结节性甲状腺肿次全切除术后激素替代治疗时机探讨

目的:探讨结节性甲状腺肿次全切除术后左甲状腺素替代治疗的时机。方法:选取2017年10月~2018年10月收治的90例拟进行结节性甲状腺肿次全切除术患者作为研究对象,按照随机数字表法分为对照组和观察组,各45例。对照组术后2周进行左甲状腺素替代治疗,观察组于术后次日即给予左甲状腺素替代治疗,比较两组促甲状腺激素情况、术后甲状腺功能减退症发生率及复发率。结果:观察组术后3 d、5 d、1周、2周、4周测定的促甲状腺激素水平和促甲状腺激素水平趋于稳定所需时间均明显低于对照组,差异显著,P<0.05;观察组甲状腺功能减退症发生率及结节性甲状腺肿复发率均明显低于对照组,差异显著,P<0.05。结论:结节性甲状腺肿次全切除术后次日给予左甲状腺素替代治疗,可明显改善患者促甲状腺激素水平,使其较快趋于稳定,同时可降低甲状腺功能减退症发生率及结节性甲状腺肿复发率。     

保留输卵管系膜的输卵管切除术对卵巢储备功能的影响

目的 探讨保留输卵管系膜的输卵管切除术对卵巢储备功能的影响。方法 收集2020年1月—2021年3月收治的输卵管疾病患者281例为研究对象,按照治疗方式的不同分为传统双侧切除组(n=53,行传统双侧输卵管切除术)、传统单侧切除组(n=56,行传统单侧输卵管切除术)、保留双侧切除组(n=60,行保留输卵管系膜的双侧输卵管切除术)、保留单侧切除组(n=54,行保留输卵管系膜的单侧输卵管切除术)、对照组[n=58,无输卵管切除术史的体外受精-胚胎移植(IVF-ET)患者]。比较各组患者手术时间、术中出血量和术后排气时间。患者术后2个月行IVF-ET并检测卵泡数量、卵子数量、妊娠率和受精率。IVF-ET后检测患者外周血抗苗勒氏管激素(AMH)、促卵泡生成素(FSH)、雌二醇(E₂)、黄体生成素(LH)水平。随访至2023年3月,记录5组患者妊娠成功率。结果 传统双侧切除组、传统单侧切除组、保留双侧切除组、保留单侧切除组患者围术期手术时间、术中出血量和术后排气时间比较,差异无统计学意义(P>0.05)。行IVF-ET后,5组患者AMH、FSH、E₂     

手术治疗复发性结节性甲状腺肿33例分析

目的：探讨结节性甲状腺肿术后复发原因、再手术技巧及预防复发措施。方法：回顾性分析33例复发性结节性甲状腺肿患者再手术的临床资料。结果：33例均再手术,术后并发暂时性喉返神经麻痹2例,暂时性低钙抽搐2例。31例获随诊,1例术后再复发。结论：结节性甲状腺肿术后复发与其病理特点、手术方式和术后不正规甲状腺激素抑制治疗有关。强调规范化手术和术后正规甲状腺激素抑制治疗可有效预防复发。     

非毒性多发结节性甲状腺肿^131I治疗进展

非毒性多发结节性甲状腺肿是无甲状腺功能亢进症的甲状腺肿大,症状性非毒性多发结节性甲状腺肿用甲状腺制剂抑制治疗的疗效不肯定,部分患者因各种原因禁忌或拒绝外科治疗1。31I治疗非毒性多发结节性甲状腺肿安全、可靠、简便、疗效好、易行。重组人促甲状腺激素(TSH)的应用,有望到达减少剂量,增加疗效的目的1。31I可以有效地减少非毒性多发结节性甲状腺肿病人的甲状腺体积,减轻局部压迫症状,尤其适用于高手术危险、术后复发及拒绝手术的患者1。31I治疗非毒性多发结节性甲状腺肿目前还需要更多病例及更长随访时间的研究。     

