甲状腺癌侵及气管的手术治疗:环绕袖式切除和端端吻合

甲状腺癌侵及气管时有的作者认为可同时楔形切除受侵的气管组织,但本文作者提出这一方法不彻底,因为分化型甲状腺癌一旦侵犯其粘膜下层间隙时,气管浸润常环绕其周边,楔形切除气管壁会遗留病灶。作者对1984～1992年期间21例甲状腺癌侵及气管病例作管环绕袖式切除和端端吻合,其中男性4例,女性17例,平均年龄531岁(19～75岁),组织学分类为乳头状腺癌18例、滤泡型腺癌2例和髓样癌1例。甲状腺手术方法有全切除16例、次全切除3例和腺叶切除2例,同时还做了双侧改良式颈淋巴结清扫5例、同侧改良式颈淋巴结清扫和对侧局部颈淋巴结清扫4例、同侧改良式颈淋巴结清扫11例     

分化型甲状腺癌初治行Ⅵ区淋巴结清扫术中喉返神经的保护

探讨分化型甲状腺癌Ⅵ区淋巴结清扫术中喉返神经的保护。选取2012年7月—2013年6月青岛市中心医疗集团肿瘤医院甲状腺外科行标准根治术的分化型甲状腺癌初治患者38例,52侧行Ⅵ区淋巴结清扫(双侧清扫14例),均游离保护喉返神经全程。术后分组检测淋巴结转移发生率,评估近期(术后1周)及远期(术后3月)喉返神经损伤情况。38例(52侧)患者Ⅵ区淋巴结转移发生率38.46%,术后近期呛咳2例,声调降低1例,确定声带麻痹1例。甲状腺癌初治患者根治术中行Ⅵ区淋巴结清扫时,通过暴露及保护喉返神经,不增加其损伤几率。     

Nd:YAP激光杓状软骨切除术治疗甲状腺术后双声带外展麻痹

目的探讨应用Nd：YAP激光杓状软骨切除术治疗甲状腺术后双声带外展麻痹的疗效。方法我科对2003年3月-2003年11月收治5例甲状腺术后双侧声带麻痹应用Nd：YAP激光在支撑喉镜下行杓状软骨切除术进行回顾性分析。结果5例患者术后随访14～24个月,无误吸及肉芽产生,保留发音功能。结论Nd：YAP激光杓状软骨切除术是治疗甲状腺术后双声带外展麻痹的有效手段。     

手术治疗双侧外展性声带麻痹效果观察

目的分析手术治疗双侧外展性声带麻痹的效果。方法选取栾川县人民医院和郑州大学第一附属医院2014-01—2016-01间收治的16例双侧外展性声带麻痹患者,均行CO_2激光单侧杓状软骨次全切除术治疗。采用频闪喉镜观察术后声门裂大小与通气情况,并评估术后患者的发声质量及呼吸功能。结果本组患者中,14例1次手术成功,术后未发生呼吸困难,吞咽功能恢复正常,发声未显著下降。纤维喉镜检查显示术区黏膜愈合良好。随访1~3 a,上述症状均未复发。2例患者术后30 d出现呼吸困难,声嘶比术前更严重。喉镜检查显示术区肉芽增生并堵塞声门后区。再次手术将肉芽切除,术后予以雾化吸入。3个月后纤维喉镜检查显示杓状软骨切除部位的创面光滑,重建声门裂深吸时宽超过3 mm。随访6个月呼吸均平稳。结论对双侧外展性声带麻痹患者行CO_2激光单侧杓状软骨次全切除术,简单易行、创伤小、患者术后恢复快,可保持其发声功能,并有效改善呼吸功能。     

手术治疗分化型甲状腺癌48例

目的探讨分化型甲状腺癌的治疗方法。方法 48例均行手术治疗,据病理组织类型、肿瘤大小、病变范围、年龄和颈部淋巴结转移选择不同术式。单侧分化型甲状腺癌行患侧甲状腺及峡部切除或加对侧甲状腺部分切除;双侧者行全甲状腺切除,保留背侧部分组织;高危患者(年龄>45岁,肿瘤>4 cm)行颈淋巴结清扫术,术后辅以内分泌治疗。结果患侧腺叶+峡部切除术12例,患侧腺叶+峡部切除术+对侧腺体部分切除术34例,双侧甲状腺全切除术2例,功能性颈淋巴结清扫术16例,中央区颈淋巴结清扫术18例。术后发生神经损伤及甲减3例,无手术死亡病例。随访5 a以上者44例,无死亡病例,颈部淋巴结转移4例,无远处转移病例。结论分化型甲状腺癌应根据病理组织类型、肿瘤大小、病变范围、年龄和颈部淋巴结转移选择不同手术方式。     

