甲状旁腺术中保护研究和探讨

目的：探讨甲状腺术中对甲状旁腺保护方法。方法选取本院自2002年1月~2014年1月行甲状腺手术患者60例,采用资料回顾性观察甲状旁腺术中保护以及血供方法,观察其术后低血钙发生情况。结果本次试验显露了60枚上甲状旁腺,其中41枚血供来自甲状腺下动脉上行支,占68.33%,13枚血供来自甲状腺上动脉分支,占21.67%,另外有6枚血供来自甲状腺表面血管分支,占10.00%。经本院的术后监测,测得血钙降到正常范围一共有21例,占35.00%,其中低血钙症状5例,则低血钙发生率为8.33%。所有低血钙患者给予术后补钙治疗之后,其血PTH水平均低于术后2w水平,且逐渐恢复正常,无永久性甲状旁腺功能下降。结论甲状旁腺血供来源与其位置存在着密切关联,其中甲状旁腺功能减退主要是由于术中未精细解剖,需尽可能保护甲状旁腺以及其血供。     

甲状腺手术中甲状旁腺保护及术后低钙血症的处理研究进展

低钙血症是甲状腺手术后常见并发症,患者由于随意肌、平滑肌痉挛可引发癫痫、哮喘等继发疾病,甚至出现窒息、心功能不全、心跳骤停等严重后果,威胁患者生活质量及生命安全.甲状腺手术中甲状旁腺保护工作是降低患者术后发生低钙血症的关键因素,其内容包括熟悉甲状旁腺解剖结构、保护甲状旁腺血供、提高安全意识等.术后及时监测血钙水平,给予针对性的预防及治疗,是保障患者预后及生活质量的有效措施.临床医师应根据患者实际情况选择合适的甲状腺手术方案,术中采取多种针对性的保护措施降低甲状旁腺损伤发生率,术后给予严密的血钙监测掌握低钙血症发生情况,保障患者预后及生活质量,值得今后实际工作中推广应用.     

甲状腺肿瘤手术中暴露并保护甲状旁腺的解剖与手术操作要点

目的　探讨甲状腺肿瘤手术中暴露并保护甲状旁腺的要点。 方法　对 2004年 1 月至2010 年 12 月 145例甲状腺弥漫性结节和甲状腺癌患者进行手术,分前、后3年两组,前3年组65例患者保留甲状腺后被膜,未寻找甲状旁腺;后3年组80例患者暴露并保护甲状旁腺,精细解剖观察被膜,尽量保存甲状旁腺的血供及完整性。术后进行动态监测血清钙变化,观察甲状旁腺的功能情况。 结果　在术中暴露并保护甲状旁腺后3年组中,术后甲状旁腺功能低下的机率较未寻找甲状旁腺前3年组患者明显降低,两组比较有统计学意义（P＜0.05）。 结论 在甲状腺肿瘤手术中,暴露并保护好甲状旁腺,可有效降低术后甲状旁腺功能低下的发生率。     

甲状腺癌手术中纳米碳示踪保护甲状旁腺的研究

目的探讨在甲状腺癌手术中采用纳米碳淋巴示踪剂保护甲状旁腺的作用。方法回顾性分析我院2014年1月至10月收治的65例甲状腺癌患者的临床资料,按是否在甲状腺内注射纳米碳分成2组,实验组30例患者操作开始前在甲状腺内注射纳米碳,对照组35例未注射纳米碳,实验组行甲状腺患侧腺叶+峡叶+对侧腺叶次全切除术22例,行双侧甲状腺全切除术8例,对照组行甲状腺患侧腺叶+峡叶+对侧腺叶次全切除术25例,行双侧甲状腺全切除术10例。2组患者均联合中央区淋巴结清扫术。结果纳米碳可使中央区淋巴结黑染,而甲状旁腺不黑染。实验组每例显露(2.6±0.8)枚甲状旁腺,误切0枚;对照组每例显露(1.9±0.7)枚甲状旁腺,误切3枚,2组之间差异有统计学意义(P0.05)。2组患者均未发生永久性甲状旁腺功能低下,实验组有1例暂时性甲状旁腺功能低下,对照组有2例甲状旁腺功能低下,差异无统计学意义。结论纳米碳混悬液有利于术中甲状旁腺的识别,降低甲状旁腺误切率,但不能降低术后甲状旁腺功能低下的发生率。     

