妇科恶性肿瘤盆腔淋巴结切除术后闭孔神经损伤的临床观察及GM-1治疗效果的初步评估

发布时间：2018-04-27 09:58

本文选题：神经节苷脂 + GM-1　；参考：《河北医科大学》2017年硕士论文

【摘要】：目的:宫颈癌、子宫内膜癌、卵巢癌为女性生殖系统常见的三大恶性肿瘤,发病率呈逐年上升且年轻化趋势。妇科恶性肿瘤手术一般需行盆腔淋巴结切除,但与盆腔淋巴结相伴有许多血管和神经,走形迂曲,分布密度大,因盆腔淋巴结切除风险较大,术中易损伤血管、淋巴管及神经,造成术中、术后相关并发症,是妇科的氋难度手术。周围神经包括闭孔神经是一种较高级的组织,非常脆弱,易受机械及电热刺激的损伤,妇科恶性肿瘤行盆腔淋巴结切除术易损伤闭孔神经,使患侧出现下肢的疼痛、麻木,运动障碍,并出现股内侧皮肤感觉障碍等。神经损伤后会发生一系列的变化,因而相比其他组织而言,修复也会困难得多。神经节苷脂(gangliosides)是含唾液酸的一族异构的鞘糖脂,存在于大多数哺乳动物细胞膜中,能够有效抑制神经细胞凋亡、促进受损部位修复及其功能恢复。其中单唾液酸四己糖神经节苷酯(monosialotetrahexosyl gangliosides,GM-1)是哺乳类动物神经节苷脂的主要种类。GM-1的发现与成功提取,直接为外周神经损伤的治疗提供了一条崭新的途径,通过生物技术从根本上促进外周神经的修复,最大程度地恢复外周神经原有的功能。本实验及研究的目的是观察妇科恶性肿瘤盆腔淋巴结切除术后闭孔神经损伤的相关影响因素,以及单唾液酸四己糖神经节苷脂纳(GM-1)对妇科恶性肿瘤盆腔淋巴结切除术后闭孔神经损伤修复治疗效果的初步评估,旨在为治疗妇科恶性肿瘤手术后闭孔神经损伤的治疗提供新的思路。方法:1观察2015年4月至2016年12月我院652例妇科恶性肿瘤患者,行盆腔淋巴结切除术后的出现的相关并发症,分析此652例患者的相关临床资料,对年龄、体重指数、肿瘤类型、内科合并症、术前腹部手术史、手术方式、术中出血量、盆腔淋巴结切除个数、盆腔淋巴结阳性个数、是否同时行腹主动脉旁淋巴结切除以及术前是否行新辅助化疗进行统计处理和分析,研究闭孔神经损伤的相关因素。2将74例妇科恶性肿瘤行妇科手术切除盆腔淋巴结后闭孔神经出现损伤症状的患者随机分为观察组(34例)和对照组(40例),观察组给予常规治疗+gm-1静脉滴注,对照组给予常规治疗。根据患者症状的严重程度,以及患者自己的意愿,选择合适的治疗方案。分别记录并进行对比研究分析用药期间患者下肢疼痛感、麻木症状、皮肤温度感觉异常症状的改善及肌力恢复情况,以及两组患者各项症状完全恢复所需的平均时间。3统计学分析将临床记录数据及术后随访数据输入excel电子表格,建立数据库。数据分析采用spss22.0统计软件进行处理。用x2检验检测临床相关因素指标(患者年龄、体重指数、肿瘤类型、手术方式、出血量、盆腔淋巴结切除个数、盆腔淋巴结阳性数,术前行新辅助化疗、是否行腹主动脉旁淋巴结清除、术中出血量)与闭孔神经损伤构成比的关系。将与闭孔神经损伤的相关的单因素放入logistic回归模型作为自变量,将闭孔神经损伤和闭孔神经未损伤作为因变量进行回归分析。gm-1的药物疗效及闭孔神经恢复率用百分率表示,疗效结果采用四格表x2检验。统计闭孔神经损伤各症状平均恢复时间用均数±标准差(x±s)表示,采取t检验。p0.05差异有统计学意义。结果:1妇科恶性肿瘤盆腔淋巴结清扫术后并发症发生情况盆腔淋巴结清扫术后最易发生术后感染,其次是淋巴囊肿,闭孔神经损伤以及下肢水肿的发生率也较大,乳糜漏的发生率最低。2闭孔神经损伤的单因素分析1)年龄与体重指数:年龄、体重指数(是否肥胖)与闭孔神经损伤的发生未发现明显相关性,差异无统计学意义(p0.05)。2)是否合并内科并发症以及术前是否有腹部手术史:合并内科并发症以及术前具有腹部手术史并不增加闭孔神经损伤几率,差异无统计学意义(p0.05)3)妇科恶性肿瘤和手术方式(开腹手术和腹腔镜手术):子宫颈癌,子宫内膜癌,应用腹腔镜与闭孔神经损伤密切相关(p0.05)。4)盆腔淋巴结清扫个数与盆腔淋巴结阳性数:闭孔神经损伤的发生与盆腔淋巴结清扫个数有关,差异有统计学差异(P0.05),与盆腔淋巴结阳性个数无关,差异无统计学意义(P0.05)。5)是否行腹主动脉旁淋巴结清除与术前是否行新辅助化疗:二者与闭孔神经损伤的发生无明显的相关性(P0.05)。6)术中出血量:术中出血量越大越易发生闭孔神经损伤,差异有统计学意义(P0.05)。3闭孔神经损伤的多因素分析对影响闭孔神经损伤的因素进行多元逐步回归分析得出,手术方式(开腹、腹腔镜)、术中出血量、盆腔淋巴结清扫数目与闭孔神经损伤的发生差异有统计学意义(P0.05),为闭孔神经损伤的独立危险因素。4 GM-1治疗闭孔神经损伤的近期疗效观察两组病例均获随访,1周内,两组病人的肌力恢复情况和皮肤感觉障碍的改善无明显不同,差异无统计学意义(P0.05),但疼痛症状改善及麻木症状改善观察组明显优于对照组,且差异有统计学意义(P0.05)。5 GM-1治疗闭孔神经损伤的远期疗效观察两组病人均获随访,1年内,两组病人闭孔神经损伤的各症状平均恢复时间无明显统计学差异(P0.05)。结论:1妇科恶性肿瘤盆腔淋巴结清扫术后最易发生术后感染,其次为淋巴囊肿。2宫颈癌与内膜癌较卵巢癌闭孔神经发生的几率大,腹腔镜手术较开腹手术闭孔神经损伤的几率大。盆腔淋巴结清扫个数越多,及术中出血量越多,越易发生闭孔神经损伤。3 GM-1在妇科恶性肿瘤盆腔淋巴结切除术后闭孔神经损伤的近期恢复具有有效和促进作用。但远期效果并不明朗。
[Abstract]:Objective: cervical cancer, endometrial cancer and ovarian cancer are the three common malignant tumors in the female reproductive system. The incidence of cancer is increasing year by year and young. The operation of gynecologic malignant tumors usually needs pelvic lymph node resection, but there are many vessels and nerves associated with pelvic lymph nodes. It is easy to damage the blood vessels, lymphatic vessels and nerves during the operation, which causes intraoperative and postoperative complications. It is a difficult operation in gynecology. The peripheral nerve, including the obturator nerve, is a more advanced tissue. It is very vulnerable and easily damaged by mechanical and electrothermal stimulation. Pelvic lymph node excision is easy to damage the obturator nerve in gynecologic malignant tumors, making it easy to damage the obturator nerve. The pain, numbness, dyskinesia, and sensory disorders of the medial femoral skin appear on the side of the lower limb. A series of changes will occur after nerve injury, and the repair is much more difficult than other tissues. The