甲状腺结节的诊断

甲状腺结节临床较常见,但其性质可以迥然不同,诊断的关键是鉴别结节的性质,外科医师的职责在于早期发现恶性肿瘤.     

甲状腺外科的现状与展望

甲状腺可发生多种疾病 ,治疗方法各异 ,其中 ,适宜外科治疗者主要是甲状腺肿瘤 ,尤其是恶性肿瘤 ,甲状腺功能亢进症虽然有些也采用外科治疗 ,但并非该病的唯一治疗方法。甲状腺肿瘤外科治疗所采用的术式及病例选择等 ,至今国内、外仍存在一些不同见解。现就甲状腺肿瘤的外科治疗现状进行重点讨论 ,并就今后发展略抒己见。1　甲状腺结节的外科处理原则1.1　甲状腺结节的定性甲状腺结节是临床最为常见的体征 ,尤其在现代B型超声检查下 ,经常可以查见临床不能触及的微小结节。应当指出 ,甲状腺是处于动态的内分泌器官 ,受机体多种因素的影响 ,…     

甲状腺结节手术适应证、术式选择及评价

甲状腺结节是甲状腺外科的最常见疾病,须根据临床症状、体征、细胞学及相关影像学等检查,综合确定甲状腺结节的绝对和相对手术适应证及相应的切除范围各异的手术方式。目前,甲状腺结节的标准手术方式包括：甲状腺部分切除术、甲状腺大部切除术、甲状腺腺叶切除术、甲状腺近全切除术和甲状腺全切除术,需根据甲状腺结节的大小、位置、良恶性等特性选择适宜的手术切除范围。中国甲状腺外科的发展,需在甲状腺外科专科化和专科医生培养制度进程逐步推进的基础上,使手术方式更为合理,从而使并发症发生风险与复发及再次手术率同步下降。     

甲状腺结节微波热消融治疗的临床进展

甲状腺结节是临床常见疾病,其治疗方式目前主要以外科开放式手术为主,微创治疗一直是临床探索的热点。经超声引导下甲状腺结节微波热消融具有重要的临床意义。本文主要对微波热消融甲状腺结节的治疗指征、临床疗效及常见并发症进行综述。     

甲状腺结节手术范围合理选择——美国及我国相关指南解读

甲状腺结节是甲状腺外科最常见的疾病,其外科治疗一直存在争议。近年来甲状腺结节的发病率在全球范围内呈持续增长趋势。标准的甲状腺手术方式联合规范化的颈淋巴结清扫,对于改善病人的预后,具有至关重要的意义。2015年,美国甲状腺协会（ATA）将发布新版《ATA甲状腺结节和分化型甲状腺癌诊治指南》。该指南内容主要涉及良性甲状腺结节和分化型甲状腺癌（DTC）的初始超声、细针穿刺细胞学检查（FNA）及分子标记物的评估以及甲状腺癌的危险分层、外科治疗、131I治疗和TSH抑制治疗。新版ATA指南将甲状腺结节和DTC外科治疗的基本原则、概念更为科学化、精准化,为今后的临床实践提供了重要的指导作用。     

甲状腺外科甲状腺结节的诊断

甲状腺结节临床较常见,但其性质可以迥然不同,诊断的关键是鉴别结节的性质,外科医师的职责在于早期发现恶性肿瘤。要强调询问病史,了解发现结节的时间,近期生长的速度,有无症状诸如疼痛与否,是否影响吞咽,发音有无变化以及全身有无症状,病人的年龄、性别、家族史均应重视。必须     

重视甲状腺结节的正确评估和随访

甲状腺结节发病率高,是甲状腺外科临床中最常见的疾病。正确评估和随访甲状腺结节十分重要,有利于改善病人预后、节约医疗成本和优化资源分配。甲状腺结节的评估和随访主要包括临床评估、实验室、影像学和细胞学检查。临床评估中应该重点了解有无甲状腺癌家族史、颈部放射史和结节压迫所致的症状;促甲状腺激素（TSH）是初步评估甲状腺结节的首要的实验室检查;甲状腺超声检查是评估和随访甲状腺结节的单个最有价值的影像学检查;细针穿刺细胞学检查（FNA）是诊断甲状腺结节的金标准,在判断结节良恶性和决定下一步治疗方案上起着至关重要的作用。规范甲状腺结节的评估和随访有助于进一步提高甲状腺结节的诊治水平。     

