稳定，进而保护肝损伤。

Objective‍
Methods‍
Results‍
Conclusion‍
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甯交琳，Email：
NING Jiaolin，E-mail：
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Epidural block relieves liver ischemia-reperfusion injury and its mechanism［D］. Hengyang：University of South China，2018., articleTitle=Epidural block relieves liver ischemia-reperfusion injury and its mechanism, refAbstract=null), Reference(id=1322210914024149374, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, doi=null, pmid=null, pmcid=null, year=2023, volume=21, issue=23, pageStart=2606, pageEnd=2609, url=null, language=null, rfNumber=28, rfOrder=38, authorNames=黄金华, 曾建强, 袁磊, journalName=癌症进展, refType=null, unstructuredReference=黄金华，曾建强，袁磊，等. 超声引导下胸椎旁神经阻滞复合右美托咪定麻醉对脏肿瘤患者血流动力学、应激反应指标的影响［J］. 癌症进展，2023，21（23）：2606-2609., articleTitle=超声引导下胸椎旁神经阻滞复合右美托咪定麻醉对脏肿瘤患者血流动力学、应激反应指标的影响, refAbstract=null), Reference(id=1322210914099646847, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, doi=null, pmid=null, pmcid=null, year=2023, volume=21, issue=23, pageStart=2606, pageEnd=2609, url=null, language=null, rfNumber=28, rfOrder=39, authorNames=HUANG J H, ZENG J Q, YUAN L, journalName=Oncol Prog, refType=null, unstructuredReference=HUANG J H，ZENG J Q，YUAN L，et al. 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Oncol Prog，2023，21（23）：2606-2609., articleTitle=Effect of ultrasound-guided thoracic paravertebral nerve block combined with dexmedetomidine anesthesia on hemodynamics and stress response indicators in patients with liver tumors, refAbstract=null)], funds=null, companyList=[AuthorCompany(id=1322210904272392483, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, xref=1, ext=[AuthorCompanyExt(id=1322210904280781092, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, companyId=1322210904272392483, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1Department of Anesthesiology, First Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China), AuthorCompanyExt(id=1322210904289169701, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, companyId=1322210904272392483, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1陆军军医大学（第三军医大学）第一附属医院麻醉科，重庆)])], figs=[ArticleFig(id=1322210908319895884, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
指标对照组（n=25）椎旁阻滞组（n=26）t/χ²/ZP
年龄/岁48.28±14.8051.73±12.80-0.8920.377
男性13（52.00）17（65.38）0.9430.400
BMI/（kg/m²）25.12±3.4924.19±3.210.9880.328
乙肝病史12（48.00）11（42.31）0.1670.781
高血压3（12.00）7（26.92）0.4490.503
糖尿病1（4.00）2（7.69）01
心脏病01（3.85）01
贫血2（8.00）00.5620.453
合并2个基础疾病及以上2（8.00）00.5620.453
术前PT/s10.80（10.25，11.20）10.90（10.28，11.63）-0.4250.671
术前肌酐/（μmol/L）69.14±20.7065.99±13.190.6410.525
切除肝脏最大直径/cm11.92±3.4410.92±3.201.0800.286
开放阻断时长/min107.20±54.2389.04±43.641.3040.198
开放阻断次数/次5.00（4.00，6.50）4.00（2.50，6.00）-1.1510.250
手术方式1.0470.627
半肝切除及以上7（28.00）5（19.23）
联合肝段8（32.00）7（26.92）
肝段或局部切除10（40.00）14（53.85）
其他腹部手术病史4（16.00）4（15.38）01
术中液体输入量/mL1 982.00±664.561 798.08±652.300.9970.323
术中尿量/mL400.00（300.00，675.00）300.00（287.50，650.00）-0.8840.376
术中输血4（16.00）2（7.69）0.2360.627
病理分类8.3200.087
肝细胞癌12（48.00）12（46.15）
肝胆管细胞癌01（3.85）
转移癌02（7.69）
肝血管瘤9（36.00）4（15.38）
肝内胆管结石04（15.38）
其他4（16.00）3（11.54）
ASA分级3.1840.225
Ⅰ6（24.00）4（15.38）
Ⅱ17（68.00）15（57.69）
Ⅲ2（8.00）7（26.93）
麻醉时长/min298.52±87.51272.27±84.361.0910.281
手术时长/min224.76±77.91200.23±75.151.1450.258
), ArticleFig(id=1322210908395393357, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, language=CN, label=表1, caption=