Dunhill手术与双侧甲状腺次全切除术治疗双侧结节性甲状腺肿的疗效比较

目的：对比一侧甲状腺全切加对侧次全切除术（Dunhill手术）和双侧甲状腺次全切除术在双侧结节性甲状腺肿患者中的应用效果。方法：前瞻性将2018年5月~2019年8月在商丘市第四人民医院就诊的60例双侧结节性甲状腺肿患者纳入研究，依据随机抽签法分为对照组和观察组各30例。对照组采用双侧甲状腺次全切除术，观察组采用Dunhill手术治疗。对比两组术中、术后相关指标及术后复发率情况。结果：两组术中相关指标、术后引流量、饮食恢复时间以及术后拔管所需时间相比，差异无统计学意义（P＞0.05）；观察组住院时间较对照组长，术后复发率较对照组低（P＜0.05）。结论：Dunhill手术与双侧甲状腺次全切除术均能有效治疗双侧结节性甲状腺肿疾病，但Dunhill手术后复发率较低，能够有效根治切除病变组织，安全性高，降低疾病恶变的风险。     

结节性甲状腺肿的治疗方法分析

目的探计结节性甲状腺肿的治疗方法,包括保守治疗、手术指征、手术方法和术后复发的预防和处理．总结结节性甲状腺肿的治疗经验。方法对87例结节性甲状腺肿患者治疗进行分析,32例行保守治疗,其中有12例成功,余20例效果欠佳改行手术治疗。手术中行双侧甲状腺次全切除术9例,一侧全切除加对侧次全切除术15例．一侧腺叶全切除＋峡部切除30例,甲状腺部分切除术18例,简化根治性甲状腺全切除术3例。结果保守治疗成功率37．5％,随访5年,保守治疗成功者复发3例（25％）,手术者术后复发8例（11％）,甲状腺功能减退12例（16％）。结论结节性甲状腺肿治疗方法和结节大小、数目以及对保守治疗药物反应有关,术前应明确结节性甲状腺肿的手术指征,根据患者具体情况合理选择手术方式,术后必须服用药物预防复发。     

结节性甲状腺肿手术后复发31例的再治疗

目的探讨结节性甲状腺肿手术后复发的相关因素及再治疗方案。方法对我院15a中31例结节性甲状腺肿术后临床复发者的手术适应证、术式及再治疗进行回顾性分析。结果结节性甲状腺肿手术后复发与病变单发或多发、手术适应证及切除范围的选择密切相关。31例甲状腺肿复发者首次手术中行一侧腺叶切除者4例，一侧腺叶次全切除者12例，腺叶部分切除者9例，结节摘除者6例。再手术24例，行一侧腺叶切除7例，一侧腺叶次全切除4例，一侧腺叶全切除加对侧次全切除5例，双侧腺叶次全切除8例。所有24例再手术者均随访，平均5a，再复发病例2例。结论术前对结节性甲状腺肿的正确诊断、明确病变部位、严格掌握手术的适应证，并废除结节摘除及腺叶部分切除术可降低复发率和再手术率。     

甲状腺全切术和甲状腺次全切术治疗双侧结节性甲状腺肿的疗效对比分析

目的研究双侧结节性甲状腺肿甲状腺全切术和甲状腺次全切术两种手术的疗效对比。方法随机抽选2014年1月~2015年1月来我院治疗双侧结节性甲状腺肿的患者122例,按随机数字表法分为观察组和对照组各61例,两组分别给予甲状腺次全切术、甲状腺全切术治疗。观察两组术后并发症发生率、术后恢复情况、复发率。结果两组患者术中出血量差异无统计学意义(P0.05)。观察组手术用时、患者出院时间均短于对照组,P0.05。对比两组患者术后疗效,观察组总有效率93.3%;对照组83.6%,P0.05。观察组并发症发生率低于对照组,分别1.6%、9.8%,P0.05。结论甲状腺次全切术更适合治疗双侧结节性甲状腺肿,并发症发生率低、恢复快,值得临床推广。     