甲状腺结节细针穿刺细胞学检查的临床意义

甲状腺结节的诊断和鉴别诊断目前仍是困扰外科医师的一个重要课题。甲状腺结节在很多甲状腺疾患中是一种很常见的临床表现。在人群中可扪及的甲状腺结节约3％～6％,平均为4％,在尸检中约10％或更高。其中约5％为恶性肿瘤,其发生率虽不算太高,但要从大量的良性结节中进行筛选,难度确实很大。国外大量文献报道,细针穿刺细胞学检查(fine needle biopsy cytology,FNC)对术前甲状腺结节的评估比临床扪诊、核素检查、生化测定等方法的准确性要明显地高出很多。但也普遍认为FNC有一定的局限性。为此结合我们的经验,对FNC进行介绍和谈谈我们的初步体会。     

老年甲状腺结节的临床特点及其诊治经验

目的 探讨老年甲状腺结节的临床特点和诊治方法.方法 回顾性分析瑞金医院外科自2003年1月-2009年12月间收治的144例大于60岁的老年和1 412例中青年甲状腺结节患者的临床资料.结果 与中青年组比较,老年甲状腺结节以多发为主且最大结节的直径都较大;压迫症状和继发性甲亢是老年者的主要手术指征;因复发而再次手术的比例高;老年者术前麻醉ASA评分较低;对老年组手术主要为在全麻下对双侧多发结节者行双甲近全切除术;术中发现喉返神经和甲状旁腺有脂肪沉着.病理方面老年者良性结节钙化率较高(P<0.05);术后除暂时性低钙血症的发生率较高外(P<0.05),其他并发症与中青年者相比无差异(P>0.05).结论 只要充分了解老年甲状腺结节的临床特点,采取合理的治疗方法,应该可避免老年甲状腺结节者手术的风险和并发症.     

重视甲状腺结节的处理

甲状腺结节的处理,此乃临床外科常见问题,而且近来变化和争论较多,应该引起临床外科足够重视. 甲状腺结节中90%～95%为良性结节,5%～10%为甲状腺癌.甲状腺结节关注所在是恶性结节.美国临床内分泌协会分别于2003年和2006年制订临床实用规范,提出有恶性结节高危倾向的因素有:髓样甲状腺癌家族史,多发内分泌肿瘤Ⅱ型(MENⅡ),头颈部放疗史,年龄<20岁或>70岁,男性,结节直径>4 cm,质地硬而结实,颈部淋巴结肿大,结节固定和声音嘶哑.     

Incidence and importance of the tubercle of Zuckerkandl in thyroid surgery.

OBJECTIVE: To define the incidence of a distinct tubercle of Zuckerkandl (TZ) and confirm its anatomical relationships with the recurrent laryngeal nerve and the superior parathyroid gland. DESIGN: Two prospective series. SETTING: University teaching hospital, Australia. SUBJECTS: 200 patients who required thyroidectomy. INTERVENTIONS: Anatomical and clinical observations in two series of patients (n = 100 in each). The first defined the incidence of a TZ and preoperative symptoms; the second delineated the relationship of the TZ to the recurrent laryngeal nerve and the superior parathyroid gland. MAIN OUTCOME MEASURES: Anatomical relationships. RESULTS: A TZ was identified in 63% of patients and was > 1 cm in 45%. In 93% of patients with an enlarged TZ, the recurrent laryngeal nerve lay medial to it and the nerve was found lateral to the TZ in 7% of cases. The superior parathyroid gland was usually cranial to the TZ and posterior to the recurrent laryngeal nerve. The size and position of the TZ did not correlate clearly with symptoms. CONCLUSIONS: The TZ is a distinct feature of the thyroid gland that can be recognised during most thyroidectomies. The size and the position of the TZ have no constant relationship to preoperative symptoms. An understanding of the consistent anatomical relationship between the TZ and recurrent laryngeal nerve and superior parathyroid gland is crucial for safe thyroidectomy.     