2组患者临床基线资料比较［x¯±s，例（%），M（P25，P75）］

, figureFileSmall=null, figureFileBig=null, tableContent=
指标对照组（n=25）椎旁阻滞组（n=26）t/χ²/ZP
年龄/岁48.28±14.8051.73±12.80-0.8920.377
男性13（52.00）17（65.38）0.9430.400
BMI/（kg/m²）25.12±3.4924.19±3.210.9880.328
乙肝病史12（48.00）11（42.31）0.1670.781
高血压3（12.00）7（26.92）0.4490.503
糖尿病1（4.00）2（7.69）01
心脏病01（3.85）01
贫血2（8.00）00.5620.453
合并2个基础疾病及以上2（8.00）00.5620.453
术前PT/s10.80（10.25，11.20）10.90（10.28，11.63）-0.4250.671
术前肌酐/（μmol/L）69.14±20.7065.99±13.190.6410.525
切除肝脏最大直径/cm11.92±3.4410.92±3.201.0800.286
开放阻断时长/min107.20±54.2389.04±43.641.3040.198
开放阻断次数/次5.00（4.00，6.50）4.00（2.50，6.00）-1.1510.250
手术方式1.0470.627
半肝切除及以上7（28.00）5（19.23）
联合肝段8（32.00）7（26.92）
肝段或局部切除10（40.00）14（53.85）
其他腹部手术病史4（16.00）4（15.38）01
术中液体输入量/mL1 982.00±664.561 798.08±652.300.9970.323
术中尿量/mL400.00（300.00，675.00）300.00（287.50，650.00）-0.8840.376
术中输血4（16.00）2（7.69）0.2360.627
病理分类8.3200.087
肝细胞癌12（48.00）12（46.15）
肝胆管细胞癌01（3.85）
转移癌02（7.69）
肝血管瘤9（36.00）4（15.38）
肝内胆管结石04（15.38）
其他4（16.00）3（11.54）
ASA分级3.1840.225
Ⅰ6（24.00）4（15.38）
Ⅱ17（68.00）15（57.69）
Ⅲ2（8.00）7（26.93）
麻醉时长/min298.52±87.51272.27±84.361.0910.281
手术时长/min224.76±77.91200.23±75.151.1450.258
), ArticleFig(id=1322210908496056654, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
时间指标对照组（n=25）椎旁阻滞组（n=26）Z/tP
术前7 d内ALT/（U/L）26.70（15.80，35.50）22.15（13.18，33.45）-0.9230.356
AST/（U/L）25.10（18.60，27.65）23.75（19.00，33.43）-0.8010.423
TBIL/（μmol/L）11.70（8.75，15.95）14.50（10.90，16.40）-1.3190.187
ALB/（g/L）41.75±3.7641.57±3.890.1670.868
术后第1天ALT/（U/L）292.20（197.20，468.95）178.40（126.55，325.86）-2.2230.026
AST/（U/L）296.60（169.00，425.75）234.45（146.95，352.18）-1.1870.235
TBIL/（μmol/L）16.10（13.70，21.22）17.75（13.40，24.45）-0.6410.522
ALB/（g/L）38.21±4.3337.47±4.360.6130.542
术后第2天ALT/（U/L）253.50（173.00，364.50）218.10（124.20，322.90）-1.4550.146
AST/（U/L）132.90（96.10，205.25）137.40（90.20，202.20）-0.4230.672
TBIL/（μmol/L）14.80（11.20，22.50）19.50（11.40，31.20）-1.2900.197
ALB/（g/L）36.63±3.9636.60±4.250.0080.979
), ArticleFig(id=1322210908563165519, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, language=CN, label=表2, caption=