甲状腺全切术喉返神经解剖方式选择对甲状旁腺功能影响的临床研究

目的：通过对比甲状腺全切术中不同喉返神经(RLN)解剖方式对术后甲状旁腺功能的影响,寻求甲状腺全切术最佳的RLN解剖方式,指导临床实践,在RLN解剖安全的前提下减低全甲状腺术后甲状旁腺功能低下的发生率。方法选择已确诊甲状腺癌需行甲状腺全切除手术的120例患者随机分成三组(a、b、c),各40例,分别完成全甲状腺切除术基础上三组不同喉返神经解剖方式(A甲状腺下动脉解剖法、B气管食管沟解剖法、C环甲关节下方解剖法)各40例的手术。观察比较三组患者术后甲状旁腺功能低下的发生率。同时观察比较三组患者术后喉返神经损伤的发生率。结果 c组患者术后甲状旁腺功能低下的发生率明显低于a、b两组。结论甲状腺全切除术时喉返神经解剖方式应选择经环甲关节下方解剖方式,有利于保护甲状旁腺功能,可明显减少甲状腺全切除术后甲状旁腺功能低下的发生率。     

甲状腺手术的围手术期并发症及其预防

目的探讨甲状腺手术围手术期并发症的相关因素和预防方法,降低并发症的发生率。方法回顾性分析1997年1月至2004年12月收治的甲状腺肿块350例的临床资料,分析其主要并发症的发生情况及其临床相关因素,总结甲状腺手术技巧。结果全组350例中术后单侧喉返神经麻痹14例(4%),不显露喉返神经组的喉返神经麻痹发生率(7.3%)高于显露返神经组(1.5%),P=0.011;恶性肿瘤组(9.4%)高于良性肿瘤组(3.0%),P=0.045,而肿瘤大小、合并症、局部敷药与术后喉返神经麻痹无关。术后出血7例,有合并症组的术后出血发生率7.4%(5/68),高于无合并症组的0.7%(2/282),P=0.004;术后出血与是否显露喉返神经及病变性质无关。甲状旁腺功能一过性低下1.1%(4/350),均发生于双侧甲状腺次全切除术。结论解剖显露喉返神经有利于降低甲状腺手术喉返神经麻痹发生率。对合并高血压病、糖尿病、甲亢患者应注意术前控制血压、血糖和血清T3、T4水平,术中彻底止血。双侧甲状腺手术在解剖甲状腺背面应紧贴真包膜充分剥离,对可疑甲状腺组织应尽量保留。     

医护一体化在甲状旁腺全切除联合 前臂自体移植术中的应用

目的 探讨医护一体化模式在甲状旁腺全切除联合前臂自体移植术患者中的应用效果。方法 选取我院2017年6月~2018年12月接受甲状旁腺全切除联合前臂自体移植术治疗的继发性甲状旁腺功能亢进症患者63例为研究对象,随机分为对照组（n=31）和试验组（n=32）,对照组采用常规护理,试验组采用医护一体化模式护理。比较两组患者术后并发症发生情况,术后第1天、第2天、第3天患者低钙血症发生率及患者满意度。结果 两组患者均未出现术后呛咳、窒息、声音嘶哑症状;术后第1天、第2天、第3天,试验组低钙血症发生率分别为:87.50%、62.50%、15.62%,均低于对照组的100.00%、87.10%、32.25%,差异有统计学意义（P＜0.05）;试验组患者满意度为100.00%,高于对照组的87.10%,差异统计学意义（P＜0.05）。结论 医护一体化模式有利于降低甲状旁腺全切除联合前臂自体移植术患者术后低钙血症的发生率,同时可提高住院患者满意度。     

甲状腺次全切除术术式改进的解剖基础与疗效观察

目的：观察改良的甲状腺次全切除术治疗甲状腺良性肿瘤的疗效及安全性。方法：回顾性分析我科1998年1月-2006年12月应用改良的甲状腺次全切除术治疗的167例甲状腺良性肿瘤的临床资料，改良要点在于低位小切口，不显露喉返神经，甲状腺包膜内分离。结果：167例中，只有1例暂时喉返神经损伤，另1例为永久性喉返神经损伤，发生率为0．6％（1／167）；1例术后出现暂时性甲状旁腺功能减退；随访1～8年，有2例复发，经过2次手术未见再次复发。结论：不显露喉返神经的甲状腺次全切除术是治疗甲状腺良性肿瘤的首选术式，熟悉甲状腺及其毗邻重要结构的解剖关系是预防术后并发症的关键。     

甲状腺次全切除术48例临床分析

目的 探讨甲状腺次全切除术的适应症、操作技巧及安全性.方法 回顾性分析48例因甲状腺功能亢进症行甲状腺次全切除术的临床资料,探讨术后并发症的发生原因和预防措施.结果 本组病例全部治愈,无手术死亡,甲状腺危象先兆有1例发生.无甲状旁腺功能低下和甲状腺功能低下等并发症.无术后大量出血及喉返神经损伤、喉上神经损伤,无手足抽搐.术后2例患者出现声音嘶哑,3个月后自行恢复.随访3月～4年,43例得到随访,随访率达89.58%,原病症复发者2例,复发率4.1%.结论 甲亢思者行甲状腺次全切除术是安全的,只要充分做好术前准备、术中注意操作,并发症的发生率是很低的,也是可以避免的.     

