甲状腺乳头状癌不规范手术的弊端和补救

目的分析甲状腺乳头状癌不规范手术的弊端，探讨甲状腺乳头状癌不规范手术后补救手术的必要性和方式。方法总结1990年1月—2000年1月因行甲状腺乳头状癌不规范手术后又在浙江省肿瘤医院头颈外科补救手术的332例和同期在头颈外科行初次规范手术的甲状腺乳头状癌561例的临床及病理资料，对相关内容进行对比。结果补救手术者术后病理证实原发灶区肿瘤阳性率53．9％（179／332），颈淋巴转移率39．2％（130／332），颈前肌保存率30．7％（102／332），甲状旁腺明确保存率74．1％（246／332），喉返神经损伤发生率3．3％（11／332），原发灶区5年复发率7．5％（25／332），总的5年、10年累积生存率分别90．2％、84．4％。初次治疗者颈淋巴转移率37．4％（210／561），颈前肌保存率96．1％（539／561），甲状旁腺明确保存率93．0％（522／561），喉返神经损伤发生率1．2％（7／561），原发灶区5年复发率3．7％（21／561），总的5年、10年累积生存率分别94．0％、92．5％。全组原发灶区复发患者10年累积生存率67．8％，未复发患者10年累积生存率92．9％。统计学分析显示补救组与初次组间颈前肌保存率、甲状旁腺明确保存率、原发灶区5年复发率的差异有统计学意义（P〈0．01）；喉返神经损伤发生率差异也有统计学意义（P〈0．05）。复发患者生存率低于无复发者，差异有统计学意义（P〈0．01）。结论甲状腺乳头状癌不规范手术后原发灶区有较高的肿瘤阳性率，有必要行补救手术，但即使补救手术仍将导致较高的复发率，进而影响生存状况。同时二次手术将增加功能损伤的发生率，因而首次手术的规范化不容忽视。     

甲状腺肿瘤10年1862例临床分析

目的:探讨甲状腺肿瘤的治疗效果。方法:回顾性分析1995年2004年十年间1862例甲状腺肿瘤(1524例甲状腺良性肿瘤,338例的甲状腺癌)的临床资料及随访结果。结果:外科手术操作技术一律采用包膜解剖技术(除峡部外),即常规显露喉返神经及逐一结扎进人甲状腺的三级血管分支,既避免损伤喉返神经,又保留了甲状旁腺血供。局限于一侧的良性肿瘤以甲状腺腺叶切除,双侧甲状腺良性肿瘤,以较大一侧的甲状腺腺叶切除加对侧肿块切除术;T1-T3期分化性甲状腺癌,行一侧的甲状腺腺叶+峡部切除,对T4期分化性甲状腺癌,则进行全甲状腺切除或近全甲状腺切除术;对甲状腺髓样癌行全甲切除+功能性颈清术;临床NO分化型甲状腺癌行甲状腺腺叶+峡部切除+中央区淋巴结清扫术。手术并发症包括术后出血2例(0.1%),乳糜漏1例(0.05%)2例暂时性甲状旁腺功能低下,无喉返神经损伤及永久性甲状腺功能低下。结论:严格掌握甲状腺肿瘤外科的治疗原则及熟悉包膜解剖技术是甲状腺外科手术的关键。     

甲状腺外科专业化的临床资料分析

目的 评价耳鼻咽喉头颈外科医师手术治疗甲状腺良性疾病的结果。方法回顾性分析北京朝阳医院耳鼻咽喉头颈外科2001年1月-2004年4月手术治疗496例甲状腺良性疾病的方式、术后并发症的发生、手术耗时、颈部切口长度、住院时间和术后复发的情况。结果甲状腺一侧腺叶加对侧腺叶部分切除314例，甲状腺一侧腺叶加峡部切除76例，甲状腺双侧腺叶次全切除29例，单纯甲状腺峡部切除3例，甲状腺全切除46例，颈部低位领式切口入路切除胸骨后结节性甲状腺肿28例。术后一侧喉返神经损伤发生率为0．2％(1／496)，无双侧喉返神经损伤。术后暂时性低钙血症发生率为1．8％(9／496)，无永久性低钙血症。术后出血发生率为0．6％(3／496)，无切口感染。手术耗时平均为66min，颈部切口长度平均为5．2cm，住院时间平均为6．3d。术后复发率0．2％(1／496)。结论受过严格头颈外科培训的耳鼻咽喉科医师行甲状腺良性疾病手术可降低喉返神经损伤的发生。     