2组肝损伤指标比较［x¯±s，M（P25，P75）］

, figureFileSmall=null, figureFileBig=null, tableContent=
时间指标对照组（n=25）椎旁阻滞组（n=26）Z/tP
术前7 d内ALT/（U/L）26.70（15.80，35.50）22.15（13.18，33.45）-0.9230.356
AST/（U/L）25.10（18.60，27.65）23.75（19.00，33.43）-0.8010.423
TBIL/（μmol/L）11.70（8.75，15.95）14.50（10.90，16.40）-1.3190.187
ALB/（g/L）41.75±3.7641.57±3.890.1670.868
术后第1天ALT/（U/L）292.20（197.20，468.95）178.40（126.55，325.86）-2.2230.026
AST/（U/L）296.60（169.00，425.75）234.45（146.95，352.18）-1.1870.235
TBIL/（μmol/L）16.10（13.70，21.22）17.75（13.40，24.45）-0.6410.522
ALB/（g/L）38.21±4.3337.47±4.360.6130.542
术后第2天ALT/（U/L）253.50（173.00，364.50）218.10（124.20，322.90）-1.4550.146
AST/（U/L）132.90（96.10，205.25）137.40（90.20，202.20）-0.4230.672
TBIL/（μmol/L）14.80（11.20，22.50）19.50（11.40，31.20）-1.2900.197
ALB/（g/L）36.63±3.9636.60±4.250.0080.979
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指标对照组（n=25）椎旁阻滞组（n=26）ZP
术前7 d内SII376.47（198.31，505.95）414.72（230.50，605.36）-0.5840.559
术后第1天SII2 029.47（1 471.12，3 568.51）2 343.97（819.78，3 673.07）-0.0190.985
术后第2天SII1 075.09（753.80，1 614.38）704.13（486.61，1 078.59）-2.2610.024
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2组炎性指标比较［M（P25，P75）］

, figureFileSmall=null, figureFileBig=null, tableContent=
指标对照组（n=25）椎旁阻滞组（n=26）ZP
术前7 d内SII376.47（198.31，505.95）414.72（230.50，605.36）-0.5840.559
术后第1天SII2 029.47（1 471.12，3 568.51）2 343.97（819.78，3 673.07）-0.0190.985
术后第2天SII1 075.09（753.80，1 614.38）704.13（486.61，1 078.59）-2.2610.024
), ArticleFig(id=1322210908777075026, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
指标对照组（n=25）椎旁阻滞组（n=26）t/ZP
心率/bpm
T175.00（69.50，82.00）82.50（73.50，93.50）-1.4430.149
T260.00（51.50，67.50）61.00（55.00，69.25）-0.3680.713
T362.00（51.50，74.00）59.00（55.00，64.50）-0.5940.552
T476.12±17.6773.32±14.170.6180.539
MAP/mmHg
T197.76±11.8892.46±13.851.4640.150
T277.48±12.5376.35±11.100.3420.733
T384.92±12.6075.27±18.852.1430.037
T485.00（74.50，91.50）77.00（70.50，83.00）-2.0100.044
), ArticleFig(id=1322210908865155411, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, language=CN, label=表4, caption=

2组血流动力学指标比较［x¯±s，M（P25，P75）］

, figureFileSmall=null, figureFileBig=null, tableContent=
指标对照组（n=25）椎旁阻滞组（n=26）t/ZP
心率/bpm
T175.00（69.50，82.00）82.50（73.50，93.50）-1.4430.149
T260.00（51.50，67.50）61.00（55.00，69.25）-0.3680.713
T362.00（51.50，74.00）59.00（55.00，64.50）-0.5940.552
T476.12±17.6773.32±14.170.6180.539
MAP/mmHg
T197.76±11.8892.46±13.851.4640.150
T277.48±12.5376.35±11.100.3420.733
T384.92±12.6075.27±18.852.1430.037
T485.00（74.50，91.50）77.00（70.50，83.00）-2.0100.044
), ArticleFig(id=1322210908936458580, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
指标对照组（n=25）椎旁阻滞组（n=26）t/ZP
术后24 h镇痛药使用量/mg31.99（28.92，40.81）29.70（27.37，32.07）-2.0190.044
术中七氟烷用量/mL32.36±11.2228.83±10.821.1450.258
术中去甲肾上腺素用量/μg918.00（82.00，1 832.80）804.00（527.00，1 318.50）-0.2450.806
), ArticleFig(id=1322210909003567445, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, language=CN, label=表5, caption=