冠心病患者不同程度冠状动脉病变与血清TSH水平的 相关性分析

目的:探讨冠心病患者不同程度冠状动脉病变与血清促甲状腺激素水平的相关性。方法:对2017年2月～2018年9月接受治疗的94例冠心病患者(观察组)及同期90例健康体检者(对照组)的资料进行回顾性分析。所有受试者抽取空腹外周静脉血5 ml检测促甲状腺激素水平。观察组患者进行冠状动脉造影检查,根据冠状动脉病变程度及支数将观察组患者分为正常组(n=24)、单支病变组(n=22)、多支病变组(n=48)。对比不同病变程度患者血清促甲状腺激素水平,并进行相关性分析。结果:观察组血清促甲状腺激素水平明显高于对照组(P<0.05);与正常组相比,单支病变组、多支病变组血清促甲状腺激素水平均显著升高,且多支病变组血清促甲状腺激素水平高于单支病变组(P<0.05)。相关性分析结果显示冠状动脉病变程度与血清促甲状腺激素水平呈显著正相关(r=0.771,P<0.05)。结论:冠心病患者血清促甲状腺激素水平明显高于健康人群,且血清促甲状腺激素水平随着冠状动脉病变严重程度的加剧而升高,冠心病患者冠状动脉病变与血清促甲状腺激素水平显著正相关。     

良性巨大甲状腺肿物手术治疗体会

目的探讨良性巨大甲状腺肿物的手术切除技巧及其并发症的预防。方法总结32例巨大甲状腺肿物患者,其中结节性甲状腺肿15例,甲状腺腺瘤12例,淋巴性甲状腺肿3例,结节性甲状腺肿合并甲状腺腺瘤2例。全身麻醉下采用甲状腺被膜解剖技术采用成功地进行了手术治疗。结果术中行双侧甲状腺部分切除术22例,单侧甲状腺部分切除术6例,单侧甲状腺全切除术4例;术中行气管悬吊8例,术后1周左右拆除悬吊线。术后无永久性喉返神经麻痹;无气管塌陷及气道梗阻者,检查甲状旁腺激素及血钙均无异常。术后甲状腺功能低下者3例,嘱其系统服用甲状腺素片治疗。结论采用被膜解剖技术,妥善处理甲状腺上、下极,注意保护颈内静脉、喉返神经、甲状旁腺,预防气管塌陷,可成功切除巨大甲状腺肿物并避免并发症的发生。     

New Daily Persistent Headache Caused by a Multinodular Goiter and Headaches Associated With Thyroid Disease

A 33‐year‐old female is presented with the first case to our knowledge of new daily persistent headache (NDPH) with a large right benign non‐toxic multinodular goiter causing carotid and vertebral compression with complete resolution of the headache immediately after thyroidectomy. Although this may be quite rare, hypothyroidism or hyperthyroidism causing NDPH, migraine, or an exacerbation of pre‐existing migraine is not. Clinicians should consider routinely obtaining serum thyroid‐stimulating hormone (TSH) and free T4 in patients with new onset frequent headaches or an exacerbation of prior primary headaches.     

Serum TSH measurements by a sensitive enzyme immunoassay discriminate euthyroid from hyperthyroid subjects and avoid the need for TRH test during suppressive therapy with L-thyroxine

Serum TSH was determined photometrically by a recently developed enzyme immunoassay (EIA) based on the use of a monoclonal antihuman TSH-beta antibody and a polyclonal antiTSH antibody coupled to horseradish peroxidase. The results obtained in patients with various thyroid disorders and in normal controls were compared with those achieved by conventional double antibody radioimmunoassay (RIA). In normal subjects, serum TSH was detectable in all cases by EIA (values ranging from 0.27 to 5.1 mU/L), but only in 76% by RIA. Ninety-two percent of hyperthyroids had undetectable serum TSH by EIA and the remaining 8% had values between 0.2 and 0.4 mU/L. In clinically euthyroid patients with nontoxic goiter, 9% had undetectable serum TSH by EIA, suggesting the presence of autonomously functioning areas within the thyroid. Serum TSH under basal conditions and after TRH stimulation was measured in 45 patients on L-thyroxine suppressive therapy. Undetectable basal serum TSH by EIA was associated with a lack of TSH response to TRH in 95% of cases. Conversely, 37.5% of patients with undetectable basal serum TSH by RIA had a normal or blunted response to TRH. Detectable basal values were predictive of a normal response to TRH by both methods. These data indicate that basal serum TSH measurement by EIA allows an almost complete differentiation of normal from thyrotoxic patients and can avoid the need of the TRH stimulation test.     