甲状腺外科手术操作与手术并发症的相关性

目的 了解甲状腺外科手术操作与手术并发症的相关性,探讨辨认及保护喉返神经、喉上神经外支、甲状旁腺的甲状腺切除术在治疗甲状腺肿物中的作用,以提高甲状腺肿物的手术治愈率,并减少手术并发症。方法 回顾分析甲状腺良性肿瘤或甲状腺癌患者152例临床资料,甲状腺切除采用"精细化被膜解剖"技术,术中辨认及保护喉返神经、喉上神经外支、甲状旁腺。结果 152例患者中,行喉返神经探查262侧,均成功辨认及保护;行喉上神经外支探查231侧,174例成功辨认(75.3%)。原位解剖保护甲状旁腺150例,行甲状旁腺移植术2例。术后发生单侧暂时性喉返神经麻痹1例,在术后3个月内恢复;无喉上神经外支功能障碍。术后发生暂时性甲状旁腺功能低下症13例,术后1周恢复9例, 4周后恢复3例, 5个月后恢复1例。无发生永久性甲状旁腺功能低下症、永久性喉返神经损伤和永久性喉上神经外支损伤病例。结论 术中辨认及保护喉返神经、喉上神经外支、甲状旁腺技术行甲状腺肿物切除术是安全的甲状腺手术操作,有效避免了永久性甲状旁腺功能低下症、喉返神经和喉上神经外支损伤并发症的发生。最大限度地保存了喉功能和甲状旁腺功能,提高了甲状腺肿物的手术治愈率。     

甲状腺手术显露喉返神经保留甲状腺动脉

目的探讨显露喉返神经及保留甲状腺动脉手术方法对预防喉返神经损伤及甲状旁腺功能低下的临床价值。方法回顾分析247例甲状腺手术患者,55例行甲状腺全切及次全切除术,192例行甲状腺部分切除术。术中均保留甲状腺上、下动脉,常规显露喉返神经,术前及术后均行电子喉镜检查,血钙及甲状旁腺素检测。结果247例患者,术后均无声嘶症状出现,无术后出血并发症发生,均无手足抽搐及麻木症状出现,术后检测血钙及甲状旁腺素均在正常范围,术后电子喉镜显示无声带麻痹。随访4～36个月,所有患者均未发生永久性甲状旁腺功能低下及声带麻痹症状。结论术中显露喉返神经及保留甲状腺动脉可以避免喉返神经损伤,保全甲状旁腺功能,值得在甲状腺手术方法上推广。     

甲状腺癌局部切除术后再手术268例临床经验总结

目的分析甲状腺癌再手术临床资料，探讨其更合理术式。方法总结1984—2000年间高分化型甲状腺癌局部切除术后，进行再次手术治疗268例患者临床资料，其中男59例，女209例；首次在其他医院行甲状腺肿块切除术或甲状腺癌患侧腺叶部分切除术256例患者，在辽宁省肿瘤医院甲状腺癌患侧腺叶次全切除12例患者。第二次手术甲状腺全切除6例，均为双侧癌；峡部扩大切除1例，为峡部癌；一侧残叶及峡部切除261例。同期行颈清扫术196例，其中颈经典性清扫术94例，改良性颈清扫术102例。结果病理结果证实残叶有癌残留78例，无癌残留190例，癌残留率29．1％（78／268）。术后病理淋巴结转移癌95例，淋巴转移率48．5％（95／196）。喉返神经损伤发生率1．1％（3／268）。应用直接法计算生存率，甲状腺癌再手术5年生存率94．0％（251／267），10年生存率85．2％（127／149）。结论甲状腺癌局切术后癌残留率较高，有选择的手术治疗是必要的。正确选择适应证和术式，可以减少癌残留复发。     

