初次甲状腺术后引流的风险拔管点及总引流量的多因素临床研究
发布时间：2018-07-20 09:20
【摘要】：[目的]选择拟初次行甲状腺开放手术的病例为研究对象,通过对甲状腺术后不同时间段引流量的测量统计,构建初次甲状腺术后时间段引流量的变化趋势图,并进一步通过术后总引流量与手术范围、手术时间、性别等多因素关系的研究,发现总引流量及置管与否对切口愈合的影响关系,临床验证甲状腺术后病人创面软组织的强重吸收能力,选择是否常规置管及置管的安全拔出时间,为甲状腺疾病术后快速康复医学的临床研究及实践提供参考。[方法]1、病例选择:1)需排除胸骨后甲状腺肿而开胸的手术病人;2)正常凝血指数,若术前口服抗凝药需停药5-7天再手术,女性非月经期;3)甲状腺再次及多次手术病人应排除;4)排除甲状腺颈部淋巴结清扫术后出现乳糜漏的患者;5)若中途出现引流管堵塞、漏气等引流失败,需排除观察范围;6)此次实验主要针对良性患者和甲癌患者无侧方淋巴结转移患者。2、手术方式:手术原则依据《2015版ATA指南》:1)经典手术方式;2)顺利完成甲状腺切除术后,创面充分止血,创腔放置引流,引流采用14#甲状腺外科专用“T”管。放置在气管前方,沿原切口正中引出,并固定于皮肤上,远端连接负压引流球,保持持续负压;3)术后6h进凉流质或半流质饮食,次日进普食;4)术中用生理盐水冲洗创面后蘸干;5)术后观察引流球,保持引流通畅(间断捏管)。3、实验方案(1)参照入组标准选择2016年5月-2016年12月昆明医科大学第一附属医院甲状腺诊疗中心住院病例,将病例分为两组,分别为不放引流组和放引流组。依住院时间按随机数列分组,单数为不放引流组,双数为放引流组。其中放引流组60例,不放引流组44例,中途退出入组10例(因手术方式的改变、术中放置止血粉等原因而退出入组)。放引流组:术闭关闭切口开始计时,每20min用量筒记录观察1次引流球中的引流量,共观察8小时,引流球保持持续低负压吸引。依据我中心之前提出的安全拔管点为8-12小时,12小时后拔出引流管。记录时间段引流量,统计患者基本信息以及疾病情况,并对数据信息进行归纳统计。(2)将放置引流组患者按照手术操作时间分为:在1小时8例、1-2小时48例、多2小时4例。将每组的平均总引流量进行统计,并进行组间的两两对比,统计手术操作时间与总引流量的关系。(3)将放置引流管组患者分为男、女两组,其中男组14例,女组46例,统计性别与平均总引流量的关系(4)将放置引流组患者按照手术范围分为10组,分别是右侧全切+右侧中央组淋巴结清扫组13例;双侧全切+双侧中央组淋巴结清扫组28例;左侧全切+左侧中央组淋巴结清扫组6例;双侧全切+右侧中央组淋巴结清扫组4例;右侧全切组1例;双侧全切组3例;右侧全切+左侧部分切除组1例;左侧全切+双侧中央组淋巴结清扫组1例;右侧全切+左侧次全切+双侧中央组淋巴结清扫组2例;双侧全切+左侧中央组淋巴结清扫组1例。统计手术范围与平均总引流量的关系。(5)将放置引流组与不放置引流组出现伤口积液的情况进行比较,并将不放引流组依据手术操作时间分为1小时以内组、1-2小时组、2小时以上组,分别比较手术时间与伤口积液的关系。最后进行放置引流组每组手术时间的积液情况与不放置引流组每组手术时间的积液情况的总体比较。[结果]1.风险拔管点的探究根据放置引流组的数据,8小时内引流量出现一个高峰之后随之逐渐下降,约在术后80min引流液引出量出现一个高峰值,每20min时间段引流量所占总引流液量的比例相比差异有显著性意义(p0.05)。说明患者的术后引流是存在一个时间点,在这个点,渗出量达到高峰,人体的重吸收和渗出量达到平衡,在这个时间点之前拔出引流管是存在积液风险的,即风险拔管点[17]。2.手术时间与总引流量的关系根据实验数据,时间段引流液与每组平均总引流液量相比有显著差异(p0.05),手术操作时间越长,术后引流量越多。将这3组数据进行两两比较时,1小时以内组与其它两组比较有统计学意义(p0.05),其余两组比较时不存在统计学意义(p0.05)。说明手术操作时间在1小时以内,总引流量较少。3.患者性别与总引流量的关系将病例分为男、女两组,其中男性患者14例、女性患者46例,对其引流量进行统计学分析,无统计学意义(p=0.481,P0.05),没有显著的统计学差异,说明患者性别并不影响手术后总引流量。4.亍术方式与总引流量的关系根据实验结果,在固定的手术范围内,进行组间两两比较时,无统计学意义(p0.05)。因本实验样本量较少,扩大手术范围后平均总引流量是否增加有待进一步验证。5.放引流组和不放引流组比较所有入组患者均未出现术后出血,术后切口积液在60例放管组中有5例,占8.3%;在44例不放管组中出现了 9例,比例20.5%。将上述数据依据手术时间进行分组,1小时以内组、1-2小时组、2小时以上组。放管组的5例切口枳液出现在1-2小时组;无切口积液的1小时以内组7例,1-2小时组42例,2小时以上组4例。未放管组:1小时以内组积液1例,无7例;1-2小时组积液7例,无26例,2小时以上组积液1例,无2例。说明伤口积液的病例集中在手术时间在1-2小时组内,1小时以内组较少。综合手术操作时间与总引流量的关系,手术操作时间在1小时以内的术后是否可以不置引流,可行进一步的实验探究。[结论]综上所述,甲状腺术后存在风险拔管点,即术后80min时,创面渗出量达到高峰,随后渗出液逐渐减少,人体软组织的重吸收能力和渗出量达到平衡,此时之前拔除引流管,存在相对风险。在风险拔管点之后,理论上讲创面重吸收能力超越了渗出量,引流量开始下降,此时拔出引流管相对安全。此观点是快速康复甲状腺外科新的实践,值得临床推广。患者的性别及在一定范围内的手术方式对平均总引流量无统计学意义,手术操作时间少相对应总引流量就较少,出现切口积液概率较小,而是否需置管,有待后续研究。
[Abstract]:[Objective] to choose the case of the first open thyroid surgery as the research object. Through the measurement of the flow rate at different time periods after the thyroidectomy, the trend map of the time interval of the initial thyroid operation was constructed, and the relationship between the total flow rate and the operation time, the sex and other factors after the operation were further studied. The relationship between the total flow rate and the effect of tube placement on the healing of the incision was found. The strong reabsorption capacity of the soft tissue in the patients after thyroid surgery was verified and the safe extraction time was selected for the routine catheterization and catheterization. [method]1, case selection: 1) should be arranged for the clinical study and practice of the postoperative rapid rehabilitation medicine for thyroid diseases. 