本文關鍵詞： 深部浸潤型子宮內膜異位癥 手術 治療　出處：《復旦大學》2014年博士論文　論文類型：學位論文

【摘要】：前言深部浸潤型內異癥(deeply infiltrating endometriosis, DIE)指所有病灶浸潤到腹膜下深度≥5mm內異癥,可以位于盆腔不同部位,包括宮骶韌帶、子宮直腸陷凹、陰道直腸隔內異癥、膀胱內異癥、輸尿管內異癥等。文獻報道其發(fā)病率約為1-2。95%的DIE患者常伴有嚴重的疼痛。近十年來手術治療方案成為DIE研究熱點。本課題研究93例深部浸潤型子宮內膜異位癥患者的病例資料及預后,通過分析深部浸潤型子宮內膜異位癥的診斷、治療以及療效,旨在啟發(fā)臨床重視對深部浸潤型子宮內膜異位癥的診斷、合理制定手術治療方案,加強患者圍手術期及術后管理,為改善患者預后提供臨床依據(jù)。第一部分深部浸潤型子宮內膜異位癥的臨床診斷及手術方案研究目的：探討深部浸潤型子宮內膜異位癥的臨床診斷以及手術治療方案制定。方法：選取2011年1月至2013年12月就診于復旦大學附屬婦產科醫(yī)院并接受手術治療的深部浸潤型子宮內膜異位癥患者93例,確定診斷標準、排除標準。手術治療原則及方法分為DIE病灶根治性切除手術及DIE病灶非根治手術兩種。對臨床診斷依據(jù)以及手術治療信息采用T檢驗、卡方檢驗及方差分析。結果：深部浸潤型子宮內膜異位癥在因子宮內膜異位癥相關疾病而住院治療病人中的比例為3.04%。93例深部浸潤型子宮內膜異位癥患者平均年齡34.99±7.15歲(24-55歲)。其中64.52%患者有明顯痛經史,慢性盆腔疼痛30.11%,性交痛17.20%。病灶累及部位以宮骶韌帶41.9%最常見。MRI病灶檢出率80.6%。DIE合并內異癥者CA125升高的陽性率較不合并者更高(66.5% VS 29.4%,P=0.021)。共93例患者接受手術治療,90.3%患者采取腹腔鏡手術,9例開腹手術,1例經陰道手術。病灶根治手術組的外科醫(yī)師參與率顯著高于非根治組(80% VS 7.9%,P0.001)。根治手術組同時合并婦科根治手術比例顯著高于非根治組(16.4% VS2.6%,P=0.022)。并發(fā)癥發(fā)生率根治組較非根治組更高((9.1 VS 0%,P0.001)。結論：深部浸潤型子宮內膜異位癥是內異癥中較為復雜、嚴重的一種類型,臨床診斷應綜合疾病史、婦科檢查以及影像學檢查。腹腔鏡手術是治療疾病的最佳方式。病灶根治切除手術常需外科醫(yī)師共同協(xié)作參與。第二部分深部浸潤型子宮內膜異位癥手術療效研究目的：分析深部浸潤型子宮內膜異位癥的手術治療效果以及圍手術期綜合管理。方法：采用VAS疼痛視覺模擬評分對患者術前術后的自身痛覺感受評分、WHOQOL-BREF評價術前術后生存質量、rAFS分期評估疾病嚴重程度、EFI評估生育功能、確定復發(fā)標準,對患者術前及術后治療效果隨訪。主要研究圍手術期治療對深部浸潤型子宮內膜異位癥患者疼痛、生存質量、生育功能以及復發(fā)的影響。結果：成功隨訪85例DIE患者,平均隨訪時間18.3±8.7個月(3-36個月)。術后疼痛VAS評分較術前降低(0.89±1.6 VS 5.4±3.9,P0.001),且DIE根治切除手術的疼痛改善較非根治手術明顯(5.6±3.9 VS 2.9±3.3,P=0.001)。術后生活質量全面提高。病灶根治組復發(fā)率較非根治組更低(3.9% VS 35.3%,P0.001)。27名生育要求者中不孕癥占63%,累計妊娠率48.1%,術后平均妊娠時間7.0±4.0個月(3-18個月)EFI5妊娠率高于EFI≤4 (54% VS 0%, P=0.038),根治性病灶切除不提高妊娠結局。輕度盆腔內異癥患者中病灶非根治組的生存質量自評總分改善更多(10.0±1.6 VS 6.8±2.7,P=0.034)。重度盆腔內異癥患者中病灶根治組的疼痛評分(6.1±4.3 VS 2.9±3.4,P=0.002)、復發(fā)率(5.9%VS 36.7%,P=0.002)改善明顯。DIE病灶根治切除同時行婦科根治術組年齡較婦科非根治組更大(43.5±6.7 VS 36.7±6.2, P=0.016)、疼痛改善更明顯(8.7±2.2 VS 5.1±3.9,P=0.036)。非根治性手術術后使用GnRHa者疼痛改善較不用藥者更明顯(4.5±3.2VS 1.2±2.7, P=0.003)。GnRHa4-6支治療組骨質疏松的發(fā)生率(25% VS 2.4%,P=0.011)較GnRHal-3支治療組更高,但復發(fā)率更低(0% VS 14.6%,P=0.040)。結論：手術治療能夠改DIE善患者的疼痛癥狀并提高生活質量。EFI評分可以預測術后的生育功能改善情況。DIE病灶根治切除合并婦科根治術更適合于更年期患者。術后藥物治療能夠預防疾病的復發(fā)。
[Abstract]:The deep infiltrating endometriosis (deeply infiltrating, endometriosis, DIE) refers to all lesions infiltration into the peritoneal endometriosis under depth more than 5mm, can be located in different parts of the pelvis, including uterosacral ligament, rectouterine pouch, rectovaginal septum endometriosis, bladder endometriosis, ureteral endometriosis. The reported incidence rate of about 1-2.95% DIE patients often accompanied by severe pain. Over the past ten years, surgical treatment has become the focus of DIE research. This research clinical data and prognosis of 93 cases of patients with deep infiltrating endometriosis, through diagnostic analysis of deep infiltrating endometriosis, treatment and curative effect, in order to inspire clinical attention the diagnosis of deep infiltrating endometriosis, reasonable surgical treatment, strengthen the perioperative and postoperative management, to provide clinical basis for improving the prognosis of patients. The first part of the deep Objective to study the clinical diagnosis and therapy of deep infiltrating endometriosis: making clinical diagnosis of deep infiltrating endometriosis and surgical treatment. Methods: from January 2011 to December 2013 the deep treatment in obstetrics and Gynecology Hospital of Fudan University and underwent surgery for infiltrating endometriosis patients in 93 cases, determine diagnostic criteria and exclusion criteria. The principle and method of surgical treatment of DIE lesions is divided into radical resection and radical resection of two non DIE lesions. Using T test for clinical diagnosis and surgical treatment of information, chi square analysis and variance. Results: deep infiltrating endometriosis in endometriosis related the disease and hospitalized patients in the proportion of 3.04%.93 cases of deep infiltrating endometriosis patients with mean age 34.99 + 7.15 years old (24-55 years old). 