甲状腺功能亢进症的外科治疗

目的探讨甲状腺功能亢进症（简称甲亢）外科手术治疗中围手术期的处理及治疗效果。方法对56例甲亢患者仔细进行病情评估及术前准备，采用暴露喉返神经、必要时显微镜下识别甲状旁腺、结扎甲状腺下动脉第三级血管行甲状腺近全切除术，观察其治疗效果。结果本组患者无死亡，无永久性喉返神经麻痹，无永久性甲状旁腺功能低下，无复发病例。随访16个月-5年，术后26例发生甲状腺功能低下，其中42．3％（11／26）经治疗甲状腺功能恢复正常，57．7％（15／26）甲状腺功能低下正在治疗观察中。所有患者血清钙水平在2．15～2．45mmol／L。结论注重围手术期的处理，采用上述方法行甲状腺近全切除术治疗甲亢有效地防止了手术并发症的发生。     

困难甲状腺手术中喉返神经解剖的研究

目的：探讨困难甲状腺手术中喉返神经解剖的方法,以最大限度减少损伤,提高手术的安全性。方法：回顾性分析52例巨大结节性甲状腺肿、胸骨后结节性甲状腺肿、位于甲状腺下极的结节性甲状腺肿、甲状腺癌以及甲状旁腺肿瘤等困难甲状腺手术中喉返神经的解剖过程和方法,了解病变累及喉返神经的状况以及避免喉返神经损伤的措施。结果：52例患者中,除2例甲状腺癌一侧喉返神经受侵予以切除外,其余50例喉返神经均解剖成功。50例喉返神经解剖成功者中,3例喉返神经拉长者术后无声嘶,2例喉返神经局部压为扁平者术后也无声嘶,3例术后轻微声嘶者经营养神经治疗1~3个月后恢复正常。1例喉不返神经,2例胸骨劈开,2例术后行气管切开。术后无并发症发生。结论：困难甲状腺手术中喉返神经的解剖大多需要游离腺叶和肿瘤并将其翻向内前上方,再以气管食管沟、甲状腺下动脉和（或）甲状软骨下角为标志进行解剖,实践证明该方法可行。     

甲状腺手术中喉返神经损伤的探讨

探讨甲状腺手术中喉返神经损伤的原因和预防措施。分析了３６８例甲状腺手术，暂时性喉返神经麻痹３例（０．８２％），未发生一例永久性喉返神经麻痹。术中喉返神经是否暴露，采用具体情况区别对待方法，对大多数甲状腺良性病变（８９．１％），尽可能术中不暴露喉返神经，但对于较大的结节性甲状腺肿、甲状腺腺瘤和再次手术病例，术中应暴露喉返神经；甲状腺癌术中常规暴露喉返神经。作者认为，只要掌握手术操作要领，熟悉喉返神经解剖和变异，喉返神经损伤，特别是永久性损伤是完全可以预防的     

甲状腺癌不规范手术后再手术相关问题的探讨

目的了解甲状腺癌再手术患者的生存情况，制定再手术的适应证，选择相应的手术方式。方法总结1986～1997年间在其他院行甲状腺癌切除术后又到中山大学肿瘤防治中心行第二次手术治疗的111例甲状腺癌患者的临床资料，分析手术情况并术后随访资料进行统计学分析。结果病理检查证实再手术患者肿瘤残留率为67．6％(75／111)；并发症发生率2．7％(3／111)，其中喉返神经损伤率0．9％(1／111)。术前CT检查发现肿瘤残留的灵敏度为80．0％(28／35)，阳性预测值为87．5％(28／32)。3年复发率为11．7％(13／111)，局部控制率为88．3％(98／111)；5年复发率14．4％(16／111)，局部控制率为85．6％(95／111)。采用寿命表法计算生存率，甲状腺癌再手术患者5年累计生存率为95．0％；10年累计生存率为93．2％。多因素分析(Cox回归)证实肿瘤复发对生存情况的影响有统计学意义。结论甲状腺癌不规范手术的肿瘤残留率较高，慎重的再手术是必要的。CT检查对于发现肿瘤残留有较高的阳性预测值，对于筛选再手术患者有重要意义。复发是影响再手术患者生存的主要因素；按适应证选择手术病例，可以使不必要再手术的患者免受手术之苦。     

