【摘要】：[目的]選擇擬初次行甲狀腺開放手術(shù)的病例為研究對(duì)象,通過對(duì)甲狀腺術(shù)后不同時(shí)間段引流量的測(cè)量統(tǒng)計(jì),構(gòu)建初次甲狀腺術(shù)后時(shí)間段引流量的變化趨勢(shì)圖,并進(jìn)一步通過術(shù)后總引流量與手術(shù)范圍、手術(shù)時(shí)間、性別等多因素關(guān)系的研究,發(fā)現(xiàn)總引流量及置管與否對(duì)切口愈合的影響關(guān)系,臨床驗(yàn)證甲狀腺術(shù)后病人創(chuàng)面軟組織的強(qiáng)重吸收能力,選擇是否常規(guī)置管及置管的安全拔出時(shí)間,為甲狀腺疾病術(shù)后快速康復(fù)醫(yī)學(xué)的臨床研究及實(shí)踐提供參考。[方法]1、病例選擇:1)需排除胸骨后甲狀腺腫而開胸的手術(shù)病人;2)正常凝血指數(shù),若術(shù)前口服抗凝藥需停藥5-7天再手術(shù),女性非月經(jīng)期;3)甲狀腺再次及多次手術(shù)病人應(yīng)排除;4)排除甲狀腺頸部淋巴結(jié)清掃術(shù)后出現(xiàn)乳糜漏的患者;5)若中途出現(xiàn)引流管堵塞、漏氣等引流失敗,需排除觀察范圍;6)此次實(shí)驗(yàn)主要針對(duì)良性患者和甲癌患者無側(cè)方淋巴結(jié)轉(zhuǎn)移患者。2、手術(shù)方式:手術(shù)原則依據(jù)《2015版ATA指南》:1)經(jīng)典手術(shù)方式;2)順利完成甲狀腺切除術(shù)后,創(chuàng)面充分止血,創(chuàng)腔放置引流,引流采用14#甲狀腺外科專用“T”管。放置在氣管前方,沿原切口正中引出,并固定于皮膚上,遠(yuǎn)端連接負(fù)壓引流球,保持持續(xù)負(fù)壓;3)術(shù)后6h進(jìn)涼流質(zhì)或半流質(zhì)飲食,次日進(jìn)普食;4)術(shù)中用生理鹽水沖洗創(chuàng)面后蘸干;5)術(shù)后觀察引流球,保持引流通暢(間斷捏管)。3、實(shí)驗(yàn)方案(1)參照入組標(biāo)準(zhǔn)選擇2016年5月-2016年12月昆明醫(yī)科大學(xué)第一附屬醫(yī)院甲狀腺診療中心住院病例,將病例分為兩組,分別為不放引流組和放引流組。依住院時(shí)間按隨機(jī)數(shù)列分組,單數(shù)為不放引流組,雙數(shù)為放引流組。其中放引流組60例,不放引流組44例,中途退出入組10例(因手術(shù)方式的改變、術(shù)中放置止血粉等原因而退出入組)。放引流組:術(shù)閉關(guān)閉切口開始計(jì)時(shí),每20min用量筒記錄觀察1次引流球中的引流量,共觀察8小時(shí),引流球保持持續(xù)低負(fù)壓吸引。依據(jù)我中心之前提出的安全拔管點(diǎn)為8-12小時(shí),12小時(shí)后拔出引流管。記錄時(shí)間段引流量,統(tǒng)計(jì)患者基本信息以及疾病情況,并對(duì)數(shù)據(jù)信息進(jìn)行歸納統(tǒng)計(jì)。(2)將放置引流組患者按照手術(shù)操作時(shí)間分為:在1小時(shí)8例、1-2小時(shí)48例、多2小時(shí)4例。將每組的平均總引流量進(jìn)行統(tǒng)計(jì),并進(jìn)行組間的兩兩對(duì)比,統(tǒng)計(jì)手術(shù)操作時(shí)間與總引流量的關(guān)系。(3)將放置引流管組患者分為男、女兩組,其中男組14例,女組46例,統(tǒng)計(jì)性別與平均總引流量的關(guān)系(4)將放置引流組患者按照手術(shù)范圍分為10組,分別是右側(cè)全切+右側(cè)中央組淋巴結(jié)清掃組13例;雙側(cè)全切+雙側(cè)中央組淋巴結(jié)清掃組28例;左側(cè)全切+左側(cè)中央組淋巴結(jié)清掃組6例;雙側(cè)全切+右側(cè)中央組淋巴結(jié)清掃組4例;右側(cè)全切組1例;雙側(cè)全切組3例;右側(cè)全切+左側(cè)部分切除組1例;左側(cè)全切+雙側(cè)中央組淋巴結(jié)清掃組1例;右側(cè)全切+左側(cè)次全切+雙側(cè)中央組淋巴結(jié)清掃組2例;雙側(cè)全切+左側(cè)中央組淋巴結(jié)清掃組1例。統(tǒng)計(jì)手術(shù)范圍與平均總引流量的關(guān)系。(5)將放置引流組與不放置引流組出現(xiàn)傷口積液的情況進(jìn)行比較,并將不放引流組依據(jù)手術(shù)操作時(shí)間分為1小時(shí)以內(nèi)組、1-2小時(shí)組、2小時(shí)以上組,分別比較手術(shù)時(shí)間與傷口積液的關(guān)系。最后進(jìn)行放置引流組每組手術(shù)時(shí)間的積液情況與不放置引流組每組手術(shù)時(shí)間的積液情況的總體比較。