ganglioside (gangliosides) is a group of isomeric sheaths containing sialic acid in most mammalian cell membranes. The four hexose Ganglioside (monosialotetrahexosyl gangliosides, GM-1), one of the main types of gangliosides of mammalian animals, can be found and successfully extracted, and the direct connection is a new treatment for the treatment of peripheral nerve injury. The purpose of this experiment and study is to observe the related factors of the obturator nerve injury after pelvic lymphadenectomy in gynecologic malignant tumors, and the single sialic acid four hexose Ganglioside (GM-1) to gynecology. A preliminary evaluation of the effect of repair of obturator nerve injury after pelvic lymphadenectomy for malignant tumors is designed to provide new ideas for the treatment of obturator nerve injury after gynecologic malignant tumor surgery. 1: 652 cases of gynecologic malignancies in our hospital from April 2015 to December 2016 were observed after pelvic lymphadenectomy. Related complications, the related clinical data of the 652 patients were analyzed, including age, body mass index, tumor type, internal medicine complication, history of abdominal surgery, surgical methods, intraoperative bleeding, number of pelvic lymph nodes, the number of pelvic lymph nodes positive, whether the lymph nodes were removed at the same time, and whether neoadjuvant chemotherapy was performed before the operation. Statistical processing and analysis, the related factors of the obturator nerve injury.2 were divided into the observation group (34 cases) and the control group (34 cases) and the control group (40 cases), 74 cases of gynecologic malignant tumor underwent gynecologic surgery. The observation group was given routine treatment of intravenous drip, and the control group was given routine treatment. According to the severity of the patient's symptoms and the patient's own will, choose the appropriate treatment. Record and compare the lower extremity pain, numbness, the skin temperature sensation abnormal symptoms and the muscle strength recovery during the medication, and the average time.3 required for the complete recovery of the two groups of patients. The clinical records and postoperative follow-up data were entered into the Excel spreadsheet to establish the database. The data analysis was processed by the spss22.0 statistical software. The clinical related factors were detected by x2 test (patient's age, body mass index, tumor type, operation mode, bleeding volume, the number of pelvic lymphadenectomy, pelvic lymphadenectomy. Sex number, neoadjuvant chemotherapy before operation, the relationship between para aortic lymph node clearance, intraoperative hemorrhage volume and the ratio of obturator nerve injury. The single factor related to the obturator nerve injury was put into the logistic regression model as the independent variable, and the obturator nerve injury and the obturator nerve were not damaged as the dependent variable for the regression analysis of.Gm-1 The efficacy of the drug and the recovery rate of the obturator nerve were indicated by the percentage of the four lattice x2 test. The average recovery time of the symptoms of the obturator nerve injury was indicated by the mean mean difference (x + s), and the.P0.05 difference was statistically significant by the t test. Results: 1 the complications of the pelvic lymph node dissection of the malignant tumor of gynecologic tumor Postoperative infection was most likely to occur after cavity lymph node dissection, followed by lymphatic cysts, obturator nerve injury and lower limb edema, the incidence of chylous leakage was the lowest in the single factor analysis of.2 obturator nerve injury. 