甲状腺乳头状腺癌选择性颈清扫术后并发症

目的 探讨甲状腺乳头状腺癌选择性颈清扫(selective neck dissection,SND)术后并发症的发生原因及预防措施.方法 回顾性分析94例行甲状腺乳头状腺癌SND的患者的临床资料.结果 颈后外侧淋巴清扫术(posterolateral neck dissection,PLND)组29例;PLND 甲状腺次全切除术组16例;PLND加颈前清扫(anterior compartment neck dissection,ACND)加甲状腺次全切除术组34例;PLND加ACND加甲状腺全切除术组15例.副神经损伤发生率为9.6%,喉返神经损伤发生率为10.7%,6例患者出现了乳糜漏,6例出现术后甲状旁腺功能减退.结论 甲状腺乳头状腺癌SDN并发症发生率较低,手术是比较安全的.     

‘Aggressive papillary’ thyroid microcarcinoma

The objective of this study is to highlight the fact that papillary thyroid microcarcinoma can be aggressive, requiring therapeutic management similar to that of other differentiated thyroid cancers. This 8-year retrospective study concerned 187 surgical patients managed in an ENT and Head and Neck surgery department for thyroid cancer. 65 patients were found to have papillary microcarcinoma. 41 microcarcinomas were considered to be aggressive because of the presence of several risk factors such as larger than 5 mm, multifocal microcarcinomas, capsular effraction, vascular embolus, tumour extension beyond the thyroid parenchyma and metastatic lymphadenopathy. All patients with aggressive papillary microcarcinoma were treated by total thyroidectomy and ¹³¹I. Ipsilateral recurrent laryngeal and lateral cervical lymph node dissections were performed in ten patients, ipsilateral cervical lymph node dissection was performed in six patients and bilateral recurrent laryngeal and lateral cervical lymph node dissections were performed in three patients. No recurrence or metastasis was observed (follow-up ranging from 6 months to 8 years). The optimal management of thyroid papillary microcarcinoma is still controversial. “Aggressive” papillary thyroid microcarcinoma is not rare and may justify aggressive treatment depending on the presence or absence of prognostic risk factors.     

Incidental thyroid carcinoma found during surgery for laryngeal carcinoma: a case report

At the histopathologic examination of neck dissection specimens of the patients who underwent surgical treatment with the diagnosis of laryngeal cancer, thyroid cancer metastases may also be detected in addition to laryngeal cancer metastases. Were retrospectively reviewed the files of 74 patients who were diagnosed with laryngeal cancer and underwent total or partial laryngectomy and neck dissection in our clinic between January 2008 and July 2010. Thyroid papillary carcinoma was found in neck dissection specimen of two patients who underwent partial laryngectomy and neck dissection. Total thyroidectomy was performed to complete the treatment. No recurrence or metastasis was found during the postoperative follow-up for an average of 9.5 months (range 5 to 14 months). Although it is a rare condition, the possibility of coexisting thyroid carcinoma in laryngeal cancer patients and the possible need for completion surgery when required should always be kept in mind.     

甲状腺癌再次手术的探讨

目的 探讨甲状腺癌再手术的必要性和方式.方法 总结1991年1月～2006年1月检查甲状腺癌局部切除术后再次手术治疗的126例患者临床资料.第1次对原发灶只进行单纯肿瘤切除或腺叶部分切除者,再手术时切除残叶及峡部,或加对侧叶部分或近全切除;颈淋巴结转移者,行经典性或改良性颈清扫术.结果 术后病理检查残叶有癌残留52例,无癌残留74例,癌残留率41.3%,术后病理检查证实淋巴结转移癌67例,颈淋巴结转移率72.8%.喉返神经损伤发生率3.2%.5年、10年累积生存率分别为93.2%、82.4%.结论 由于误诊等原因致甲状腺癌术后残留率高,积极合理的再手术是必要的.     

Prophylactic central neck dissection and local recurrence in papillary thyroid microcarcinoma: a meta-analysis

Introduction

For papillary thyroid microcarcinoma patients, the reported incidence of lymph node metastasis is as high as 40%, and these occur mainly in the central compartment of the neck. Because these metastases are difficult to detect using ultrasonography preoperatively, some authors advocate routine central neck dissection in papillary thyroid microcarcinoma patients at the time of initial thyroidectomy.