[結(jié)果]1.風(fēng)險(xiǎn)拔管點(diǎn)的探究根據(jù)放置引流組的數(shù)據(jù),8小時(shí)內(nèi)引流量出現(xiàn)一個(gè)高峰之后隨之逐漸下降,約在術(shù)后80min引流液引出量出現(xiàn)一個(gè)高峰值,每20min時(shí)間段引流量所占總引流液量的比例相比差異有顯著性意義(p0.05)。說明患者的術(shù)后引流是存在一個(gè)時(shí)間點(diǎn),在這個(gè)點(diǎn),滲出量達(dá)到高峰,人體的重吸收和滲出量達(dá)到平衡,在這個(gè)時(shí)間點(diǎn)之前拔出引流管是存在積液風(fēng)險(xiǎn)的,即風(fēng)險(xiǎn)拔管點(diǎn)[17]。2.手術(shù)時(shí)間與總引流量的關(guān)系根據(jù)實(shí)驗(yàn)數(shù)據(jù),時(shí)間段引流液與每組平均總引流液量相比有顯著差異(p0.05),手術(shù)操作時(shí)間越長,術(shù)后引流量越多。將這3組數(shù)據(jù)進(jìn)行兩兩比較時(shí),1小時(shí)以內(nèi)組與其它兩組比較有統(tǒng)計(jì)學(xué)意義(p0.05),其余兩組比較時(shí)不存在統(tǒng)計(jì)學(xué)意義(p0.05)。說明手術(shù)操作時(shí)間在1小時(shí)以內(nèi),總引流量較少。3.患者性別與總引流量的關(guān)系將病例分為男、女兩組,其中男性患者14例、女性患者46例,對(duì)其引流量進(jìn)行統(tǒng)計(jì)學(xué)分析,無統(tǒng)計(jì)學(xué)意義(p=0.481,P0.05),沒有顯著的統(tǒng)計(jì)學(xué)差異,說明患者性別并不影響手術(shù)后總引流量。4.亍術(shù)方式與總引流量的關(guān)系根據(jù)實(shí)驗(yàn)結(jié)果,在固定的手術(shù)范圍內(nèi),進(jìn)行組間兩兩比較時(shí),無統(tǒng)計(jì)學(xué)意義(p0.05)。因本實(shí)驗(yàn)樣本量較少,擴(kuò)大手術(shù)范圍后平均總引流量是否增加有待進(jìn)一步驗(yàn)證。5.放引流組和不放引流組比較所有入組患者均未出現(xiàn)術(shù)后出血,術(shù)后切口積液在60例放管組中有5例,占8.3%;在44例不放管組中出現(xiàn)了 9例,比例20.5%。將上述數(shù)據(jù)依據(jù)手術(shù)時(shí)間進(jìn)行分組,1小時(shí)以內(nèi)組、1-2小時(shí)組、2小時(shí)以上組。放管組的5例切口枳液出現(xiàn)在1-2小時(shí)組;無切口積液的1小時(shí)以內(nèi)組7例,1-2小時(shí)組42例,2小時(shí)以上組4例。未放管組:1小時(shí)以內(nèi)組積液1例,無7例;1-2小時(shí)組積液7例,無26例,2小時(shí)以上組積液1例,無2例。說明傷口積液的病例集中在手術(shù)時(shí)間在1-2小時(shí)組內(nèi),1小時(shí)以內(nèi)組較少。綜合手術(shù)操作時(shí)間與總引流量的關(guān)系,手術(shù)操作時(shí)間在1小時(shí)以內(nèi)的術(shù)后是否可以不置引流,可行進(jìn)一步的實(shí)驗(yàn)探究。[結(jié)論]綜上所述,甲狀腺術(shù)后存在風(fēng)險(xiǎn)拔管點(diǎn),即術(shù)后80min時(shí),創(chuàng)面滲出量達(dá)到高峰,隨后滲出液逐漸減少,人體軟組織的重吸收能力和滲出量達(dá)到平衡,此時(shí)之前拔除引流管,存在相對(duì)風(fēng)險(xiǎn)。在風(fēng)險(xiǎn)拔管點(diǎn)之后,理論上講創(chuàng)面重吸收能力超越了滲出量,引流量開始下降,此時(shí)拔出引流管相對(duì)安全。此觀點(diǎn)是快速康復(fù)甲狀腺外科新的實(shí)踐,值得臨床推廣�；颊叩男詣e及在一定范圍內(nèi)的手術(shù)方式對(duì)平均總引流量無統(tǒng)計(jì)學(xué)意義,手術(shù)操作時(shí)間少相對(duì)應(yīng)總引流量就較少,出現(xiàn)切口積液概率較小,而是否需置管,有待后續(xù)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.
【學(xué)位授予單位】：昆明醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R653

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