546例分化型甲状腺癌手术治疗分析

目的 探讨分化型甲状腺癌的手术治疗方式.方法 回顾性分析2001年1月至2006年12月收治的546例行手术治疗的分化型甲状腺癌患者的临床资料,均行双侧甲状腺全切除术和选择性颈淋巴结清扫术.结果 全组无手术及住院期间死亡.颈部淋巴结转移阳性率为76,2%(358/470).单侧喉返神经损伤的发生率1.1%(6例),双侧喉返神经损伤0例;甲状旁腺部分损伤0.4%(2例),甲状旁腺完全损伤0例;喉上神经损伤0.7%(4例),术后出血0.6%(3例),食管损伤0.2%(1例).结论 对于分化型甲状腺癌患者,均应行双侧甲状腺全切除术;对于肿瘤直径＞1 cm的患者,还应行双侧中央组+患侧颈深组淋巴结清扫.     

胸腔镜袖式肺叶切除治疗中央型肺癌4例

目的探讨胸腔镜袖式肺叶切除术治疗中央型肺癌的安全性、可行性。 方法2015年12月至2016年7月完成4例肺癌胸腔镜右肺上叶袖式切除术,均采用"三孔法"腔镜下行肺叶动脉、静脉、叶间裂切断,淋巴结系统性清扫,并袖式切除支气管。采用3-0滑线连续吻合,自支气管后壁开始,经主操作孔行支气管端端吻合术。 结果4例患者均顺利完成肺叶切除、支气管袖式切除吻合及系统性淋巴结清扫。手术时间180～400 min,平均225 min;支气管吻合时间45～75 min,平均55 min。术后无吻合口漏、肺不张、肺部感染等严重并发症,无围手术期死亡。1例患者术后第6天出现气胸、胸壁皮下气肿,行胸腔闭式引流术后治愈。4例患者随访1～7个月,均健在,无刺激性咳嗽、吻合口狭窄等并发症。 结论胸腔镜袖式肺叶切除术治疗中央型肺癌安全、可行。     

分化型甲状腺癌的外科治疗

目的总结分化型甲状腺癌的诊治经验。方法回顾性分析110例分化型甲状腺癌的临床资料。结果全组均行手术治疗辅以内分泌治疗,110例分化型甲状腺癌中,乳头状癌88例(80.0%),滤泡状腺癌22例(20.0%);淋巴结转移者22例(20.0%)。手术方式包括单侧病变行患侧腺叶 峡部及对侧大部切除60例(其中功能性颈清扫12例),患侧腺叶 峡部切除29例(其中功能性颈清扫7例);双侧病变行一侧腺叶 峡部及对侧大部分切除18例(其中功能性颈清扫5例),甲状腺全切除术 双侧颈清扫2例;1例肺转移患者行甲状腺全切及颈部淋巴结清扫术后行131I内放射治疗。98例术后随访,10年生存率91.8%。结论分化型甲状腺癌预后较好,治疗关键是正确选择适当的手术方式。     

