执行临床路径对垂体瘤围术期患者内分泌功能的影响

发布时间：2018-04-28 09:41

本文选题：临床路径 + 垂体瘤手术　；参考：《浙江大学》2017年硕士论文

【摘要】：目的观察垂体瘤围术期患者的内分泌功能评估及替代治疗情况,分析执行临床路径对其产生的影响,并阐明对垂体瘤围术期患者进行临床路径管理的重要性。方法:从内分泌科的垂体瘤患者随访数据库以及全院病案系统中,选取2009.7至2015.12期间在我院接受垂体瘤手术治疗及门诊随访的患者作为研究对象。根据是否执行临床路径,将研究对象分为路径组和非路径组。收集术前(合并症、临床症状,影像学,内分泌评估等)、术中(术式、病理、并发症等)、术后(内分泌评估,药物治疗等)等相关资料。其中内分泌评估资料包括泌乳素、性腺轴激素、甲状腺轴激素、皮质轴激素、生长激素、胰岛素样生长因子-1、血钠、尿比重等指标以及相关内分泌动态试验资料。按照术前1周、术后1周,术后1、3、6、12月的评估时间点,对资料进行整理录入。路径组和非路径组患者,分别以性别、年龄(+/-5岁)进行1:2配对。观察比较两组在内分泌评估以及替代治疗上的差异,并对术后激素轴(性腺轴、甲状腺轴、肾上腺轴)以及整体内分泌功能的恢复情况(激素水平达到正常或已行相关替代治疗)进行单因素分析,并将单因素分析中P0.05的因素纳入有序回归分析。因变量:在术后激素轴功能恢复的因素分析中,以"靶腺激素水平达到正常的时间"作为因变量,并以术后1、3月为切点,将因变量分为"早、中、晚"三组进行统计。在术后整体内分泌功能恢复的因素分析中,自定义"整体内分泌恢复评分"做为因变量。总评分为泌乳素、性腺轴、甲状腺轴、肾上腺轴、生长激素、抗利尿激素的功能恢复评分之和,并根据评分高低,分为整体内分泌功能恢复情况"好、中、差"三组进行统计。自变量:组别、性别、年龄、学历,术前症状,合并症、烟酒史,肿瘤直径、肿瘤分型、侵袭性,手术术式,术后并发症以及依从性评分(门诊的内分泌随访次数之和)、有效评估评分(激素或激素轴功能的有效评估次数之和)等。使用SPSS 20.0进行统计分析。结果:研究最终纳入180例患者进入分析统计,男性87人,女性93人,平均年龄(49.82±12.76)岁,其中路径组60人,非路径组120人,两组肿瘤直径无明显差异(22.10mm VS.25.08mm,P=0.09)。相较于非路径组,路径组的内镜使用率更高(86.7%VS.18.3%,P0.01),脑脊液漏发生率更高(28.3%VS.10%,P=0.002)。术前1周,术后1周,术后1、3、6、12月,性腺轴、甲状腺轴、肾上腺轴、生长激素、后叶功能的有效评估率,路径组均高于非路径组;功能低下患、者中,路径组的药物替代率也较非路径组更高。术后单激素轴功能恢复的有序回归分析显示,相较于良好评估(有效评估得分3)的患者,不良评估(有效评估得分≤3)患者的甲状腺轴、皮质轴功能在术后短期内未能达到正常的风险更高(P0.05),OR分别为3.26,3.13。性激素轴的有序回归分析结果显示,相较于路径组,非路径组患者在术后短期内功能未能达到正常的风险更高(OR=2.66,P0.05)。术后整体内分泌功能恢复的有序回归分析显示,相比于路径组,非路径组患者,其术后内分泌功能恢复的情况更差(OR=13.46,P=0.000);有效评估得分低的患者比有效评估得分高的患者,术后内分泌功能的恢复情况更差(OR=12.80,P=0.002)。结论:执行临床路径,有助于提高垂体瘤围术期患者的内分泌有效评估率、药物替代率,有助于垂体瘤手术患者的内分泌功能在术后早期达到正常。
[Abstract]:Objective To observe the endocrine function assessment and replacement therapy in the perioperative patients with pituitary adenomas, to analyze the effect of the clinical pathway on its production, and to clarify the importance of the clinical path management for the patients in the perioperative period of pituitary adenomas. Methods: 2009.7 to the follow-up database of the pituitary tumor patients in the Department of Endocrinology and the whole hospital medical record system were selected. 2015.12 patients who received pituitary adenoma surgery and outpatient follow-up were studied in our hospital. According to whether the clinical pathway was performed, the subjects were divided into the path group and the non path group. The preoperative (complication, clinical symptoms, imaging, endocrine assessment, etc.), intraoperative (surgical, pathological, complications, etc.), postoperative (endocrine assessment, drugs) were collected. Endocrine assessment data included prolactin, gonadotropin, thyroid axis hormone, corticosteroid, growth hormone, insulin-like growth factor -1, blood sodium, urine specific gravity, and related endocrine dynamic test data. The data were measured at 1 weeks before operation, 1 weeks after operation, and the time points for 1,3,6,12 months after operation. The patients in the path group and the non path group were paired with the sex and age (+/-5 years). The differences in the endocrine assessment and the replacement therapy were observed and compared between the two groups, and the recovery of the postoperative hormone axis (gonadal axis, thyroid axis, adrenal axis) and the overall secretory function (the hormone levels reached normal or already had been achieved. A single factor analysis was carried out and the factors of P0.05 in the single factor analysis were included in the sequential regression analysis. Variable: in the factor analysis of postoperative hormone axis function recovery, the "target adenoid level reached the normal time" as the dependent variable and the three groups were divided into "early, middle, late" by 1,3 months after the operation. In the analysis of postoperative overall endocrine function recovery factor analysis, a custom "overall endocrine recovery score" was used as a dependent variable. The total score was prolactin, gonadal axis, thyroid axis, adrenal axis, growth hormone, and the functional recovery of antidiuretic hormone, and the overall endocrine function was recovered according to the level of the score, "good, medium," Difference "three groups of statistics. Independent variables: group, sex, age, education, preoperative symptoms, complications, smoking and alcohol history, tumor diameter, tumor typing, invasive, surgical procedures, postoperative complications and compliance score (the number of endocrine follow-up times in outpatients), effective assessment score (the number of hormone or hormone axis function evaluation, and so on) and so on. SPSS 20 was statistically analyzed. Results: the study was finally included in the analysis of 180 patients, 87 men, 93 women, and average age (49.82 + 12.76) years old, including 60 in the path group, 120 in the non path group and no significant difference in the diameter of the tumor (22.10mm VS.25.08mm, P= 0.09). Compared with the non path group, the use of endoscopy in the path group was higher (86.7. %VS.18.3%, P0.01), the incidence of cerebrospinal fluid leakage was higher (28.3%VS.10%, P=0.002). 1 weeks before operation, 1 weeks after operation, 1,3,6,12 months after operation, the effective evaluation rate of gonadal axis, thyroid axis, adrenal axis, growth hormone and posterior leaf function was higher than that of non path group; the replacement rate of the path group was higher than that in the non path group. The sequential regression analysis of single hormone axis functional recovery showed that the thyroid axis of patients with poor assessment (effective assessment of score 3) was higher than that of a good assessment (effective assessment of score 3). The axial function of the cortical axis did not reach the normal risk in the short term after the operation (P0.05), and the results of the sequential regression analysis of the 3.26,3.13. sex hormone axis of OR were significant. Compared to the path group, the patients in the non path group had a higher risk of failure to achieve normal function in the short term (OR=2.66, P0.05). The sequential regression analysis of the postoperative overall endocrine function recovery showed that the postoperative endocrine function recovery was worse (OR=13.46, P=0.000) in the non path group than in the path group (OR=13.46, P=0.000); the effective assessment of the score was low. The recovery of endocrine function after operation is worse than that of patients with high score (OR=12.80, P=0.002). Conclusion: the implementation of clinical pathway helps to improve the effective rate of endocrine evaluation in patients with pituitary tumor perioperative period, and the replacement rate of drugs can help the endocrine function of the patients with pituitary tumor surgery to reach normal early after operation.

【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R736.4

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