The effect of thyroxine-suppressive therapy in patients with solitary non-toxic thyroid nodules -- a randomised, double-blind, placebo-controlled study

The efficacy of thyroxine (T(4)) for solitary non-toxic thyroid nodule remains uncertain. In this study, 60 patients with solitary non-toxic thyroid nodule were divided randomly into two groups. Group I (n = 30) received thyroxine 100 microg/day for 6 months and group II (n = 30) received placebo. The volume of the thyroid nodules in 11 patients decreased more than 50% after thyroxine therapy (36.7%, responders). In these 11 patients, the mean serum thyroglobulin level decreased significantly (340 +/- 115 to 162 +/- 86 microg/l, p < 0.01). Compared with the non-responders (n = 19, 63.3%), the serum thyroglobulin level before treatment was significantly higher (340 +/- 115 vs. 220 +/- 102 microg/l, p < 0.05). Thyroxine-suppressive therapy is proved as a useful tool in reducing nodule size in some patients with solitary thyroid nodules. The patients with a higher serum thyroglobulin level generally respond better to thyroxine-suppressive therapy.     

Suppression of T4 secretion in a metastatic follicular carcinoma

Despite total thyroidectomy, a patient with metastatic follicular carcinoma of the thyroid remained biologically euthyroid three months after stopping thyroxine (T4) therapy. Thyroid hormone production was investigated by means of a modified tri-iodothyronine (T3) suppression test, in which serum T4 was used as a suppression marker. After three weeks of oral T3 (Cytomel) therapy (50 micrograms/day), the serum T4 decreased from normal (108 nmol/L) to undetectable values. However, even though suppressive therapy was effective in preventing TSH dependent hormone secretion by the tumor, it did not prevent tumor growth and the eventual death of the patient.     

Effect of dexamethasone on TSH secretion induced by TRH in human obesity.

BACKGROUND: The presence of an abnormally high thyroid-stimulating hormone (TSH) response to thyrotropin-releasing hormone (TRH) makes it difficult to distinguish some euthyroid obese subjects from subelinically hypothyroid obese patients. Here, we examine whether such distinction may be achieved after treatment with glucocorticoids, which inhibit TSH secretion at the hypothalamic-pituitary level. METHODS: TRH tests (200 microg as an intravenous bolus injection) were performed in 30 age- and weight-matched, obese, but otherwise healthy, men. All subjects were tested again with TRH after treatment with dexamethasone (dex) (2 mg/d in four divided doses orally for 3 days). RESULTS: In all subjects, total thyroxine and triiodothyronine concentrations were in the normal range. According to basal and TRH-stimulated serum thyrotropin (TSH) levels, subjects were divided into the following three groups: group I (n=10), euthyroid subjects; group II (n=10), euthyroid subjects with normal basal but abnormally elevated TSH responses to TRH; group III (n=10), subjects with elevated basal and TRH-induced TSH levels (subclinical hypothyroidism). Basal TSH levels were 1.8+/-0.4 mU/L in group I, 1.7+/-0.3 in group II, and 6.0+/-0.7 in group III. In both groups II and III, TRH-induced TSH increments were above the normal range (maximal increment> 15 mU/L) and were significantly higher than in group I. After the second treatment with TRH, pretreatment with dex significantly decreased both basal TSH levels and peak TSH responses to TRH in all groups. However, a striking percentage decrease (>50%) in TRH-induced peak TSH responses was observed in euthyroid obese subjects of groups I and II, whereas hypothyroid subjects of group III showed only a slight decrement (<25%). CONCLUSIONS: The sensitivity of the TSH secretory system to glucocorticoid inhibitory action is preserved in obese subjects with abnormally elevated TSH response to TRH, but not in subclinically hypothyroid obese patients. The TRH plus dex test might be useful in future studies to understand the mechanisms underlying alterations in TSH secretion in obesity.     

