问与答

问:甲状腺手术中如何保护喉上神经?(解放军二六三医院耳鼻咽喉头颈外科张颖主治医师)答:在甲状腺手术中,尤其是在做腺叶切除或全甲状腺切除时,除了要注意保护喉返神经、甲状旁腺以外,在处理甲状腺上极血管时,还要注意保护喉上神经。喉上神经起源于迷走     

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。     

第六期甲状腺内镜手术及颈部内镜外科学习班通知

由中山大学孙逸仙纪念医院耳鼻咽喉头颈外科主办的国家级医学继续教育项目"第六届甲状腺内镜手术及颈部内镜外科手术学习班"将于2012年9月21～23日在中山大学孙逸仙纪念医院举行,授予I类继续教育学分8分(参加时请带上华医网学分IC卡)。讲课内容涵盖甲状腺内镜手术及颈部内镜手术(包括涎腺手术、颈清扫手术、先天性囊肿手术、茎突手术等)和喉返神经监测的最新技术和进展,届时将邀请国内外著名耳鼻咽喉头颈外科、甲状腺外科和微创外科专家联合授课、手术演示和手术录     

第八期内镜甲状腺手术及头颈肿瘤微创外科学习班通知

由中山大学孙逸仙纪念医院耳鼻咽喉头颈外科主办的国家级医学继续教育项目：第八届＂内镜甲状腺手术及头颈肿瘤微创外科学习班＂【项目编号：2014-07-01-228】将于2014年11月28~30日在中山大学孙逸仙纪念医院举行,授予Ⅰ类学分10分,参加时请带上华医网学分IC卡。讲课内容涵盖甲状腺内镜手术及颈部内镜手术（包括涎腺手术、颈清扫手术、先天性囊肿手术、茎突手术等）和喉返神经监测等最新技术和进展,届时将邀请国内外著名耳鼻咽喉头颈外科、甲状腺外科和微创外科专家联合授课、手术演示和手术录像。欢迎各位耳鼻咽喉科、头颈外科、普外甲状腺专科、口腔颌面外科医师参加。     

甲状腺腺叶切除术精细化操作技术临床结果初步报告

目的 回顾总结集程序化、精细化操作与质控为一体的甲状腺腺叶切除术外科模式在甲状腺全切除术中临床应用结果.方法 2013年5月至2014年8月应用该外科模式实施甲状腺全切除72例,按程序化的设计和步骤进行精细化操作完成手术,对手术切口、手术时间、术中出血量、术中重要结构保护、切口愈合、术后并发症、患者满意度情况进行总结.结果 颈部第二皮纹切口更符合患者立位的社会属性;一侧腺叶手术时间30 ～ 50 min;出血约2～5 ml;无喉上神经损伤,出现暂时性喉返神经麻痹4侧,术后3～4周均自行恢复;暂时性甲状旁腺功能减退10例,术后4～6周自行恢复;切口均一期愈合;手术切口非常满意66例,满意4例,可接受2例.结论 集程序化、精细化操作与质控为一体的甲状腺腺叶切除外科模式对甲状腺手术的实施是一种良好的外科模式,对标准化流程的建立、质控和临床教学均有积极的推动作用.     

下期要目

由中华耳鼻咽喉头颈外科杂志编辑部、中华医学会耳鼻咽喉科分会、中华外科杂志编辑部共同主办的2005全国甲状腺外科专题研讨会于2005年11月15日至18日在海口市召开。会议收到论文120余篇，内容涉及甲状腺手术中喉返神经的解剖、甲状腺癌的综合治疗、甲状腺手术中甲状旁腺的保护、侵犯周围器官的甲状腺癌的手术治疗、甲状腺的小切口手术等。大会还邀请国内著名教授做专题报告。与会的外科、头颈外科、耳鼻咽喉科、内分泌科和影像学专家共同对甲状腺疾病的外科治疗进行了广泛的交流和深入的讨论。本期述评充分肯定了这种多学科间开展学术交流的形式，提倡学科间互补互学，     