Salient Anatomical Landmarks of Thyroid and Their Practical Significance in Thyroid Surgery: a Pictorial Review of Thyroid Surgical Anatomy (Revisited)

Thyroid surgery is a prototype of operations requiring thorough knowledge of surgical anatomy. There are many vital and delicate anatomical structures such as recurrent laryngeal nerve, superior laryngeal nerve, parathyroid glands, and distinct fascial planes surrounding the thyroid gland. A protean range of pathologies such as goiter, nodules, thyroiditis, and malignancy distort or alter the location and course of these structures and planes. The distinct vascular supply and high vascularity of thyroid region challenges the surgeon’s expertise. Several pathologies like malignancy, multinodularity, toxicity, and retrosternal extension further compounds this vascular aspect of surgery. Several structures of embryological importance such as pyramidal lobe, tubercle of Zuckerkandl, and ligament of Berry have decisive clinical implications in the surgical management of thyroid disorders. Surgeons attempting thyroidectomy need to have thorough knowledge of embryology and surgical anatomy of the thyroid gland. In this context, we highlight through a pictorial assay the embryological and anatomical aspects of the thyroid gland emphasizing on their clinical and surgical importance.     

Zuckerkandl结节的临床解剖学观察及其对解剖喉返神经的意义

【摘要】〓目的〓了解Zuckerkandl结节在甲状腺腺叶的出现几率,确认它与喉返神经的解剖关系。方法〓通过102例连续的甲状腺手术患者的回顾性分析,观察甲状腺腺叶中Zuckerkandl结节的大小及其与喉返神经的关系。结果〓本组102例患者共行甲状腺腺叶切除术124侧,在78侧甲状腺叶(62.9%)中观察到有明显的Zuckerkandl结节存在,平均长径为9.5 mm。Zuckerkandl 结节主要出现在甲状腺叶背侧中1/3处(83.3%),而ZT出现在右侧甲状腺叶(68.2%,45/66)的几率与左侧甲状腺叶(56.7%,33/58)没有明显差别。当Zuckerkandl结节存在时,97.4%(76/78)的喉返神经走行在Zuckerkandl 结节的深面。结论〓Zuckerkandl 结节存在于大多数甲状腺叶中,Zuckerkandl结节与喉返神经有密切且恒定的解剖关系,可作为甲状腺手术中显露喉返神经的解剖标志之一;Zuckerkandl结节也是解剖显露喉返神经的一个难点,重视Zuckerkandl 结节这一解剖结构对避免喉返神经损伤有重要的作用。     

Zuckerkandl's tuberculum: could it be useful in thyroid surgery?

A thorough knowledge of thyroid anatomy could reduce the incidence of lesions to the inferior laryngeal nerve. In view of its relationship with the recurrent laryngeal nerve and the parathyroid gland, Zuckerkandl's tuberculum should be considered an anatomical landmark for the recurrent laryngeal nerve in thyroid surgery. The aim of the study was to verify whether the identification of Zuckerkandl's tuberculum could be useful to reduce the incidence of recurrent laryngeal nerve lesions. Four hundred and thirty-two patients underwent thyroid surgery over the period from January 2001 to December 2003 for benign (377 patients) or malignant disease (55 patients). Three-hundred and forty-eight (81%) underwent total thyroidectomy. Zuckerkandl's tuberculum was found in 74.5% of patients, with a high prevalence in the right lobe: in 5% of patients it was grade I, in 50% grade II and in 45% grade III. Its presence was associated with the recurrent laryngeal nerve in almost all cases. Eight of the patients undergoing total thyroidectomy suffered recurrent nerve paralysis, only 4 of which proved definitive. Identification of Zuckerkandl's tuberculum allows safer isolation of the recurrent laryngeal nerve and superior parathyroid gland dissection.     