2组围术期用药比较［x¯±s，M（P25，P75）］

, figureFileSmall=null, figureFileBig=null, tableContent=
指标对照组（n=25）椎旁阻滞组（n=26）t/ZP
术后24 h镇痛药使用量/mg31.99（28.92，40.81）29.70（27.37，32.07）-2.0190.044
术中七氟烷用量/mL32.36±11.2228.83±10.821.1450.258
术中去甲肾上腺素用量/μg918.00（82.00，1 832.80）804.00（527.00，1 318.50）-0.2450.806
), ArticleFig(id=1322210909070676310, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
指标对照组（n=25）椎旁阻滞组（n=26）t/ZP
拔管时间/min50.69±21.3037.46±24.742.0410.047
PACU停留时间/min89.00（76.00，104.50）67.00（58.50，97.75）-2.1770.029
住院时间/d8.00（7.00，9.00）6.00（5.00，8.00）-2.4570.014
), ArticleFig(id=1322210909141979479, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322210900975669536, language=CN, label=表6, caption=

2组恢复情况比较［x¯±s，M（P25，P75）］

, figureFileSmall=null, figureFileBig=null, tableContent=
指标对照组（n=25）椎旁阻滞组（n=26）t/ZP
拔管时间/min50.69±21.3037.46±24.742.0410.047
PACU停留时间/min89.00（76.00，104.50）67.00（58.50，97.75）-2.1770.029
住院时间/d8.00（7.00，9.00）6.00（5.00，8.00）-2.4570.014
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椎旁神经阻滞复合全身麻醉对腹腔镜下肝切除术后肝损伤的保护作用
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宋雨汐 , 徐小 , 高宪 , 段家翔 , 文静 , 甯交琳
陆军军医大学学报 | 临床医学 2025,47(7): 720-727
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陆军军医大学学报 |临床医学 2025 , 47 (7) : 720 -727
椎旁神经阻滞复合全身麻醉对腹腔镜下肝切除术后肝损伤的保护作用
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宋雨汐, 徐小, 高宪, 段家翔, 文静, 甯交琳
作者信息
  • 1陆军军医大学（第三军医大学）第一附属医院麻醉科，重庆
通讯作者:
甯交琳，Email：
NING Jiaolin，E-mail：
Protective effect of paravertebral nerve block combined with general anesthesia on postoperative liver injury in patients undergoing laparoscopic hepatectomy
Yuxi SONG, Xiao XU, Xian GAO, Jiaxiang DUAN, Jing WEN, Jiaolin NING
Affiliations
  • 1Department of Anesthesiology, First Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
出版时间: 2025-04-15 doi: 10.16016/j.2097-0927.202410091
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摘要
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目的

探究椎旁神经阻滞复合全身麻醉对腹腔镜下肝切除（laparoscopic hepatectomy，LH）术后肝损伤的保护作用。

方法

本研究为随机对照研究，纳入2024年4-8月陆军军医大学第一附属医院肝胆外科收治的51例接受LH的患者作为研究对象，采用随机数表法将入组患者随机分为对照组（n=25）和椎旁阻滞组（n=26）。对照组采用全身麻醉，椎旁阻滞组在全麻诱导前进行椎旁神经阻滞，其余医疗处置相同。比较2组患者：术前7 d内、术后第1、2天谷丙转氨酶（alanine aminotransferase，ALT）、谷草转氨酶（aspartate aminotransferase，AST）、胆红素（total bilirubin，TBIL）、白蛋白（albumin，ALB）、全身免疫炎症指数（systemic-immune inflammation index，SII）水平，麻醉诱导前（T1）、建立气腹前5 min（T2）、建立气腹时（T3）、第1次肝门阻断时（T4）心率和平均动脉压（mean arterial pressure，MAP），术中去甲肾上腺素、七氟烷、术后24 h镇痛药物使用量以及2组患者手术时间、拔管时间、麻醉复苏室（postanesthesia care unit，PACU）停留时间、住院时间。

结果

椎旁阻滞组患者术后第1天ALT［178.40（126.55，325.86）vs 292.20（197.20，468.95）U/L］、术后第2天SII［704.13（486.61，1 078.59） vs 1 075.09（753.80，1 614.38）］、术后24 h镇痛药使用量［29.70（27.37，32.07）vs 31.99（28.92，40.81）mg］均较对照组降低（P<0.05）；椎旁阻滞组T3、T4时MAP、拔管时间、PACU停留时间及住院时间均较对照组显著下降（P<0.05）。

结论

椎旁神经阻滞复合全身麻醉可在一定程度上减轻患者LH术后炎症反应和疼痛，维持血流动力学稳定，进而保护肝损伤。

Objective‍
Methods‍
Results‍
Conclusion‍
椎旁神经阻滞  /  腹腔镜下肝切除术  /  肝损伤  /  术后康复

To investigate the protective effect of paravertebral nerve block combined with general anesthesia on liver injury after laparoscopic hepatectomy (LH).