2) normal coagulation index, if oral anticoagulants should be reoperated for 5-7 days before operation, female non menstrual period, 3) thyroid again and multiple operation patients should be excluded; 4) exclude patients with chylic leakage after cervical lymph node dissection; 5) if drainage tube blockage, leakage, etc. The drainage failure should exclude the observation range; 6) this experiment mainly aimed at benign patients and cancer patients without lateral lymph node metastases.2, the operation method: the operation principle according to the <2015 version ATA Guide >: 1) classic operation mode; 2) after the successful completion of thyroidectomy, the wound was fully hemostasis, the cavity was placed drainage, and the drainage adopted 14# thyroidectomy specialist. Use "T" tube. Placed in front of the trachea, lead out in the middle of the original incision, and fix it on the skin, distal to the negative pressure drainage ball, maintain continuous negative pressure; 3) after the operation, 6h into the cold fluid or semi fluid diet, the next day into the general food, 4) after the operation with saline rinse the wound after dipping dry; 5) observation drainage ball, maintain drainage patency (intermittent pinch tube).3, experiment The scheme (1) selected the hospitalized cases in the First Affiliated Hospital of Kunming Medical University, May 2016 -2016 December, and divided the cases into two groups, the drainage group and the drainage group respectively. According to the time of hospitalization, the number of patients was divided into groups according to the random number, the single number was the non discharge group, and the double number was the drainage group. Among them, 60 cases were drainage group. There were 44 cases in the non drainage group. 10 cases were withdrawn from the group (because of the change of the operation and the hemostat in the operation). The drainage group was closed down the incision to start the timing, and the drainage volume in the 1 drainage ball was observed with the tube recorded by the measuring cylinder for 8 hours, and the flow ball kept the low negative pressure. According to the premise of my center. The safe extubation point was 8-12 hours, and the drainage tube was pulled out after 12 hours. The time interval was recorded, the basic information of the patients and the condition of the disease were recorded and the data were summed up. (2) the patients placed in the drainage group were divided into 1 hours, 8 cases, 1-2 hours 48 cases, 2 hours 4 cases, and the average total drainage of each group. Statistics, and the 22 comparison between groups, statistical operation time and the relationship between the total flow rate. (3) the patients were divided into male and female two groups, including 14 male and 46 female group, and the relationship between sex and average total flow rate (4) was divided into 10 groups according to the scope of operation, respectively, right full cut +. Right central group lymph node dissection group 13 cases, bilateral full cut + bilateral central group lymph node dissection group 28 cases, left full cut + left central group lymph node dissection group 6 cases, bilateral full cut + right central group of lymph node dissection group 4 cases, right total cut 1 cases, bilateral total resection group 3 cases, right full cut + left partial resection group 1 cases, left full cut + bilateral central Group lymph node dissection group 1 cases, right total cut + left subtotal cut + bilateral central group lymph node dissection group 2 cases, bilateral total cut + left central group of lymph node dissection group 1 cases. Statistical range of operation and the average total flow rate. (5) the drainage group is compared with the drainage group, and the drainage group is compared. The operation time was divided into 1 hours group, 1-2 hour group, and more than 2 hours, and the relationship between the operation time and the wound effusion was compared. Finally, the overall ratio of the effusion of the operation time of each group in each group was compared with that in the group without drainage group. [results]1. risk extubation point was explored according to the placement. The data of the drainage