Approach to and treatment of goiters

The main causes of simple diffuse goiter (SDG) and multinodular goiter (MNG) are iodine deficiency, increase in serum thyroid-stimulating hormone (TSH) level, natural goitrogens, smoking, chronic malnutrition, and lack of selenium, iron, and zinc. Increasing evidence suggests that heredity is equally important. Treatment of SDG and MNG still focuses on L-thyroxine-suppressive therapy surgery. Radioiodine alone or preceded by recombinant human TSH stimulation is widely used in Europe and other countries. Each of these therapeutic options has advantages and disadvantages, with acute and long-term side effects.     

Basal TSH levels compared with TRH-stimulated TSH levels to diagnose different degrees of TSH suppression: diagnostic and therapeutic impact of assay performance

BACKGROUND: The estimated prevalence of endogenous subclinical hyperthyroidism varies from 4% to 6% and a basal thyroid stimulating hormone (TSH) level < 0.5 mU L-1 may be associated with increased mortality in subjects over 60 years of age who are not on thyroid medication. Exogenous TSH suppression is a mainstay in the treatment of thyroid cancer. Because of recent concerns about potential adverse effects, especially of endogenous TSH suppression on bone, the cardiovascular system and cognitive functions, subclinical hyperthyroidism obtained new clinical importance. We therefore re-evaluated the diagnostic value of basal and thyrotrop in TRH-stimulated serum TSH measurements using TSH assays with different sensitivities. MATERIALS AND METHODS: A total of 805 oral and nasal TRH stimulation tests were performed on 409 ambulatory subjects with low basal serum TSH concentrations of less than 0.1 mIU L-1. Basal serum TSH was measured either using a second generation assay (functional sensitivity > 0.03 mIU L-1) or two third generation assays (functional sensitivity 0.01 mIU L-1 and 0.007 mU L-1, respectively). Serum TSH concentration was determined before and 3 h after oral administration of 40 mg of TRH and before and 30 min after nasal administration of 2 mg of TRH. RESULTS: In the oral testing group, the basal TSH levels measured by the different TSH assays were 0.06 +/- 0.03, 0.04 +/- 0.02 and 0.03 +/- 0.02, respectively, whereas the peak TSH levels were 0.4 +/- 0.6, 0.4 +/- 0.6 and 0.3 +/- 0.5 in the patients with subclinical hyperthyroidism. In overt hyperthyroidism, the basal TSH levels were 0.06 +/- 0.02, 0.03 +/- 0.02 and 0.03 +/- 0.02, whereas the peak TSH levels were 0.19 +/- 0.3, 0.16 +/- 0.3 and 0.15 +/- 0.2, respectively. Basal TSH values could discriminate between different degrees of TSH suppression if measured with a third generation assay (P < 0.001), but not with a second generation assay. There was only a weak correlation between basal TSH and peak TSH when measured by a second generation assay (n = 126; r = 0.3; P < 0.001) in contrast to the strong correlation found using the third generation assays (n = 128; r = 0.7; P < 0.001 and n = 69; r = 0.8; P < 0.001, respectively). CONCLUSIONS: In view of the recent concerns about potential adverse effects in TSH suppression and based on our data, it is mandatory to select a TSH assay with a functional sensitivity of < or = 0.01 mIU L-1 for optimal titration of L-T4 suppressive therapy, especially in patients with thyroid cancer. If, however, only a second generation TSH assay is available, additional TRH testing allows a more careful titration of suppressive thyroxine therapy.     