1) age and body mass index: age, body mass index (no obesity) and obturator nerve injury were not found to be obvious No statistically significant difference (P0.05).2) the complication of internal medicine and the history of abdominal surgery before operation: complications of internal medicine and the history of abdominal surgery did not increase the risk of obturator nerve injury, there was no statistical difference (P0.05) 3) gynecologic malignancies and surgical methods (laparotomy and laparoscopy): Cervical cancer, endometrial carcinoma, the use of laparoscopy and obturator nerve injury closely related (P0.05).4) the number of pelvic lymph node dissection and pelvic lymph node positive number: the occurrence of the obturator nerve injury and the number of pelvic lymph node dissection, the difference is statistically significant (P0.05), not related to the number of pelvic lymph node positive, there is no statistical difference (P0 .05).5) whether or not para aortic lymph node clearance and preoperative neoadjuvant chemotherapy: there is no significant correlation between the two and the occurrence of obturator nerve injury (P0.05).6) the amount of bleeding during the operation: the greater the amount of bleeding in the operation, the more easily the obturator nerve injury, the difference is statistically significant (P0.05) the multifactor analysis of the obturator nerve injury to the obturator, which affects the obturator. Multiple stepwise regression analysis of the factors of nerve injury showed that the operation mode (laparotomy, laparoscope), intraoperative bleeding, the number of pelvic lymph node dissection and the occurrence of obturator nerve injury were statistically significant (P0.05), which was an independent risk factor of obturator nerve injury by.4 GM-1 for the treatment of obturator nerve injury in the near future. There was no significant difference between the recovery of muscle strength and the improvement of skin sensory disturbance in the two groups within 1 weeks. The difference was not statistically significant (P0.05), but the improvement of pain symptoms and the improvement of numbness symptoms in the observation group were obviously superior to those of the control group, and the difference was statistically significant (P0.05) the long-term effect of.5 GM-1 in the treatment of obturator nerve injury was two. The patients were followed up, and the average recovery time of the two groups of patients with obturator nerve injury had no significant difference in 1 years (P0.05). Conclusion: 1 after pelvic lymph node dissection of gynecologic malignant tumors, postoperative infection was the most likely to occur, followed by lymphatic cysts.2 cervical cancer and endometrial carcinoma more likely than ovarian cancer. The higher the number of pelvic lymph node dissection and the more intraoperative bleeding, the more easily the obturator nerve injury.3 GM-1 will be effective and useful for the immediate recovery of obturator nerve injury after pelvic lymphadenectomy for gynecologic malignant tumors.

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R737.3

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