group, after a peak in 8 hours, gradually declined, and a high peak was found in the 80min drainage volume after the operation. The proportion of the total drainage volume per 20min period was significantly higher than that of the difference (P0.05). It indicated that the postoperative drainage was a time point at this point, The amount of exudation reached the peak, the body reabsorption and exudation reached a balance. The drainage tube was pulled out before the time point. That is, the relationship between the [17].2. operation time of the risk extubation point and the total flow rate was based on the experimental data. The time period of drainage was significantly different from that of the average total drainage fluid in each group (P0.05). The longer the time was, the more flow rate was after the operation. When the 3 groups of data were compared, the group within 1 hours was statistically significant (P0.05) compared with the other two groups. The other two groups had no statistical significance (P0.05). The operation time was within 1 hours, and the relationship between the total drainage volume of.3. patients and the total flow rate was less than that of the total flow rate. Two groups of men and women, including 14 male patients and 46 female patients, were analyzed statistically with no statistical significance (p=0.481, P0.05), there was no significant statistical difference, indicating that the gender did not affect the relationship between the total flow rate of.4. and the total flow rate after the operation, according to the experimental results, within the fixed operative range, There was no statistical significance in the 22 comparison between groups (P0.05). Because of the less sample size in this experiment, the increase of the average total flow rate after the enlargement of the operative scope was further verified by the further verification that all the patients in the.5. drainage group and the non drainage group had no postoperative bleeding. There were 5 cases in the 60 cases, and 44 cases in the 44 cases. There were 9 cases in the non tube group, and the ratio of 20.5%. was divided into groups, 1 hours group, 1-2 hour group, and more than 2 hours. 5 cases of incisional incision of orange juice appeared in 1-2 hours group, 7 cases within 1 hours without incisional effusion, 42 cases in 1-2 hour group, and 4 cases over 2 hours. There were no 7 cases; there were 7 cases of effusion in 1-2 hour group, no 26 cases, 1 cases of fluid accumulation over 2 hours and no 2 cases. It showed that the cases of wound effusion were concentrated in the operation time within 1-2 hours and less than 1 hours. The relationship between the operation time and the total flow rate, and whether the operation time was within 1 hours without drainage, it was feasible to enter one. In conclusion, there is a risk extubation point after thyroidectomy, that is, after 80min, the exudation of the wound reaches the peak, then the exudation is reduced gradually, the reabsorption capacity and exudation of the human soft tissue are balanced, and the drainage tube is removed before the relative risk. After the risk of the extubation point, the wound is theoretically wound. The reabsorption capacity exceeds the exudation, the flow rate begins to decline, and it is relatively safe to pull out the drainage tube. This view is a new practice in the rapid rehabilitation of thyroid surgery. It is worthy of clinical application. The sex of the patients and the surgical methods within a certain range have no statistical meaning to the average total flow rate, and the operation time is less relative to the total flow rate. Less, the probability of occurrence of incisional effusion is small, and whether or not catheterization is needed remains to be followed up.