‍A randomized controlled trial was conducted on 51 patients undergoing LH in our hospital between April and August 2024. They were randomly divided into control group (n=25, general anesthesia) and paravertebral block group (n=26, paravertebral nerve block before general anesthesia induction). Beside anesthesia, they received same other medical treatment. The following indicators were compared between the 2 groups, that is, serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL) and albumin (ALB), and systemic-immune inflammation (SII) index within 7 d before and on the 1st and 2nd days after surgery; heart rate and mean arterial pressure (MAP) before anesthesia induction (T1), before pneumoperitoneum establishment (T2), pneumoperitoneum establishment (T3), and at the first hilar occlusion (T4); usages of intraoperative norepinephrine, sevoflurane, and analgesic drugs 24 h postoperatively; as well as operation time, extubation time, and lengths of postanesthesia care unit (PACU) stay and hospital stay.

The paravertebral block group had significantly lower ALT on the 1st day after surgery [178.40 (126.55, 325.86) vs 292.20 (197.20, 468.95) U/L], SII on the 2nd day after surgery [704.13 (486.61, 1 078.59) vs 1 075.09 (753.80, 1 614.38)], and amount of analgesic drugs in 24 h after surgery [29.70 (27.37, 32.07) vs 31.99 (28.92, 40.81) mg], and decreased MAP level at T3 and T4, early extubation, and shorter lengths of PACU stay and hospital stay when compared with the control group (all P<0.05).

Paravertebral nerve block combined with general anesthesia can reduce inflammatory responses, relieve postoperative pain, stabilize hemodynamics for patients undergoing LH, and thereby alleviate postoperative liver injury in them.