侵犯气管的局部晚期甲状腺癌的外科诊疗经验

背景与目的 手术是治疗侵犯气管的局部晚期甲状腺癌的首选方法。根据侵犯气管位置和程度的不同,其处理方法也不尽相同。选择合适的治疗方式对患者的预后和生活质量尤为重要。通常甲状腺癌气管侵犯时已伴有颈淋巴结转移、颈部大血管粘连,甚至食管和喉的侵犯,因其解剖结构复杂多变,目前仍没有高级别的循证医学证据指导治疗。本文旨在探讨侵犯气管的局部晚期甲状腺癌的临床特点和外科处理方法。方法 回顾2019年7月—2021年7月重庆大学附属肿瘤医院头颈肿瘤中心诊治的20例侵犯气管的局部晚期甲状腺癌患者资料,其中,男16例,女4例;年龄13~78岁,中位年龄53.5岁;甲状腺滤泡癌2例,髓样癌2例,甲状腺乳头状癌16例;3例锐性削除受侵气管外壁,5例行局部气管窗式切除术,10例行气管袖式切除+端端吻合术,1例行全喉切除+气管永久造瘘,1例行全喉切除+永久气管造瘘+胸大肌皮瓣修复,术后均接受131I治疗或分子靶向药物的综合治疗。结果 患者随访时间4个月至2年不等。3例锐性削除受侵气管外壁患者未见肿瘤复发,无气管瘘;5例行气管窗式切除患者均Ⅰ期缝合气管创面;10例气管袖式切除+端端吻合患者均未出现气道狭窄和双侧声带麻痹,其中1例出现术后局部感染和局部气管瘘口,换药后愈合;1例同时侵犯喉行全喉切除+气管永久造瘘,1例同时侵犯喉和颈部皮肤行全喉切除+永久气管造瘘+胸大肌皮瓣修复,后2例患者带管生存。截止投稿时本文纳入患者未出现肿瘤进展情况。结论 颈段气管的切除和修复是外科医生常常需要面对和处理的难题,笔者的治疗原则是在病灶可完整切除和患者能耐受的前提下,尽可能选择外科手术治疗。对于侵犯气管及其邻近器官的局部晚期甲状腺癌患者,应在MDT讨论指导下制定治疗方案,术前进行充分的方案准备和应对并发症的措施。根据侵犯程度不同选择合适的气管切除范围和修复重建方式,首选Ⅰ期修复和重建的方案,其次选择Ⅱ期或多期方案。但无论选择手术治疗还是综合治疗,治疗宗旨都是延长甲状腺癌患者生存期和提高生活质量。     

分化型甲状腺癌局部切除术后再次手术的探讨

目的探讨甲状腺结节初次手术方式的选择,以及分化型甲状腺癌局部切除术后再次手术的必要性。方法回顾性分析4年间收治的138例分化型甲状腺癌局部切除术后行再次手术的患者的临床资料。再次手术均行双侧甲状腺全切加不同范围的颈部淋巴结清扫。结果再次手术后病理检查腺体和淋巴结内有残余癌的发生率为76.8%。院外首次手术后单侧喉返神经损伤的22例及双侧损伤的1例(总发生率为16.7%),经修复后恢复19例。再次手术后新发的喉返神经损伤3例(2.2%),甲状旁腺部分损伤2例(1.4%),喉上神经损伤2例(1.4%);无食管损伤及术后出血。结论分化型甲状腺癌局部切除术后癌残留的发生率较高,应再次手术。再次手术以选择双侧甲状腺全切和颈部淋巴结清扫为宜。     

A case of thyroid carcinoma required the incision of the thyroid cartilage for inserting the silicone T tube after extensive tracheal resection and reconstruction

A 57-year-old female with thyroid carcinoma, who had developed tracheal stenosis, underwent extensive tracheal resection and reconstruction. After the tracheal sleeve resection 5.2 cm in length, primary tracheal reconstruction was performed. Although complication did not occur at the anastomotic site, the patient had dyspnea due to cord dysfunction by bilateral recurrent nerve paralysis. After 20 days transnasal intubation we reoperated to perform a tracheostomy under neck incision. But the reconstructed trachea was too short to pull out from the mediastinum. In order to insert the silicone T tube, the incision of thyroid cartilage must be done and vocal cords were injured. The patient inserting the T tube through the laryngeal stoma had no dyspnea and no aspiration about two years after the operation in spite of palliative operation. It seemed likely that the trouble that tracheostomy could not be done would occur in some patients who had undergone extensive tracheal resection and reconstruction. But the insertion of silicone T tube through the laryngeal stoma provided a satisfactory result for airway problem.     

Results of tracheal or esophageal resections in invasive thyroid carcinomas

STUDY AIM: The aim of this retrospective study was to report results of 21 tracheal or esophageal resections for invasive thyroid carcinomas. PATIENTS AND METHODS: Between January 1988 and August 2000, 21 patients (mean age: 66 years) had a tracheal (n = 10) or esophageal (n = 11) resection for involvement by an invasive thyroid carcinoma. There were eight undifferentiated carcinomas, 11 papillary, one follicular and one epidermoid carcinomas. RESULTS: One patient died from pulmonary embolism during the postoperative period. Complications were: tracheal fistula (n = 2), tracheal stenosis (n = 1), esophageal fistula (n = 2), recurrent nerve palsies (n = 8) and hypoparathyroidism (n = 4). Seven patients presented local recurrence and seven presented distant metastases. Ten patients were alive and ten patients died of their carcinoma. The mean survival in this study was 26 months (21 months for anaplastic carcinomas and 41 months for differentiated carcinomas). CONCLUSION: Differentiated thyroid carcinomas have to benefit from a complete tumoral resection; tracheal or esophageal resection is indicated in case of involvement. Anaplastic carcinomas have a poor prognosis; complete resection is indicated only for selected patients; radiotherapy and chemotherapy are used, because surgery is often impossible.     