【学位授予单位】：昆明医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R653
本文编号：2133085
[Abstract]:[Objective] to choose the case of the first open thyroid surgery as the research object. Through the measurement of the flow rate at different time periods after the thyroidectomy, the trend map of the time interval of the initial thyroid operation was constructed, and the relationship between the total flow rate and the operation time, the sex and other factors after the operation were further studied. The relationship between the total flow rate and the effect of tube placement on the healing of the incision was found. The strong reabsorption capacity of the soft tissue in the patients after thyroid surgery was verified and the safe extraction time was selected for the routine catheterization and catheterization. [method]1, case selection: 1) should be arranged for the clinical study and practice of the postoperative rapid rehabilitation medicine for thyroid diseases. 2) normal coagulation index, if oral anticoagulants should be reoperated for 5-7 days before operation, female non menstrual period, 3) thyroid again and multiple operation patients should be excluded; 4) exclude patients with chylic leakage after cervical lymph node dissection; 5) if drainage tube blockage, leakage, etc. The drainage failure should exclude the observation range; 6) this experiment mainly aimed at benign patients and cancer patients without lateral lymph node metastases.2, the operation method: the operation principle according to the <2015 version ATA Guide >: 1) classic operation mode; 2) after the successful completion of thyroidectomy, the wound was fully hemostasis, the cavity was placed drainage, and the drainage adopted 14# thyroidectomy specialist. Use "T" tube. Placed in front of the trachea, lead out in the middle of the original incision, and fix it on the skin, distal to the negative pressure drainage ball, maintain continuous negative pressure; 3) after the operation, 6h into the cold fluid or semi fluid diet, the next day into the general food, 4) after the operation with saline rinse the wound after dipping dry; 5) observation drainage ball, maintain drainage patency (intermittent pinch tube).3, experiment The scheme (1) selected the hospitalized cases in the First Affiliated Hospital of Kunming Medical University, May 2016 -2016 December, and divided the cases into two groups, the drainage group and the drainage group respectively. According to the time of hospitalization, the number of patients was divided into groups according to the random number, the single number was the non discharge group, and the double number was the drainage group. Among them, 60 cases were drainage group. There were 44 cases in the non drainage group. 10 cases were withdrawn from the group (because of the change of the operation and the hemostat in the operation). The drainage group was closed down the incision to start the timing, and the drainage volume in the 1 drainage ball was observed with the tube recorded by the measuring cylinder for 8 hours, and the flow ball kept the low negative pressure. According to the premise of my center. The safe extubation point was 8-12 hours, and the drainage tube was pulled out after 12 hours. The time interval was recorded, the basic information of the patients and the condition of the disease were recorded and the data were summed up. (2) the patients placed in the drainage group were divided into 1 hours, 8 cases, 1-2 hours 48 cases, 2 hours 4 cases, and the average total drainage of each group. Statistics, and the 22 comparison between groups, statistical operation time and the relationship between the total flow rate. (3) the patients were divided into male and female two groups, including 14 male and 46 female group, and the relationship between sex and average total flow rate (4) was divided into 10 groups according to the scope of operation, respectively, right full cut +. Right central group lymph node dissection group 13 cases, bilateral full cut + bilateral central group lymph node dissection group 28 cases, left full cut + left central group lymph node dissection group 6 cases, bilateral full cut + right central group of lymph node dissection group 4 cases, right total cut 1 cases, bilateral total resection group 3 cases, right full cut + left partial resection group 1 cases, left full cut + bilateral central Group lymph node dissection group 1 cases, right total cut + left subtotal cut + bilateral central group lymph node dissection group 2 cases, bilateral total cut + left