paravertebral nerve block  /  laparoscopic hepatectomy  /  liver injury  /  postoperative rehabilitation
宋雨汐, 徐小, 高宪, 段家翔, 文静, 甯交琳. 椎旁神经阻滞复合全身麻醉对腹腔镜下肝切除术后肝损伤的保护作用. 陆军军医大学学报, 2025 , 47 (7) : 720 -727 . DOI: 10.16016/j.2097-0927.202410091
Yuxi SONG, Xiao XU, Xian GAO, Jiaxiang DUAN, Jing WEN, Jiaolin NING. Protective effect of paravertebral nerve block combined with general anesthesia on postoperative liver injury in patients undergoing laparoscopic hepatectomy[J]. Journal of Army Medical University, 2025 , 47 (7) : 720 -727 . DOI: 10.16016/j.2097-0927.202410091
正文
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肝切除术是目前治疗肝脏各种良恶性肿瘤的主要方法［1］。随着微创技术的不断进步，腹腔镜技术凭借创伤小、术后疼痛轻等优势已在临床广泛应用［2］。尽管我国腹腔镜下肝切除术（laparoscopic hepatectomy，LH）日趋成熟，但术后并发症发生率仍居高不下，严重影响患者术后恢复及长期预后［3］。肝损伤作为LH常见围术期并发症，与肝门阻断及手术创伤密切相关，严重者可进展为肝功能衰竭，威胁患者生命。目前国内外学者关于防治LH术后肝损伤的研究主要聚焦于抗氧化剂、微循环改善药物及抗炎药物等干预措施，但大多数尚未应用于临床［4］。因此，减少LH围术期肝损伤的发生率是亟待解决的关键问题。过度炎症反应是引起围术期肝损伤的主要因素之一，目前已有研究证明肝脏交感神经可通过释放神经递质参与炎症反应的发生发展，进而介导肝损伤［5］。肝交感神经起源于脊髓胸段第7至第12节，经交感干到腹腔神经节换元后发出纤维汇成肝神经丛分布至肝脏各处［6］。椎旁神经阻滞在外科手术中常具有维持血流动力学稳定、减轻术后疼痛的优点［7-8］，已广泛应用于临床，通过将罗哌卡因注射到椎旁间隙，阻滞椎旁交感干，达到阻滞肝交感神经的目的。此外，有研究报道椎旁神经阻滞可减轻冠脉搭桥术后心肌损伤及胸腔镜肺癌根治术后肺损伤［9-10］。然而，目前尚缺乏关于椎旁神经阻滞对LH患者术后影响的研究，因此，本研究拟探讨椎旁神经阻滞复合全身麻醉对LH患者肝损伤和康复情况的影响，旨在为临床治疗提供参考。
1　资料与方法
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1.1　研究对象
本研究为随机对照研究，纳入2024年4-8月在陆军军医大学第一附属医院肝胆外科接受LH的患者。所有纳入研究的患者均于术前取得知情同意并签署知情同意书。纳入标准：①择期接受LH的患者；②年龄20~75岁；③美国麻醉医师协会健康情况分级（american society of anesthesiologists，ASA）Ⅰ~Ⅲ。排除标准：①术前肝功能Child-Pugh分级标准＞A级、肾功能失代偿（肌酐＞133 μmol/L）；②注射部位皮肤或软组织感染者；③HAS-BLED评分≥3分的出血倾向者；④近6个月有脑梗死或脑出血史；⑤近6个月有不稳定性心绞痛或心肌梗死史；⑥严重的肺部疾病及第1秒钟用力呼气容积（forced expiratory volume in one second，FEV1）<50%预计值；⑦严重的精神疾病；⑧拒绝参加研究者。剔除标准：①术中改变既定手术方式者；②资料不全者；③患者在研究期间主动要求退出或终止治疗的。根据上述标准，剔除2例手术中改变手术方式患者和1例资料不完整患者，共纳入患者51例，采用随机数表法将入组患者分为对照组（n=25）和椎旁阻滞组（n=26）。本研究经中国人民解放军陆军军医大学第一附属医院伦理委员会批准［（A）KY2024048］。
1.2　样本量估算
本研究以术后第1天谷丙转氨酶（alanine aminotransferase，ALT）为主要终点指标。根据预试验结果，椎旁阻滞组术后第1天ALT为（204.89±118.38）U/L，对照组术后第1天ALT为（364.57±265.11）U/L，采用非配对t检验计算样本量，设置α=0.05，把握度为80%，椎旁阻滞组及对照组各23例，考虑10%脱落率，总样本量应为51例。根据样本量计算结果纳入51例行LH的患者。
1.3　手术麻醉方法
