【作者】 孙伯民；

【导师】 庞琦；

【作者基本信息】 山东大学 ， 外科学， 2012， 博士

【摘要】 背景和目的：神经性厌食症是一种进食障碍,其特征是由于进食明显减少所致体重明显减轻、闭经,通常伴有体像障碍、强迫症状等其它精神障碍。随着病情进展,患者可出现阵发性暴食与暴食后呕吐症状。传统的神经性厌食症的治疗方法主要有心理治疗和药物治疗,往往对早期患者有一定疗效,但大多数患者经历长期的心理、药物治疗无明显效果,成为难治性神经性厌食症。难治性神经性厌食症具有较高的死亡率,常死于严重营养不良、电解质紊乱、多器官衰竭等并发症。近年来脑立体定向手术用于治疗难治性强迫症,具有安全、微创、副作用少的特点,显著改善率在90%以上。由于神经性厌食症与强迫症都属于强迫谱系障碍,临床上具有许多共同特点,因此从2006年以来,我们采用手术方法治疗难治性神经性厌食症患者,即心理、药物治疗无效的严重患者。在长期的手术治疗中我们发现,由于病程长短、临床症状严重程度对于手术方法的选择及治疗预后及起了关键作用,因此我们依据患者的不同临床特征进行临床分级研究(Ⅰ-Ⅳ级),期望该临床分级可以在手术时机的判断、手术方式的选择及预后判断有所帮助。方法：在所有接受手术治疗的104例神经性厌食症患者中随访到术后6个月以上的61例患者,将这61例患者手术前后主要症状、病程、体重身高指数、月经是否正常、是否伴人格改变及日常生活能力量表(ADL量表)、简明智力量表、Yale-Brown强迫症量表(Y-Bocs量表),汉密顿焦虑量表(HAMA量表),汉密顿抑郁量表(HAMD量表)等指标进行对照研究,依据术前临床症状进行分级,根据不同分级选择不同手术方式,如立体定向下双侧伏隔核电刺激术或立体定向下双侧内囊前肢毁损术,随访时间6-64个月,平均(26.15±10.47)个月。结果：大部分患者术后神经性厌食症症状明显缓解,其中有2例于术后6个月、10个月复发,再次行立体定向下双侧内囊前肢毁损术,症状有明显改善,至随访时病情稳定。1例Ⅳ级患者术后症状无改善,于术后18个月自杀死亡。其余所有患者至随访时,体重身高指数大于17.5者占85.37%,其中Ⅱ、Ⅲ级患者均恢复正常；30例术前闭经者术后恢复正常,7例由不规律转为规律,其中Ⅱ、Ⅲ级患者均治愈,Ⅳ级患者中有83.87%治愈；手术前后除简明智力量表无明显统计学意义,其余4项量表评分显示手术前后有显著差异,Ⅱ、Ⅲ级患者改善程度为明显有效或有效,Ⅳ级患者分别出现明显有效、有效、改善甚至无效。其中对强迫症状缓解程度最佳,焦虑症状其次,抑郁症状最差；手术前后体像障碍变化有统计学意义,术后对肥胖恐惧者远少于术前,术前休学或不能工作的患者术后恢复学习和工作,有明显统计学差异。结论：通过对神经厌食症分级可以根据疾病严重程度实施相应的治疗方案,选择适当的手术方式,有利于提高患者术后的疗效及预后判断,对术后患者的后续治疗有指导意义；手术对神经性厌食症患者的体重改善疗效显著,改善率达到90.24%,t统计检验表明手术后体重身高指数(BMI值)增高达到极显著水平(t=9.32.P<0.0001)；手术对神经厌食症患者的月经具有显著的治愈和改善效果(Wilcoxon符号秩和检验,统计量为S,得S=297.5,P<0.01)；手术对神经性厌食症患者的精神科量表相关指标改善明显,Y-BOCS量表, HAMA量表,HAMD量表评分手术前后t检验有明显统计学意义,总有效率(显效+有效+改善)分别为82.94%,85.37%,90.25%。t统计检验表明手术前后各项指标差异均达到极显著水平。更多还原

【Abstract】 Background and Objectives:Anorexia nervosa is an eating disorder which is an important cause of physical and psychosocial morbidity in adolescent girls and young adult women. Common signs and symptoms include loss of subcutaneous fat tissue, orthostatic hypotension, bradycardia, impaired menstruation, hair loss and hypothermia. Many other psychiatric conditions often co-exist in50to70percent of patients such as major depression or dysthymia, anxiety disorders and obsessive-compulsive disorder (OCD). Almost50%of patients are refractory to all current medical treatment and never fully recover and the standardized mortality ratio over the first10years is about10%.With the progress of the illness,the symptom of episodic overeating and vomiting will emerge.Thetraditional treatment for AN are psychological treatment and medication.Patients often have a certain effect with these treatment on early stage.However,most of patient have experienced repeated long-term medical treatment,and become refractory AN patients with a high mortality rate.Patients often died of severe malnutration,electrolyte imbalance,multiple organ failure and other complications.In recent years,the sterotactic brain surgery became a safe、minimal invasive、less side effect treatment that is used for the treatment of retractory Obssessive-compulsive disorder(OCD).AN and OCD are all belong to the forcing spectrum disorders.There are many common clinical features.Our center have been used surgical treatment with AN patients since the year2006.We discovered from the surgical treatment that:The severity of clinical symptoms played a key role in the choice of surgical methods and the prognosis of the illness.Therefore,we based on different clinical features of patients to outline and classify the illness,expect that the clinical classification can be of help for determing the timing of surgery,the chooice of surgery procedure and prognosis.Method:61patients from the overall104surgical treated patients were successfully follow-up.The material of major symptoms such as course of disease、body mass index(BMI)、menia、Yale-brown OCD Scale、Hamilton Anxiety Scale、Hamilton Depression Scale、Concise Intelligent Scale were well collected for controlled study.The clinical classifucation is based on the clinical symptoms before the surgery.Results:2DBS cases of grade IV patient were relapsed6and10months after the surgery, respectively. Who then have received biladeral stereotactic internal capsulotomy and then significantly inproved.They were still in stable condition the time of follow-up.1case of grade IV patient have no improvement and died from suicide18months after surgery.85.37%patients have their BMI over17.5in all living patients.Ⅱ、Ⅲ grade patients returned to normal level;30cases of amenorrhea before surgery returned to normal after the operation.7cases were menia irregular and retured to normal after surgery.Grade Ⅱ、Ⅲ patients were cured,83.87%of grade IV patients were cured;Except to Concise Intelligent Scale was no statistically significant before and after surgery,the scores of the remaining four scales showed a significant difference before and after surgery. The operation is best for the improvement of obsessive symptoms,second,anxiety symptoms,last,depression.Change in body image disorders before and after surgery was ststistically significant.更多还原