central group of lymph node dissection group 1 cases. Statistical range of operation and the average total flow rate. (5) the drainage group is compared with the drainage group, and the drainage group is compared. The operation time was divided into 1 hours group, 1-2 hour group, and more than 2 hours, and the relationship between the operation time and the wound effusion was compared. Finally, the overall ratio of the effusion of the operation time of each group in each group was compared with that in the group without drainage group. [results]1. risk extubation point was explored according to the placement. The data of the drainage group, after a peak in 8 hours, gradually declined, and a high peak was found in the 80min drainage volume after the operation. The proportion of the total drainage volume per 20min period was significantly higher than that of the difference (P0.05). It indicated that the postoperative drainage was a time point at this point, The amount of exudation reached the peak, the body reabsorption and exudation reached a balance. The drainage tube was pulled out before the time point. That is, the relationship between the [17].2. operation time of the risk extubation point and the total flow rate was based on the experimental data. The time period of drainage was significantly different from that of the average total drainage fluid in each group (P0.05). The longer the time was, the more flow rate was after the operation. When the 3 groups of data were compared, the group within 1 hours was statistically significant (P0.05) compared with the other two groups. The other two groups had no statistical significance (P0.05). The operation time was within 1 hours, and the relationship between the total drainage volume of.3. patients and the total flow rate was less than that of the total flow rate. Two groups of men and women, including 14 male patients and 46 female patients, were analyzed statistically with no statistical significance (p=0.481, P0.05), there was no significant statistical difference, indicating that the gender did not affect the relationship between the total flow rate of.4. and the total flow rate after the operation, according to the experimental results, within the fixed operative range, There was no statistical significance in the 22 comparison between groups (P0.05). Because of the less sample size in this experiment, the increase of the average total flow rate after the enlargement of the operative scope was further verified by the further verification that all the patients in the.5. drainage group and the non drainage group had no postoperative bleeding. There were 5 cases in the 60 cases, and 44 cases in the 44 cases. There were 9 cases in the non tube group, and the ratio of 20.5%. was divided into groups, 1 hours group, 1-2 hour group, and more than 2 hours. 5 cases of incisional incision of orange juice appeared in 1-2 hours group, 7 cases within 1 hours without incisional effusion, 42 cases in 1-2 hour group, and 4 cases over 2 hours. There were no 7 cases; there were 7 cases of effusion in 1-2 hour group, no 26 cases, 1 cases of fluid accumulation over 2 hours and no 2 cases. It showed that the cases of wound effusion were concentrated in the operation time within 1-2 hours and less than 1 hours. The relationship between the operation time and the total flow rate, and whether the operation time was within 1 hours without drainage, it was feasible to enter one. In conclusion, there is a risk extubation point after thyroidectomy, that is, after 80min, the exudation of the wound reaches the peak, then the exudation is reduced gradually, the reabsorption capacity and exudation of the human soft tissue are balanced, and the drainage tube is removed before the relative risk. After the risk of the extubation point, the wound is theoretically wound. The reabsorption capacity exceeds the exudation, the flow rate begins to decline, and it is relatively safe to pull out the drainage tube. This view is a new practice in the rapid rehabilitation of thyroid surgery. It is worthy of clinical application. The sex of the patients and the surgical methods within a certain range have no statistical meaning to the average total flow rate, and the operation time is less relative to the total flow rate. Less, the probability of occurrence of incisional effusion is small, and whether or not catheterization is needed remains to be followed up.
【学位授予单位】：昆明医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R653
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