甲状旁腺素检测试剂于术中快速识别及保护甲状旁腺的作用

目的 探讨甲状旁腺素(PTH)检测试剂在甲状腺全/近全切除联合中央区淋巴结清扫术中快速识别及保护甲状旁腺的临床价值。方法 纳入44例甲状腺癌患者,根据术中是否使用PTH检测试剂分为观察组(使用PTH检测试剂)和对照组(未使用PTH检测试剂),每组22例。观察组患者于术中遇到疑似的甲状旁腺,由手术医生进行标记,对疑似的甲状旁腺进行PTH检测,根据检测结果确定是否切除;对照组根据经验判断是否切除。记录2组患者甲状旁腺检出结果,并比较2组患者手术前后血清钙、PTH水平及术后并发症情况。结果 2组甲状旁腺检出比较,差异无统计学意义(P 0. 05)。2组患者术前血清钙及PTH水平比较,差异无统计学意义(P 0. 05);观察组患者术后PTH水平及血清钙水平明显高于对照组,差异有统计学意义(P 0. 05)。2组术后低钙症状比较,差异有统计学意义(P 0. 05); 2组患者术后均未出现永久性甲状旁腺功能受损。结论 PTH检测试剂可快速识别甲状旁腺,防止其被误切除,从而降低患者术后甲状旁腺功能减退及低血钙的发生。     

环甲间隙在腔镜甲状腺手术中的重要意义

目的　探讨环甲间隙在颈部无瘢痕腔镜甲状腺手术（scarless in the neck endoscopic thyroidectomy,SET）中对保护喉上神经外支（external branch of superior laryngeal nerve,EBSLN）、喉返神经（recurrent laryngeal nerve,RLN）、甲状旁腺（parathyroid gland,PT）及处理甲状腺上极的重要意义。 方法　回顾分析本院2014年4月至2018年7月腔镜甲状腺手术128例,包括单侧或双侧切除、次全切除或部分切除等。在处理甲状腺上极时均采用环甲间隙入路,结合甲状腺下极及外侧操作完成甲状腺叶部分或腺叶全部切除术。 结果　全部SET在分离进入环甲间隙后处理甲状腺上极血管,其中59.3%（76例）显露EBSLN。在甲状腺下极区域首先显露RLN者82.8%（106例）,其余17.2%在经环甲间隙入路处理甲状腺上极血管后显露RLN入喉点。术中显露UPT位于近环甲关节处者83%（106例）,位于甲状腺上极背面者17%（22例）。84例随访至今,术后暂时性声音嘶哑并单侧喉返神经麻痹2例,无声音低钝及饮水呛咳者,无永久性低钙者。 结论　环甲间隙在SET中对于安全切断甲状腺上极血管和有效保护EBSLN、RLN及上甲状旁腺具有重要意义,因此结合甲状腺峡部、下极及外侧操作可以形成腔镜甲状腺的程式化手术步骤,提升了该术式的安全性,有利于该术式的推广。     

Parathyroid gland anatomical distribution and relation to anthropometric and demographic parameters: a cadaveric study

Parathyroid glands play an important role in controlling calcium levels, which influence muscular contraction and neurotransmission. The number of variants, localization and ectopic positions make these glands tricky during surgical exploration. Detailed anatomical knowledge of these glands is fundamental to avoid postsurgical hypoparathyroidism, such as failures during thyroidectomy and parathyroid procedures. The purposes of this work were to study and report practical knowledge for surgeons in order to localize the glands. Dissections were performed on 56 cadavers. Gland identity was confirmed by histological study. Also, mediastinal tissue and the carotid sheath were treated with Carnoy’s solution to identify ectopic glands. The thyroid gland was divided and sliced to identify parathyroid glands in the parenchymal and subcapsular space. Four or more parathyroid glands were found in 89.3% of the studied specimens. Mean gland weight was 33.1 mg, and its mean measurements were 6.7 × 3.9 × 2.0 mm. In more than 90% of the cases there was a correlation with the inferior laryngeal nerve and the parathyroid glands: the upper glands were located in medial positions, and the lower ones were found to be located laterally. In 42.8% of cases at least one ectopic gland was observed. The main ectopic regions were the mediastinum and thymus (19.6%), thyroid subcapsular space (12.5%) and thyroid parenchyma (5.4%). Quantity, gland characteristics and location were not influenced by anthropometric and demographic parameters. Here we show the high incidence of parathyroid glands positioned at “abnormal” locations, and as a controversial topic in endocrine surgery, this matter must be continuously studied and reported in the literature.     