Total thyroidectomy: the evolution of surgical technique

The present paper outlines the development of thyroid surgery from early times to the twenty-first century. The significant changes that have occurred in the past few decades in relation to the evolution of techniques for safe and effective total thyroidectomy are then summarized. In the last 25 years total thyroidectomy has replaced bilateral subtotal thyroidectomy as the preferred option for the management of all patients with bilateral benign multinodular goitre, Graves' disease, and all but very low-risk thyroid cancer patients. The principal change in operative technique has been the move from 'lateral dissection' to 'capsular dissection'. Associated with that has been a focus on 'encountering' the recurrent laryngeal nerve (RLN), recognizing sympathetic-laryngeal nerve anastomoses, and routinely identifying the external branch of the superior laryngeal nerve (EBSLN). Completeness of resection has been assured by moving from an anatomically based approach to an embryologically based approach. This requires an awareness of the vagaries of thyroid development including attention to pyramidal remnants, to abnormalities associated with the tubercle of Zuckerkandl, and to thyrothymic thyroid rests. Preservation of parathyroid function has moved from the time-consuming technique of dissection of a vascularized pedicle in all cases, to initially selective, and then routine, parathyroid autotransplantation. These changes have ensured that total thyroidectomy can now be offered as a safe and efficacious procedure with a minimal complication rate.     

Recurrent laryngeal nerve in thyroid surgery: a critical appraisal

Background: Identification and preservation of the recurrent laryngeal nerve (RLN) is of major concern in surgery of the thyroid gland. The purpose of this study was to review the surgical anatomy of the nerve and to describe its relationship to other important structures. Methods: A total of 325 patients were accrued in this prospective non‐randomized study from January 1999 to December 2000. All patients who had total, subtotal and hemithyroidectomies were included in this study. Each side of the thyroid gland was considered as a separate unit in the analysis of the results. Results: Two hundred and seventy‐six patients had thyroidectomies as their primary operation, while 49 patients had them as a reoperative procedure. There were 276 women and 46 men (6:1 female to male ratio) with a mean age of 43.1 years (range: 10?84 years). The total number of dissections was 502. The RLN was clearly identified in 491 (97.8%) dissections: single trunk in 323 dissections (65.8%), two extralaryngeal branches in 164 dissections (33.4%), and three extralaryngeal branches in three dissections (0.6%). One non‐recurrent laryngeal nerve was encountered (0.2%) in the series. The proximity of the RLN to the inferior thyroid artery (ITA) was noted in 444 (90.4%) dissections: 372 (83.8%) nerves were described to be posterior and intertwined between the branches of the ITA, and in 72 (16.2%) RLNs, they were observed to be anterior to the ITA. The close association of RLN to an enlarged tubercle of Zuckerkandl was documented in 381 dissections (73.7%). A total of 231 RLNs (60.8%) was seen in the tracheoesophageal groove, 18 (4.9%) nerves were observed to be lateral to the trachea, and in 109 (28.3%), they were posterior in location. Of concern in 23 (6.0%) dissections the RLN was on the anterior surface of the thyroid gland, which is at highest risk of injury before curving down to pass behind the tubercle of Zuckerkandl. It appears that the anterior course of the RLN was seen more often in the reoperative procedures to the thyroid gland (20%). Conclusions: Although various methods of localizing the RLN have been described, surgeons should be aware of the variations and have a thorough knowledge of normal anatomy in order to achieve a high standard of care. This will ensure the integrity and safety of the RLN in thyroid surgery. The anatomical variation may be minor in degree, but is of great importance as it may affect the outcome of the surgery and the patient's quality of life.     