对照组常规手术准备，入室后连接心电监护并建立静脉通路。麻醉诱导采用0.05 mg/kg咪达唑仑注射液、0.5~1.0 μg/kg枸橼酸舒芬太尼、0.2~0.3 mg/kg依托咪酯、0.2 mg/kg顺式阿曲库铵。麻醉维持采用2.0~3.0 ng/mL注射用盐酸瑞芬太尼靶控输注（target controlled infusion，TCI）、2%~3%七氟烷，顺式阿曲库铵间断注射维持肌肉松弛，维持脑电双频指数（bispect ral index，BIS）值在40~60。椎旁阻滞组在对照组基础上，麻醉前给予椎旁神经阻滞，患者取右侧卧位，屈曲颈部、背部、髋关节，常规消毒铺巾后行局部浸润麻醉，在超声引导下行胸段第7节和第9节平面内入路进行椎旁神经阻滞，回抽无血后，给予10 mL 0.5％罗哌卡因阻滞，观察药液扩散位置和胸膜变化位置，并在胸段第7节和第9节椎旁间隙进行双侧椎旁神经阻滞。
1.4　观察指标
采集患者的人口学信息如年龄、体质量指数（body mass index，BMI）、性别及基础疾病史、术前ASA分级、术前乙肝病史、其他腹部手术病史、术前凝血酶原时间（prothrombin time，PT）及肌酐水平、术中外科及麻醉相关情况（切除肝脏最大直径、开放阻断时长和次数、手术方式、输血输液情况、尿量、手术及麻醉时长）、术后病理分类。根据试验的研究目的确定并记录主要终点指标为评估肝损伤的直接指标：术后第1天ALT。次要终点指标：①术前7 d内、术后第1天和术后第2天的谷草转氨酶（aspartate aminotransferase，AST）、胆红素（total bilirubin，TBIL）、白蛋白（albumin，ALB），术前7 d内、术后第2天ALT。②术前7 d内、术后第1、2天全身免疫炎症指数（systemic-immune inflammation index，SII），SII=血小板计数×中性粒细胞计数/淋巴细胞计数。③2组麻醉诱导前（T1）、建立气腹前5 min（T2）、建立气腹时（T3）、第1次肝门阻断时（T4）心率和平均动脉压（mean arterial pressure，MAP）。④术后24 h镇痛药使用量（术后镇痛药使用曲马多或氢吗啡酮，均换算为吗啡剂量来比较［11］）、术中七氟烷、去甲肾上腺素使用量。⑤拔管时间、麻醉复苏室（postanesthesia care unit，PACU）停留时间及住院时间。
1.5　统计学分析
采用SPSS 25.0软件进行数据分析。计量资料符合正态分布的采用x¯±s表示，组间比较采用独立样本t检验；非正态分布的采用M（P25，P75）表示，组间比较采用Wilcoxon秩和检验；计数资料以例（%）表示，组间比较采用χ²检验或Fisher确切概率法，P<0.05表示差异具有统计学意义。
2　结果
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2.1　2组患者临床基线资料比较
对照组患者年龄（48.28±14.80）岁，椎旁阻滞组患者年龄（51.73±12.80）岁，差异无统计学意义。对照组男性13例，女性12例，椎旁阻滞组男性有17例，女性9例，差异无统计学意义。2组患者BMI、ASA分级、乙肝病史、基础疾病史、其他腹部手术病史、术前PT及肌酐水平、术中外科及麻醉相关情况（切除肝脏最大直径、开放阻断时长和次数、手术方式、输血输液情况、尿量、手术及麻醉时长）、术后病理分类差异无统计学意义（表1）。
2.2　2组患者术前7 d内、术后第1天和术后第2天ALT、AST、TBIL、ALB比较
与对照组比较，椎旁阻滞组患者术后第1天ALT明显降低（P<0.05），但2组患者术前7 d内AST、ALT、TBIL、ALB，术后第1天AST、TBIL、ALB，术后第2天ALT、AST、TBIL、ALB差异均无统计学意义（表2）。
2.3　2组术前7 d内，术后第1、2天SII对比
与对照组比较，椎旁阻滞组患者术后第2天SII显著降低（P<0.05），但2组患者术前7 d内、术后第1天SII比较，差异无统计学意义（表3）。
2.4　2组麻醉诱导前（T1）、建立气腹前5 min（T2）、建立气腹时（T3）、第1次肝门阻断时（T4）心率、MAP比较
与对照组比较，椎旁阻滞组患者T3、T4的MAP显著降低（P<0.05），但2组患者T1、T2的心率和MAP以及T3、T4的心率组间比较，差异无统计学意义（表4）。
2.5　2组患者术后24 h镇痛药物用量、术中七氟烷、去甲肾上腺素用量比较
椎旁阻滞组患者术后24 h镇痛药使用量低于对照组（P<0.05），但2组患者术中七氟烷和去甲肾上腺素用量差异无统计学意义（表5）。
2.6　2组恢复情况比较
与对照组比较，椎旁阻滞组患者拔管时间、PACU停留时间、住院时间均显著缩短（P<0.05，表6）。
3　讨论
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术后肝损伤是LH常见并发症，其发生发展涉及缺血再灌注损伤、应激反应及炎症因子级联激活等多重病理生理过程，严重者将影响患者围术期恢复及长期生存质量［12］。传统全身麻醉虽能维持基本手术条件，但对术中应激调控及器官保护作用有限［13］，椎旁神经阻滞是指将局麻药物注射到椎旁间隙来有效阻滞患者脊神经前支、后支和椎旁交感神经节的区域阻滞方式［14］，已在多种外科手术中被证明能显著减轻应激反应和炎症反应［12，15-16］。有研究报道，颈交感神经阻滞可以减轻烧伤早期小鼠肝脏的炎症反应［17］。因此，椎旁神经阻滞是否能通过阻滞肝脏交感神经来减轻LH术后的炎症反应，进而减少肝损伤值得深入研究。