The intrathyroidal hyperfunctioning parathyroid gland

Six cases of primary hyperparathyroidism due to hyperfunctioning intrathyroidal parathyroid glands are reported. In five cases, hyperparathyroidism was due to an intrathyroidal parathyroid adenoma; in the sixth case, hyperparathyroidism resulted from an intrathyroidal parathyroid carcinoma. All five patients with adenoma were female with ages ranging from 40 to 70 yr. The patient with carcinoma was a 55-yr-old male. In all five patients with intrathyroidal parathyroid adenoma, thyroidectomy was performed when an abnormal parathyroid gland could not be located in the neck during surgery for hyperparathyroidism. The patient with intrathyroidal parathyroid carcinoma presented with hypercalcemia and a palpable right thyroid mass. The differential diagnosis of intrathyroidal parathyroid adenoma includes thyroid follicular adenoma. In some cases, the possibility of medullary carcinoma of thyroid might also be considered. Immunocytochemical staining for parathormone (PTH), thyroglobulin, and calcitonin is valuable in establishing the correct diagnosis.     

Langerhans cell histiocytosis involving the thyroid and parathyroid glands.

Langerhans cell histiocytosis (LCH) is a rare illness, and the disease afflicting the thyroid gland is very uncommon, even in the presence of multisystem involvement. In this report, we document histologically, for the first time, concurrent involvement of the thyroid and parathyroid glands by LCH. A young Chinese woman with a history of diabetes insipidus and hypogonadism underwent a total thyroidectomy for enlarged thyroid gland secondary to LCH causing airway obstruction. Microscopic examination of the excised specimen disclosed CD1a- and S-100-positive LCH cells involving the thyroid and parathyroid glands. In a patient with LCH affecting the thyroid gland, parathyroid gland disease should be suspected when the serum calcium levels are depressed in association with an inappropriate serum parathyroid hormone level, such as a normal parathyroid hormone level in this case.     

Zuckerkandl结节在甲状腺外科中的重要意义

目的探讨Zuckerkandl结节(Zuckerkandl’s tubercle,ZT)在甲状腺手术中出现的机率,以及ZT与喉返神经(recurrent laryngeal nerve,RLN)、上甲状旁腺(superior parathyroid gland,SPG)的解剖关系。方法回顾分析2016年12月至2017年12月,在赣南医学院第一附属医院耳鼻咽喉-头颈外科住院施行单侧或双侧甲状腺腺叶切除的120例甲状腺肿瘤患者的病历资料。对146个腺叶进行记录,观察ZT,分析其与RLN、SPG的解剖关系。结果 76例(63.3%)患者发现ZT,而54例(45.0%)患者其结节最长径大于1 cm。ZT较大者,87例(92.6%)RLN在ZT内侧,7例(7.4%)RLN横过ZT。SPG通常位于ZT之上,RLN之后。结论 ZT是甲状腺的显著特征之一,多数甲状腺手术中可以发现。ZT的大小和位置与术前症状没有确切的关系。理解ZT与RLN和SPG的解剖关系,对甲状腺手术的安全性具有重要意义。     