Resection of thyroid carcinoma infiltrating the trachea.

We have treated surgically 11 patients with thyroid carcinoma that had infiltrated into the trachea. Three patients had primary tumours, and eight had recurrent tumours after previous operations. Sleeve resection of trachea was performed where thyroid carcinoma had proliferated; the trachea was reconstructed by end-to-end anastomosis. In two patients 10 rings of the trachea were resected. In three patients the anterior half of the cricoid cartilage was resected along with the cervical trachea. In one patient tracheoplasty was performed using partial extracorporeal circulation because severe tracheal stenosis prevented endotracheal intubation. Two of the 11 patients died from the surgery and one from disseminated metastases. One patient who had undergone tracheal resection for thyroid carcinoma three years and five months previously had a recurrence of the tumour in the trachea adjacent to the anastomosis, and a second tracheal resection was performed. In three patients postoperative laryngeal stenosis occurred. Five patients are alive and well two years and one month to four years and seven months after their operations. The histological pattern of the tumour was papillary adenocarcinoma in all 11 patients.     

Surgical management of tracheal tumours

The annual incidence of primary tracheal tumours in Sweden is less than 1 per million population. Five cases of malignant tracheal neoplasm treated with segmental resection and primary reconstruction are described. Exploration and mobilization of the trachea were performed via right thoracotomy. Suprahyoid laryngeal release was also done in two cases, using a cervicomediastinal approach. The length of resected segment in these cases was 6 and 7 cm. High-frequency positive-pressure ventilation was used in four of the five cases and greatly facilitated the operation. Recovery was uneventful. Adenoid cystic carcinoma was too extensive for extirpation in one case, but 4 months after radiotherapy a 7 cm tracheal segment with residual tumour was removed; 3 years later the patient is well. There was no stenosis or other late complication and no local recurrence in the long-term survivors. No vocal paralysis occurred. The two patients with laryngeal release had remarkably little and transitory dysphagia. Technical problems are discussed and conclusions are presented.     

Results of the treatment of locally invasive thyroid carcinoma

BACKGROUND: Well-differentiated thyroid carcinoma usually has an excellent prognosis. However, when extrathyroidal invasion occurs, it is associated with significant morbidity and mortality. This report presents the experience of a single institution in the treatment of patients with locally invasive, well-differentiated thyroid carcinoma. PATIENTS AND METHODS: Forty-six patients with locally invasive well-differentiated thyroid carcinoma were diagnosed. Histopathologic types included: 28 papillary carcinoma and 18 follicular. RESULTS: Patients with exclusive invasion of the muscle or recurrent laryngeal nerve usually had complete tumor resection. Patients with tracheal, laryngeal, or esophageal invasion usually underwent shave resection. The factors that adversely affected survival were: age >45 years, preoperative diagnosis of extrathyroidal extension, and incomplete resection (p <.05). CONCLUSIONS: There were similar survival results after complete or shave resection and poor survival when the resection was incomplete. Tumors with minimal invasion can be treated by shave resection with acceptable survival and low morbidity.     

Lateral Mobilization of the Recurrent Laryngeal Nerve to Facilitate Tracheal Surgery in Patients with Thyroid Cancer Invading the Trachea Near Berry’s Ligament

Background Thyroid cancer often invades the trachea and the recurrent laryngeal nerve (RLN) at or near Berry’s ligament, which fixes the thyroid gland to the trachea. In patients with thyroid cancer invading the trachea near the ligament, preservation of the RLN is very difficult. Regardless of whether the nerve is preserved or is resected and reconstructed, the presence of the nerve interferes with tracheal resection and repair. We proposed a new technique to solve this problem. Methods Before tracheal surgery, the inferior pharyngeal constrictor muscle was divided along the lateral edge of the thyroid cartilage, and the RLN was mobilized and retracted laterally. We applied this technique in 11 patients with papillary thyroid carcinoma invading the trachea. Two patients demonstrated vocal cord paralysis preoperatively. The procedures used for tracheal surgery in this series were partial resection of the trachea with creation of a tracheocutaneostomy, that with direct suture, and shaving off the tumor in 7, 2, and 2 patients, respectively. Results The RLN could be preserved and mobilized laterally in eight patients. While three patients demonstrated transient vocal cord paralysis, the remaining five had functioning cords postoperatively. In three patients the RLN was resected, and the remaining distal stump was mobilized and anastomosed with the ansa cervicalis. These patients recovered their voices and maximum phonation time increased to the normal level. The tracheocutaneous stoma was closed with local skin flap about four months later in all patients. Conclusion Lateral mobilization of the RLN facilitates the preservation of the nerve and the performance of tracheal surgery in patients with thyroid cancer invading the trachea at or near Berry’s ligament.     