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??Modified thyroid lobectomy??360 cases report LIU Quan-fang ,YAO Yuan , HUANG Chi-ming ,et al. Department of General Surgery,Guangdong Provincial People’s Hospital, Guangzhou 510080,China
Corresponding author :LIU Quan-fang , E-mail: doc.liuquanfang @163.com
Abstract Objective To explore the feasibility of thyroid surgery mainly composed of modified thyroid lobectomy with the purpose of averting superior laryngeal nerve,exposing recurrent laryngeal nerve and preserving parathyroid gland. Methods This retrospective review analyzed the clinical data of 360 cases of thyroid surgery mainly composed of modified thyroid lobectomy in Guangdong Provincial People’s Hospital from Dec 2004 to June 2009. Results 360 cases of thyroid surgery including 411 sides of modified thyroid lobectomy was performed on the basis of eradicating lesion,thyroid function was preserved to the greatest extent, exposing rate of recurrent laryngeal nerve was 100%, a total of 543 parathyroid glands was preserved (average 1.32 parathyroid gland per lobe),no relative complications such as injuries of superior laryngeal nerve,recurrent laryngeal nerve and parathyroid gland were followed. Conclusion Thyroid surgery mainly composed of modified thyroid lobectomy might preserve thyroid function to the greatest extent,decrease all kinds of complications relating to thyroid surgery,and reduce postoperative recurrence.     

The Zuckerkandl tubercle

Identification and preservation of the recurrent laryngeal nerve is a major concern during thyroidectomies. The Zuckerkandl tubercle is an anatomic landmark that can be used for this purpose. It is generally found in 63% to 80% of patients undergoing thyroidectomy and is located between the superior and inferior lobes and points toward the tracheoesophageal groove. It is classified into three grades according to size: I <.5 cm, II .5 to 1 cm, III >1 cm. A grade III tubercle, present in 45% of patients, is sometimes associated with significant pressure symptoms in otherwise small-sized goiters.     

Surgeon's Approach to the Thyroid Gland: Surgical Anatomy and the Importance of Technique

The cornerstone of safe and effective thyroid surgery is thorough training in and understanding of thyroid anatomy and pathology. With appropriate techniques, total thyroid lobectomy and total thyroidectomy (which should be considered simply as a bilateral total thyroid lobectomy performed during the same operation) can be undertaken with minimal risk of damage to the recurrent laryngeal nerves, the external branches of the superior laryngeal nerves, and the parathyroid glands. Safe surgery requires a specific operative plan, progressing in a series of logical, orderly, anatomically based steps. Exposure of the thyroid gland is followed by careful dissection of the superior pole, utilizing the avascular plane between the superior pole and the cricothyroid muscle to identify and preserve the external branch of the superior laryngeal nerve. Medial retraction of the gland then allows dissection of the lateral aspect of the thyroid lobe. Protection of the recurrent laryngeal nerves and preservation of the blood supply to the parathyroid glands is best achieved by “capsular dissection,” ligating the tertiary branches of the inferior thyroid artery on the gland surface. If a parathyroid gland cannot be preserved or becomes ischemic after dissection of its vascular pedicle, it should be immediately minced and autotransplanted into the ipsilateral sternocleidomastoid muscle. The current evolution of outpatient or short-stay thyroidectomy emphasizes the need to avoid complications by utilizing meticulous surgical technique. Minimally invasive thyroidectomy utilizing endoscopic techniques may also affect the practice of thyroid surgery. Even so, understanding the surgical anatomy of the thyroid gland and its possible variations is paramount to safe and effective surgery.     

甲状腺手术喉返神经与甲状旁腺的识别与保护183例分析

目的:探讨甲状腺手术中识别与保护喉返神经与甲状旁腺的技术改进方法及其临床效果.方法:回顾性总结分析183例甲状腺手术病例,以暴露喉返神经方法分组:对照组81例,于甲状腺下动脉下方解剖暴露喉返神经;治疗组102例,以寻找Zuckerkandl结节为主要途径暴露喉返神经.比较两组病人术后喉返神经的损伤、甲状旁腺功能及并发症等方面情况.结果:治疗组102例均临床治愈,术后并发暂时声嘶1(0.9%)例.2例(1.9%)甲状腺次全切除术加颈廓清扫术后出现暂时性甲状旁腺功能低下,32例(31.3%)术后2 d内血钙水平较术前一过性降低.对照组81例有6例(7.4%)损伤喉返神经,4例(4.9%)出现甲状旁腺功能低下.两组差异有统计学意义.结论:甲状腺手术技巧的一系列改进,尤其是对喉返神经和甲状旁腺的识别和保护,可控制术中出血量,减少术后并发症,促进术后康复.