本文選題：慢性腎臟病 + 繼發(fā)性甲狀旁腺功能亢進(jìn)　； 參考：《青島大學(xué)》2017年碩士論文

【摘要】：目的:本研究通過(guò)系統(tǒng)檢索文獻(xiàn),初步制定出一個(gè)提供證據(jù)等級(jí)并給出推薦意見(jiàn)的手術(shù)治療繼發(fā)性甲狀旁腺功能亢進(jìn)(SHPT)的臨床路徑,并初步在臨床實(shí)踐中加以應(yīng)用,旨在通過(guò)多學(xué)科合作、強(qiáng)化圍手術(shù)期病人管理,降低醫(yī)療成本,提高手術(shù)成功率,降低并發(fā)癥發(fā)生率,改善臨床結(jié)局。方法:檢索發(fā)表在PubMed、Embase、Cochrane數(shù)據(jù)庫(kù)中的關(guān)于手術(shù)治療SHPT的英文文獻(xiàn),去除綜述、個(gè)案報(bào)道、社論等類(lèi)型的文章,并去除重復(fù)發(fā)表的文章,進(jìn)行手術(shù)治療SHPT的文獻(xiàn)方面的研究。系統(tǒng)檢索Pub Med數(shù)據(jù)庫(kù)發(fā)表的關(guān)于SHPT的英文文獻(xiàn),檢索時(shí)間為從建庫(kù)到2016年12月30日,采用主題詞和自由詞聯(lián)合的檢索策略,并手工檢索部分相關(guān)文獻(xiàn)。將檢索到的文獻(xiàn)進(jìn)行分類(lèi),分為臨床隨機(jī)對(duì)照試驗(yàn)(RCTs)、隊(duì)列研究和病例對(duì)照研究等,采用美國(guó)醫(yī)師協(xié)會(huì)(ACP)分級(jí)系統(tǒng),將檢索到的文獻(xiàn)綜合分析后給出證據(jù)等級(jí),并從患者和醫(yī)生的立場(chǎng)綜合考慮給出推薦意見(jiàn)。自2014年7月到2017年2月,青島大學(xué)附屬醫(yī)院普通外科共對(duì)24例患者實(shí)施手術(shù)治療,回顧性收集分析患者的臨床資料。其中2例患者行甲狀旁腺全切除術(shù)(t PTX),22例患者行甲狀旁腺全切除伴自體移植術(shù)(t PTX+AT)。收集患者術(shù)前、術(shù)中、術(shù)后的血鈣、血磷、全段甲狀旁腺素(i PTH)結(jié)果、臨床癥狀的改善情況和病理結(jié)果進(jìn)行統(tǒng)計(jì)分析。結(jié)果:最終納入43篇文章進(jìn)行分析,發(fā)表的年限為從1980年到2016年,納入的患者數(shù)量范圍從10例到898例,文章發(fā)表數(shù)量隨時(shí)間呈上升趨勢(shì)。SHPT患者圍手術(shù)期管理從疾病的診斷、手術(shù)指征、術(shù)前定位、術(shù)前常規(guī)準(zhǔn)備、手術(shù)方式、手術(shù)過(guò)程中的輔助措施和術(shù)后管理等方面分別進(jìn)行描述和證據(jù)的分級(jí)。疾病的診斷主要依據(jù)病史、實(shí)驗(yàn)室檢查和臨床表現(xiàn),其中實(shí)驗(yàn)室檢查主要包括血鈣、血磷和i PTH。比較常用的術(shù)前定位技術(shù)包括高頻超聲、99m Tc-MIBI、CT等,其中高頻超聲為首選檢查方法(中級(jí)證據(jù),強(qiáng)烈推薦)。其中高頻超聲聯(lián)合99m Tc-MIBI為主要的術(shù)前定位方法(中級(jí)證據(jù),強(qiáng)烈推薦)。其余各方面的描述見(jiàn)正文結(jié)果部分。24例患者中有10例男性患者,14例女性患者;患者的平均年齡為45.79±8.62歲,范圍從28歲到64歲;平均透析齡為7.15±2.64年,范圍從1.5年到15年。術(shù)后1個(gè)月20例患者的手術(shù)總成功率為90.00%。術(shù)后1周內(nèi)骨痛的緩解率為92.86%,皮膚瘙癢的緩解率為100.00%,術(shù)后低鈣血癥的發(fā)生率為95.83%。24例患者共切除90枚甲狀旁腺腺體,其中病理結(jié)果為結(jié)節(jié)性增生的腺體共47枚,占切除腺體總數(shù)的52.22%;病理結(jié)果為甲狀旁腺腺瘤的共43枚,占切除腺體總數(shù)的47.78%。結(jié)論:根據(jù)文獻(xiàn)檢索、分析,證據(jù)等級(jí)認(rèn)證,建立尿毒癥長(zhǎng)期血液透析繼發(fā)性甲狀旁功能亢進(jìn)圍手術(shù)期管理臨床路徑,初步臨床應(yīng)用證實(shí)該路徑能夠有效用于病人圍手術(shù)期管理,可以改善病人近期臨床結(jié)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 鹵8.62 years, ranging from 28 to 64 years, and the average dialysis age is 7.15 鹵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.
【學(xué)位授予單位】：青島大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R692.5;R653

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