64.52% patients had obvious history of dysmenorrhea, chronic pelvic pain 30.11%, sexual pain 17.20%. lesions involving parts of the uterosacral ligament of 41.9% most common.MRI lesion detection rate of 80.6%.DIE with endometriosis were CA125 positive rate increased less with higher (66.5% VS 29.4%, P=0.021). A total of 93 patients underwent surgical treatment, 90.3% patients take laparoscopic surgery, 9 cases of laparotomy, 1 cases of vaginal surgery. Surgeons were radical surgery group participation rate was significantly higher than that in non eradication group (80% VS 7.9%, P0.001). Radical surgery group combined with gynecological radical operation was significantly higher than the proportion of non eradication group (16.4% VS2.6%, P=0.022). The complication rate of radical group non radical groups were higher (9.1 VS (0%, P0.001). Conclusion: deep infiltrating endometriosis is complicated in endometriosis, serious type, clinical diagnosis should be comprehensive medical history, gynecological examination and imaging Check. Laparoscopic surgery is the best way to treat the disease. The lesion resection surgery often require surgical physicians together. The second part involved in deep infiltrating endometriosis surgery clinical study objective: to analyze the effect of surgical treatment of deep infiltrating endometriosis and peri operative management. Methods: analog scale patients with preoperative and postoperative pain score by VAS its visual, WHOQOL-BREF evaluation of preoperative and postoperative quality of life, rAFS staging to evaluate the severity of the disease, EFI assessment of reproductive function, determine the recurrence criterion on the therapeutic effect of patients with preoperative and postoperative follow-up. The treatment of deep infiltrating endometriosis patients with pain. In the quality of life mainly study the perioperative period, fertility and recurrence effects. Results: follow-up of 85 cases of DIE patients, the mean follow-up time was 18.3 + 8.7 months (3-36 months). After the pain VAS score decreased (0.89 + 1.6 VS 5.4 + 3.9, P0.001), and DIE radical resection of pain improvement than non radical surgery significantly (5.6 + 3.9 VS 2.9 + 3.3, P=0.001). Improving the quality of life after surgery. The lesion eradication group the recurrence rate is lower (3.9% non radical group. 35.3% VS, P0.001).27 fertility requirements in infertility accounted for 63%, the cumulative pregnancy rate was 48.1%, the average postoperative pregnancy time was 7 + 4 months (3-18 months) the pregnancy rate of EFI5 is higher than that of EFI is less than or equal to 4 (54% VS 0%, P=0.038), radical resection does not improve pregnancy outcome of mild pelvic disease of lesions. The quality of life in patients with lesions of non radical group self rating scores improved more (10 + 1.6 VS 6.8 + 2.7, P=0.034). Severe pain lesions radical group of patients with pelvic endometriosis score (6.1 + 4.3 VS 2.9 + 3.4, P=0.002), the recurrence rate (5.9%VS 36.7%, P=0.002) Gai Shanming.DIE lesion resection at the same time for gynecology Radical surgery group than non gynecological age more radical group (43.5 + 6.7 VS 36.7 + 6.2, P=0.016), pain improved obviously (8.7 + 2.2 VS 5.1 + 3.9, P=0.036). Non radical surgery after GnRHa pain was improved without medicine more obvious (4.5 + 3.2VS 1.2 + 2.7. P=0.003).GnRHa4-6 treatment group, the incidence of osteoporosis (25% VS 2.4%, P=0.011) than the GnRHal-3 branch of treatment group is higher, but the recurrence rate is lower (0% VS 14.6%, P=0.040). Conclusion:.EFI can improve the quality of life score and pain surgery can change the DIE good patients can improve the situation of.DIE lesions with radical resection gynecological radical operation is more suitable for menopause patients in predicting postoperative reproductive function. Postoperative drug therapy to prevent recurrence of the disease.

【學位授予單位】：復旦大學
【學位級別】：博士
【學位授予年份】：2014
【分類號】：R713.4

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