3.1　椎旁神经阻滞通过减轻炎症反应从而减轻肝损伤
SII是一个反应免疫系统和炎症活动程度的新型炎症标志物，与多种肿瘤术后远期预后［18-20］及上腹部手术术后严重并发症有显著的相关性［21］。椎旁阻滞组患者术后第2天SII显著低于对照组提示椎旁神经阻滞具有一定程度减轻炎症反应的作用。为降低出血风险并确保手术区域视野清晰，肝门阻断技术被广泛应用于LH，其引发的缺血再灌注损伤通常表现为术后ALT水平升高［22］。ARDITO等［23］及张搏伦等［24］的试验表示术后第1天血清ALT水平与肝切除术术后肝功能不全最为相关，是评估手术变量相关肝细胞损伤的替代指标。因此，可以把术后第1天ALT水平用于评估LH术后肝脏损伤的直接指标。本研究结果显示2组术后第1天ALT均明显升高，这说明手术操作及肝门阻断后引发的肝细胞缺血缺氧可导致LH术后肝损伤。椎旁阻滞组术后第1天ALT相比对照组明显下降，这可能是由于肝交感神经可通过神经递质激活Kupffer细胞、活化肝实质细胞、加强脂质过氧化等发挥促炎作用［5，25-26］，而椎旁神经阻滞可实现肝脏去交感神经化来减轻上述病理过程，最终达到减轻肝损伤的目的。这与罗中辉［27］关于硬膜外阻滞减弱炎症反应，进而减轻了腹腔镜下左半肝切除术患者术后肝损伤的研究一致。胆红素及白蛋白是反映肝脏转化和合成功能的重要指标，随着手术技术不断优化，目前LH更加精准有效，相比传统肝切除术已大大降低手术创伤性，加之本研究对患者术前肝功能具有严格的纳入标准，或许是导致术后胆红素、白蛋白未见明显异常且两组间差异无统计学意义的原因。
3.2　椎旁神经阻滞通过减轻术中应激反应使术中血流动力学稳定
LH是一种侵入性操作，建立气腹以及肝门阻断等有创操作均会引起强烈应激反应，间接或直接兴奋交感肾上腺，引起剧烈的血流动力学波动，加剧炎症反应，影响患者术后恢复。尽管2组术中麻醉药物及血管活性药物使用量无显著差异，但T3、T4时椎旁阻滞组患者MAP显著低于对照组，提示椎旁神经阻滞可通过阻滞相关区域的神经传导，降低因有创性操作引起的交感神经兴奋性，稳定术中血流动力学，与既往研究一致［28］。此外2组心率在T1、T2、T3、T4时差异均无统计学意义，推测可能是支配心脏的交感神经位于胸段第1节~胸段第5节，本研究于胸段第7节、第9节 2个节段进行椎旁神经阻滞，阻滞节段较低。
3.3　椎旁神经阻滞减轻术后疼痛，促进术后恢复
尽管LH相较于开腹手术具有创伤小，术后恢复快等优势，但术后剧烈疼痛仍旧无法避免。本研究中，椎旁阻滞组患者术后24 h镇痛药使用量显著小于对照组，表明椎旁神经阻滞可减轻LH患者术后疼痛。同时，椎旁阻滞组拔管时间、PACU停留时间、住院时间均短于对照组。这可能得益于椎旁神经阻滞实施后，炎症反应减轻，术后镇痛药使用量减少，阿片类药物不良反应减轻，从而加速患者术后康复进程。
本研究仍存在一定的不足及局限。在本研究中，只通过血清学指标来评估术后肝损伤的严重程度，缺乏直观性。观察2组患者术中切除肝组织病理变化将更加客观和直观地显示椎旁神经阻滞对肝损伤的作用。此外，本研究为单中心，样本量较小，可能难以全面覆盖研究对象所涉及的复杂多样的总体特征，缺乏普遍性，后续研究中将进一步扩大样本加强结果的普适性及可靠性。
综上所述，椎旁神经阻滞可稳定LH患者术中血流动力学，减轻术后疼痛，减弱炎症反应，对术后肝损伤具有一定的保护作用，具有一定的临床参考意义。

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2025年第47卷第7期
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doi: 10.16016/j.2097-0927.202410091
  • 接收时间：2024-10-23
  • 首发时间：2026-10-28
  • 出版时间：2025-04-15
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  • 收稿日期：2024-10-23
  • 修回日期：2025-02-17
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    1陆军军医大学（第三军医大学）第一附属医院麻醉科，重庆

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甯交琳，Email：
NING Jiaolin，E-mail：
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2种不同金属材料的力学参数
科
Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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