Assessment of the morbidity and complications of total thyroidectomy

OBJECTIVE: To determine the incidence and predictive factors for complications after total thyroidectomy. DESIGN: Cross-sectional analysis of a national database on total thyroidectomy cases. METHODS: The National Hospital Data Survey database was examined and all cases of total thyroidectomy performed during 1995 to 1999 were extracted. In addition to demographic information, postoperative complications including hypocalcemia, recurrent laryngeal nerve paralysis, wound complications, and medical morbidities were identified. Statistical analysis was conducted to determine potential predictive factors for postoperative complications. RESULTS: A total of 517 patients were identified (mean age, 48.3 years). The most common indications for total thyroidectomy were thyroid malignancy and goiter (73.9% of cases). Eighty-one patients (15.7%) underwent an associated nodal dissection along with total thyroidectomy, and 16 patients (3.1%) underwent parathyroid reimplantation. The mean length of stay was 2.5 days (95% confidence interval, 2.3-2.8 days). The incidence of postoperative wound hematoma was 1.0%, wound infection was 0.2%, and mortality rate was 0.2%. The incidence of postoperative hypocalcemia was 6.2%. Younger age was statistically associated with an increased incidence of hypocalcemia (P =.002, t test), whereas sex (P =.48), indication for surgery (P =.32), parathyroid reimplantation (P>.99), and associated neck dissection (P =.21) were not. The mean length of stay was 2.5 days and was unaffected by occurrence of postoperative hypocalcemia. The incidences of unilateral and bilateral vocal cord paralyses were 0.77% and 0.39%, respectively. CONCLUSIONS: Postoperative hypocalcemia is the most common immediate surgical complication of total thyroidectomy. Other complications, including recurrent laryngeal nerve paralysis, can be expected at rates approximating 1%.     

甲状腺外科无喉返神经损伤的可能性

目的探讨甲状腺外科手术喉返神经(recurrenlaryngealnerve,RLN)零损伤的可能性。方法回顾性分析我科2001年3月～2005年3月659例甲状腺疾病的手术方式、术后RLN损伤、甲状旁腺功能低下、术后出血和术后复发等并发症的发生。术中常规解剖RLN,保护并勿过度解剖甲状旁腺及其供应的血管。结果甲状腺一侧腺叶加对侧腺叶部分切除376例、甲状腺一侧腺叶加峡部切除87例、甲状腺双侧腺叶次全切除76例、甲状腺全切除73例、颈部低位领式切口入路切除胸骨后结节性甲状腺肿47例。术后无一例发生RLN损伤。术后暂时性低钙血症发生率为1.67%(11/659)。无永久性低钙血症。术后出血需再手术止血和术后伤口血肿的发生率分别为0.60%(4/659)和0.45%(3/659)。甲状腺功能低下和术后复发的发生率分别为0.45%(3/659)和0.15%(1/659),无切口感染。结论甲状腺外科手术中熟悉RLN的解剖知识,常规紧贴甲状腺被膜外分离并全程解剖RLN及其分支可避免RLN的损伤。     

Para-tracheal neck dissection - is dissection of the upper part of level Ⅵ necessary?

Papillary thyroid carcinoma (PTC) has a high propensity for regional metastases, however, the impact of such metastases on the outcome of the patients is minimal. The central compartment of the neck is considered the first and the most common echelon of metastases from thyroid carcinoma. Physical examination along with ultrasonography are the gold standard pre-operative evaluation of patients with PTC. Ultrasonography is highly sensitive in evaluating lateral neck nodes, however, its value in evaluating the central compartment is limited, resulting in a relatively high rate of occult metastases in this compartment. The main potential complications of para-tracheal neck dissection (PTND) are recurrent laryngeal nerve paralysis and hypocalcemia and these may be higher in patients undergoing PTND compared to thyroidectomy alone. New histological data is available showing no evidence of lymph nodes in the central compartment above a level parallel to the inferior border of the cricoid cartilage. These findings support withholding dissection of the upper para-tracheal region routinely as a part of PTND in patients with well-differentiated thyroid cancer. By doing that, the complications may be lower and identical to thyroidectomy alone, thus may abolish arguments against more common use of elective PTND in patients with thyroid carcinoma.