A case of carcinoma of the esophagus involving the trachea undergoing anterior mediastinal tracheostomy with pedicled omental wrapping

A 62-year-old male who complained of dysphagia, body weight loss and hoarseness was admitted to our hospital. Chest x-ray film disclosed right superior mediastinal mass compressing membranous portion of trachea. Esophageal fiberscope revealed carcinoma of cervical esophagus. Bronchofiberscope revealed the paralysis of right recurrent laryngeal nerve and the invasion of esophageal cancer to tracheal membranous portion from the 5th tracheal ring to the 12th. The cancer also invaded the right lobe of thyroid which was shown by echogram. Operation was performed. On dissecting the cervical region, it was found that the tumor invaded both sides of the trachea so that tracheal reconstruction could not be done without injuring left recurrent laryngeal nerve. Sternotomy was added. Anterior mediastinal tracheostomy was done after laryngeal resection with total thoracic esophagectomy and tracheal resection leaving 5 rings long cartilage from carina. The trachea was wrapped with pedicled omentum. Post-operative course was uneventful. This procedure helps to increase blood supply to the tracheal anastomosis and turns to advantage in preventing infectious extension around trachea to mediastinum as well as tracheal compression to major vessels.     

Improvement of vocal cord paresis after thyroidectomy

Iatrogenic vocal cord paralysis is a well-publicized complication of thyroid and parathyroid operations. Less appreciated is the improvement of vocal cord function after resection of a thyroid or parathyroid tumor. Over the last 22 years, 14 patients presented with vocal cord paresis in the presence of thyroid or parathyroid tumors. Of these 14 patients, nine had complete resolution of paresis following resection of the thyroid or parathyroid tumors: three had a thyroid carcinoma impinging upon the nerve, three had large colloid goiters, two had a follicular adenoma and one had a parathyroid adenoma displacing the nerve. In five of the 14 patients the vocal cord paralysis persisted after operation. In three, the pathology accounted for the vocal cord paralysis and was not amenable to operative improvement: one patient had an unresectable anaplastic thyroid carcinoma, one patient had long-standing idiopathic unilateral vocal cord paralysis, and one patient had laryngeal adenoid cystic carcinoma with thyroid invasion. The fourth patient had an extensive thyroid hemangioma. The paralysis persisted after resection. The fifth patient had long-standing idiopathic vocal cord palsy. A preoperative vocal cord paresis in a patient with thyroid or parathyroid disease does not indicate permanent loss of recurrent nerve function, even in the presence of carcinoma. In this series, vocal cord function was restored in 9 of 10 patients with resectable thyroid or parathyroid tumors.     

Cartilage-shaving procedure for the control of tracheal cartilage invasion by thyroid carcinoma

This study was carried out to ascertain whether the cartilageshaving procedure is appropriate to control thyroid carcinoma with tracheal cartilage invasion. Of 432 thyroid carcinoma patients treated between 1979 and 1988, 16 had tracheal cartilage invasion only. This patient population was made up of 3 men and 13 women, with a mean age of 55.8 years. Fourteen were diagnosed histologically as having papillary carcinoma and the remaining two as having follicular carcinoma. Cartilage shaving was the primary treatment in all the patients, and subsequent radioactive iodine (¹³¹) or external-beam radiotherapy was administered to control any possible residual disease. Lifelong thyroid hormone replacement was instituted in all patients, and the follow-up period averaged 70.7 months. Only four of the 16 patients remained disease free; the disease was not controlled in the other 12, and seven of this latter group eventually died of their disease. We feel that a more extensive resection procedure than cartilage shaving should be considered, even in patients with superficial tracheal invasion, to increase the diseasefree survival rate.