纳米碳颗粒显色对甲状旁腺的保护作用

BACKGROUND: So far there are many studies about the uses of nano-carbon tracers in the diagnosis and treatment of malignancies. However, little has been reported on the mechanism underlying protective effect of nano-carbon tracers on the parathyroid glands during thyroid cancer surgery. OBJECTIVE: To study the protective effect of nano-carbon tracers on the parathyroid in thyroid cancer surgery. METHODS: 180 cases of thyroid cancer were randomly divided into nano-carbon and control groups (n=90 per group): patients in the nano-carbon group were injected with nano-carbon tracers into the thyroid before surgery, and those in the control group underwent routine thyroid cancer surgery. Then comparisons of the operating time, incision length, blood loss, postoperative hospital stay, number of lymph node dissection, lymph node metastasis as well as hypoparathyroidism rate were performed between two groups. Besides, levels of serum calcium and parathyroid hormone in the two groups were detected at 3 days after surgery. RESULTS AND CONCLUSION: There were no significant differences in the operating time, incision length, blood loss, postoperative hospital stay and lymph node metastasis between the two groups (P > 0.05). The number of dissected lymph nodes of nano-carbon group was significantly higher than that of control group (P < 0.05); the mis-resection rate of parathyroid and hypoparathyroidism of nano-carbon group were significantly lower than those of control group (P < 0.05). Furthermore, the incidences of hypocalcemia and low parathyroid hormone of nano-carbon group were significantly lower than those of control group (P < 0.05). These results suggest that the nano-carbon tracer plays a protective role on the parathyroid glands in thyroid cancer surgery, which can reduce the mis-resection rate of parathyroid, as well as the incidences of hypoparathyroidism, hypocalcemia and low-level parathyroid hormone.     

Near-infrared autofluorescence for the detection of parathyroid glands

A major challenge in endocrine surgery is the intraoperative detection of parathyroid glands during both thyroidectomies and parathyroidectomies. Current localization techniques such as ultrasound and sestamibi scan are mostly preoperative and rely on an abnormal parathyroid for its detection. In this paper, we present near-infrared (NIR) autofluorescence as a nonintrusive, real-time, automated in vivo method for the detection of the parathyroid gland. A pilot in vivo study was conducted to assess the ability of NIR fluorescence to identify parathyroid glands during thyroid and parathyroidectomies. Fluorescence measurements at 785 nm excitation were obtained intra-operatively from the different tissues exposed in the neck region in 21 patients undergoing endocrine surgery. The fluorescence intensity of the parathyroid gland was found to be consistently greater than that of the thyroid and all other tissues in the neck of all patients. In particular, parathyroid fluorescence was two to eleven times higher than that of the thyroid tissues with peak fluorescence occurring at 820 to 830 nm. These results indicate that NIR fluorescence has the potential to be an excellent optical tool to locate parathyroid tissue during surgery.     

Sonographic detection of thyroid cancer in breast cancer patients

The purpose of our study was to analyze the incidence of incidental thyroid cancers which were detected by simultaneous sonographic examination of breast and thyroid glands. Between January 2001 and March 2004, 518 patients were diagnosed with breast cancer after modified radical mastectomy (n=369) or breast conserving surgery (n=149). We screened thyroid glands when we examined breast for diagnosis and follow-up after surgery. If we found the sonographic finding of suspicious for malignancy in thyroid, we immediately performed ultrasound-guided fine needle aspiration biopsy (FNAB). Forty-two cases showed suspicious sonographic findings and of those, 18 cases (42.9%) were determined to have suspicious malignant cytology by ultrasound guided FNAB. Among 518 breast cancers, total 13 cases (2.5%) were diagnosed with papillary carcinoma after thyroidectomy. The mean longest diameter of the thyroid masses was 9.9 mm (range 1-30 mm). Six cases (6/13, 46.2%) were diagnosed as simultaneous breast and thyroid cancers, and the rest of the thyroid cancers were detected after 6 to 33 months (mean 16.5 months) after surgery. In conclusion, the patients with breast cancer had a high incidence (2.5%) of thyroid cancer. Sonographic screening is useful for the early detection of thyroid cancer.     

Postresection parathyroid hormone and parathyroid hormone decline accurately predict hypocalcemia after thyroidectomy

Hypocalcemia is the most frequent complication after total thyroidectomy. Parathyroid hormone (PTH) measurement has been proposed as an early predictor of this condition. Total thyroidectomy was performed in 39 patients. Hypocalcemia was present in 15 cases (38%). Patients undergoing hemithyroidectomy (n = 13) were considered control subjects not developing hypocalcemia. PTH was measured before surgery and 10 minutes after resection of the gland using a rapid (15 minutes) chemiluminescent immunometric assay. Patients developing hypocalcemia had lower calcium and postresection PTH levels and higher PTH decline than patients not developing hypocalcemia (P < .0001). PTH decline (cutoff value, 62.5%) had the better sensitivity (93.3%) for predicting hypocalcemia, allowing for a fairly safe early discharge. However, the best overall results corresponded to the combination of postresection PTH level (< or = 18 pg/mL [< or = 1.9 pmol/L]) and PTH decline (>62.5%), with a sensitivity of 90% and a specificity of 97.9%. Perioperative PTH measures can accurately predict hypocalcemia after thyroidectomy, granting the laboratory a key role in the immediate decision about calcium supplementation for patients at risk.