小剂量丙基硫氧嘧啶联合普萘洛尔治疗亚临床甲亢合并阵发性房颤临床疗效观察

目的探讨小剂量丙基硫氧嘧啶联合普萘洛尔治疗亚临床甲亢合并阵发性房颤的临床疗效。方法 56例亚临床甲亢合并阵发性房颤患者,随机分为:丙基硫氧嘧啶联合普萘洛尔组(A组),31例,给予丙基硫氧嘧啶50 mg/d,口服,同时给予普萘洛尔10 mg/d,口服;安慰剂组(B组)25例,给予等量的安慰剂治疗。观察患者治疗前后FT3、FT4、TSH、心功能、TGAb阳性率、TPOAb阳性率变化情况。结果 A组治疗后FT4较治疗前明显下降(P<0.01),TSH较治疗前显著升高(P<0.01)。2组治疗后,TGAb、TPOAb阳性率前后均无显著差异。A组治疗后平均心率显著下降(P<0.05)。结论小剂量丙基硫氧嘧啶联合普萘洛尔对于亚临床甲亢合并阵发性房颤,可协同改善血清TSH水平,降低甲减现象,改善心脏功能,有效缓解房颤的发生。     

全乳晕入路腔镜甲状腺全切除术与开放手术治疗多发性结节性甲状腺肿的临床对照研究

目的对比全乳晕人路腔镜甲状腺全切除术与开放手术治疗多发性结节性甲状腺肿患者的临床效果。方法纳入2010年9月-2013年3月收治的138例需要手术治疗的双侧多发性结节性甲状腺肿患者,采用奇偶数分配的方法分为腔镜组和开放组,腔镜组（n=69）采用全乳晕入路腔镜甲状腺全切除术,开放组（n=69）采用传统开放甲状腺全切除术。观察并比较两组患者手术时间、术中出血、术中术后疼痛、术后引流、术后并发症发生情况。结果①腔镜组手术时间为（108．6±20.3）min,明显长于开放组[（77．6±11.3）min],差异有统计学意义（t=11．084,P=0．000）;腔镜组术中出血量为（28．7±9．2）mL,明显少于开放组[（42．1±10.3）mL],差异有统计学意义（t=8．060,P=0．000）。②腔镜组患者术中、术后各时间点疼痛评分明显低于同期开放组患者（P〈0．05）。③腔镜组、开放组术后引流量、引流时间无明显差异（P〉0．05）。④两组术后暂时性低钙血症、甲状旁腺功能减退症和喉返神经损伤发生率差异无统计学意义（P〉0．05）,术后均未发生永久性甲状旁腺功能减退症和喉返神经损伤等严重并发症。结论两种手术方式均可用于治疗双侧多发性结节性甲状腺肿,但腔镜手术能明显减少患者术中出血,减轻术后疼痛,且较开放手术美观。     

泛影葡胺注射液对甲状腺手术后引流量的影响

目的 探讨泛影葡胺注射液对甲状腺手术后创面引流量的临床效果。 方法 收集2016年5月~2017年5月在佳木斯大学附属第一医院普外二科行开放性甲状腺大部切除术和甲状腺切除术+颈淋巴结清扫术患者共60例,根据术中快速病理报告组分为良性组和恶性组,良、恶性组内分实验组（泛影葡胺组）及对照组（生理盐水组）,每组根据病例手术切除范围不同继续分组,即:A良性单侧实验组（8例）、B良性单侧对照组（7例）、C良性双侧实验组（7例）、D良性双侧对照组（8例）、E恶性单侧实验组（8例）、F恶性单侧对照组（9例）、G恶性双侧实验组（7例）、H恶性双侧对照组（6例）。其中实验组患者（30例）术中切除甲状腺病灶或淋巴清扫完成后,彻底止血,取泛影葡胺注射液10 mL均匀冲洗于手术操作创面,吸出残液放置引流;对照组患者（30例）术中主要步骤完成后,彻底止血,取生理盐水冲洗创面,吸出残液放置引流,记录术后组0~8、8~24、24~48 h时间段引流量,观察切口愈合情况。 结果 根据收集各组引流量,比较A/B组、C/D组、E/F组、G/H组引流量数据,观察到使用泛影葡胺注射液作为创面冲洗剂的实验组引流量少于使用生理盐水的对照组,差异有统计学意义（P<0.05）。 结论 泛影葡胺注射液作为创面冲洗剂在甲状腺术中应用可通过减少血液渗出及封闭微小淋巴漏机制来减少术后创面引流量,具有临床推广价值。