尿毒症长期血液透析继发性甲状旁腺功能亢进围手术期管理研究

发布时间：2018-06-19 00:11

本文选题：慢性肾脏病 + 继发性甲状旁腺功能亢进　；参考：《青岛大学》2017年硕士论文

【摘要】：目的:本研究通过系统检索文献,初步制定出一个提供证据等级并给出推荐意见的手术治疗继发性甲状旁腺功能亢进(SHPT)的临床路径,并初步在临床实践中加以应用,旨在通过多学科合作、强化围手术期病人管理,降低医疗成本,提高手术成功率,降低并发症发生率,改善临床结局。方法:检索发表在PubMed、Embase、Cochrane数据库中的关于手术治疗SHPT的英文文献,去除综述、个案报道、社论等类型的文章,并去除重复发表的文章,进行手术治疗SHPT的文献方面的研究。系统检索Pub Med数据库发表的关于SHPT的英文文献,检索时间为从建库到2016年12月30日,采用主题词和自由词联合的检索策略,并手工检索部分相关文献。将检索到的文献进行分类,分为临床随机对照试验(RCTs)、队列研究和病例对照研究等,采用美国医师协会(ACP)分级系统,将检索到的文献综合分析后给出证据等级,并从患者和医生的立场综合考虑给出推荐意见。自2014年7月到2017年2月,青岛大学附属医院普通外科共对24例患者实施手术治疗,回顾性收集分析患者的临床资料。其中2例患者行甲状旁腺全切除术(t PTX),22例患者行甲状旁腺全切除伴自体移植术(t PTX+AT)。收集患者术前、术中、术后的血钙、血磷、全段甲状旁腺素(i PTH)结果、临床症状的改善情况和病理结果进行统计分析。结果:最终纳入43篇文章进行分析,发表的年限为从1980年到2016年,纳入的患者数量范围从10例到898例,文章发表数量随时间呈上升趋势。SHPT患者围手术期管理从疾病的诊断、手术指征、术前定位、术前常规准备、手术方式、手术过程中的辅助措施和术后管理等方面分别进行描述和证据的分级。疾病的诊断主要依据病史、实验室检查和临床表现,其中实验室检查主要包括血钙、血磷和i PTH。比较常用的术前定位技术包括高频超声、99m Tc-MIBI、CT等,其中高频超声为首选检查方法(中级证据,强烈推荐)。其中高频超声联合99m Tc-MIBI为主要的术前定位方法(中级证据,强烈推荐)。其余各方面的描述见正文结果部分。24例患者中有10例男性患者,14例女性患者;患者的平均年龄为45.79±8.62岁,范围从28岁到64岁;平均透析龄为7.15±2.64年,范围从1.5年到15年。术后1个月20例患者的手术总成功率为90.00%。术后1周内骨痛的缓解率为92.86%,皮肤瘙痒的缓解率为100.00%,术后低钙血症的发生率为95.83%。24例患者共切除90枚甲状旁腺腺体,其中病理结果为结节性增生的腺体共47枚,占切除腺体总数的52.22%;病理结果为甲状旁腺腺瘤的共43枚,占切除腺体总数的47.78%。结论:根据文献检索、分析,证据等级认证,建立尿毒症长期血液透析继发性甲状旁功能亢进围手术期管理临床路径,初步临床应用证实该路径能够有效用于病人围手术期管理,可以改善病人近期临床结局。
[Abstract]:Objective: to establish a clinical pathway for secondary hyperparathyroidism parathyroid hyperparathyroidism (SHPTT) by means of systematic literature retrieval, and to establish a clinical pathway for the treatment of secondary hyperparathyroidism. The aim is to strengthen the perioperative patient management, reduce the medical cost, improve the success rate, reduce the incidence of complications and improve the clinical outcome through multidisciplinary cooperation. Methods: the English literature on surgical treatment of SHPT published in the PubMeden Embase Cochrane database was retrieved, the review, case reports, editorials, and repeated articles were removed, and the literature on the surgical treatment of SHPT was studied. The English literature on SHPT published in Pub Med database was searched systematically. The retrieval time was from the construction of the database to December 30, 2016. The retrieval strategy of the combination of theme words and free words was adopted, and some related documents were retrieved manually. The literature was classified into clinical randomized controlled trials (RCTs), cohort studies and case-control studies. And from the patient and the doctor's position comprehensive consideration gives the recommendation. From July 2014 to February 2017, a total of 24 patients were treated by general surgery in Qingdao University affiliated Hospital. The clinical data of the patients were collected and analyzed retrospectively. Two patients underwent total parathyroidectomy and 22 patients underwent total parathyroidectomy with autotransplantation. The results of preoperative, intraoperative and postoperative blood calcium, phosphorus, PTH, the improvement of clinical symptoms and pathological results were analyzed statistically. Results: 43 articles were analyzed. The published years ranged from 1980 to 2016, and the number of patients included ranged from 10 to 898. The number of articles published showed an increasing trend with time. The perioperative management of patients with SHPT was diagnosed from the disease. The indications of operation, preoperative localization, preoperative routine preparation, operative methods, assistant measures during operation and postoperative management were described and classified respectively. The diagnosis of the disease is mainly based on the history, laboratory examination and clinical manifestation, in which the laboratory examination mainly includes blood calcium, blood phosphorus and I PTH. The commonly used preoperative localization techniques included 99m Tc-MIBICT, among which high-frequency ultrasound was the first choice (intermediate evidence, strongly recommended). High frequency ultrasound combined with 99m Tc MIBI was the main preoperative localization method (intermediate evidence, strongly recommended). The other aspects are described in the results section of the text. 10 male patients and 14 female patients, the average age of the patients is 45.79 卤8.62 years, ranging from 28 to 64 years, and the average dialysis age is 7.15 卤2.64 years, ranging from 1.5 to 15 years. The total operative power of 20 patients 1 month after operation was 90.00g. The remission rate of bone pain was 92.86%, the relief rate of skin pruritus was 100.00g, and the incidence of hypocalcemia was 95.83.24 cases were excised 90 parathyroid glands, of which 47 were nodular hyperplasia glands. The pathological results showed that 43 parathyroid adenomas accounted for 47.78 percent of the total excision glands. Conclusion: according to the literature retrieval, analysis and evidence level certification, the clinical path of perioperative management of secondary hyperthyroidism secondary to uremia in long-term hemodialysis was established. The preliminary clinical application shows that this pathway can be used effectively in perioperative management and can improve the patients' short-term clinical outcome.
【学位授予单位】：青岛大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R692.5;R653

【参考文献】