第8期内镜甲状腺手术及头颈肿瘤微创外科学习班通知

由中山大学孙逸仙纪念医院耳鼻咽喉头颈外科主办的国家级医学继续教育项目：第8期＂内镜甲状腺手术及头颈肿瘤微创外科学习班[项目编号：2014-07-01-228]＂将于2014年11月28-30日在中山大学孙逸仙纪念医院举行,授予Ⅰ类学分10分,参加时请带上华医网学分IC卡。讲课内容涵盖甲状腺内镜手术及颈部内镜手术（包括涎腺手术、颈清扫手术、先天性囊肿手术、茎突手术等）和喉返神经监测等最新技术和进展，     

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。     

胸骨后甲状腺肿物32例外科治疗

目的：探讨胸骨后甲状腺肿物的手术入路及方法。方法：良性甲状腺肿物采用颈部低领式切口入路,按甲状腺切除的方法给予处理;胸骨后甲状腺乳头状癌,采用颈部低领式切口加颈部正中纵切口,行肿瘤姑息切除加气管切开术。结果：31例良性甲状腺肿物患者采用颈部切口入路均获成功;1例甲状腺乳头状癌患者采用颈部纵切口,姑息切除肿瘤加气管切开,术后追加放疗及同位素治疗,生存期超过5年。32例患者中,9例（28．1％）出现并发症;5例（15．6％）出现喉返神经损伤;出血3例（9．4％）。结论：颈部低领式切口是切除胸骨后甲状腺良性肿瘤的理想入路,恶性肿瘤手术径路有待进一步探讨。     

甲状腺手术中避免喉返神经损伤的体会

甲状腺手术中避免喉返神经损伤是术者关注的重要环节。我科 2年多来手术治疗甲状腺疾病82例 ,术中注意解剖喉返神经 ,无一例喉返神经损伤 ,报告如下。1　资料与方法本组 82例中 ,男 2 8例 ,女 5 4例 ;年龄 1 4～ 72岁。腺瘤 5 9例 ,结节性甲状腺肿 9例 ,亚急性甲状腺炎 2例 ,甲状腺功能亢进 3例 ,甲状腺癌 9例 (其中微小癌 5例 ,并发甲状腺功能亢进 1例 )。若肿物局限于一侧腺体则行患侧腺体及峡部切除 ;若双侧腺叶皆有肿物或为甲状腺功能亢进则行甲状腺次全切除 ,保留一侧或两侧甲状腺被膜及上极或下极部分甲状腺组织。手术先处理上极再断…     

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。     

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%.     

Complications following thyroid surgery

The incidence of severe complications following thyroid gland surgery is a major reason to recommend total thyroidectomy or a less radical procedure in treating thyroid gland diseases. A retrospective study on 335 thyroidectomies was performed to assess the incidence of postoperative complications. Rates for hypocalcemia were based on patients undergoing bilateral procedures (n = 185) and on nerves at risk for recurrent laryngeal nerve injury (n = 513). Permanent hypocalcemia (8%) and unilateral laryngeal nerve injury (2.3%) were the major complications, with 0.8% having fatal complications. The achievement of long-term normal serum calcium levels has been the most frequent complication. Recurrent laryngeal nerve injury had a significant relationship with secondary procedures, histologic findings, and no nerve identification during surgery. In our series, major complications can be blamed on technical pitfalls, even in the hands of experienced surgeons.     

甲状腺肿瘤外科手术2228例临床分析

目的探讨甲状腺肿瘤外科治疗效果，总结甲状腺肿瘤的诊疗经验。方法回顾性分析1992年-2004年间2228例甲状腺肿瘤(2072例甲状腺良性肿瘤，156例甲状腺癌)的临床资料及随访结果。结果2072例甲状腺良性肿瘤中，术后喉返神经损伤4例，永久性喉返神经损伤率是0．1％，暂时性喉返神经损伤率为0．1％；55例复发行二次手术，复发率为2．6％。术后无甲状旁腺功能低下和出血。甲状腺癌156例，8例复发，3例死亡，直接法统计5年生存率为95．50k，(64／67)，Kaplan-Meier法统计5年生存率为98．0％。60例微小癌中无1例复发或转移，5年生存率为100．0％。156例甲状腺癌中1例喉返神经损伤，发生率为0．6％，术后无出血和甲状旁腺功能低下。结论遵循甲状腺肿瘤正确外科治疗原则能有效降低甲状腺疾病患者手术并发症、复发率等，并改善预后。     

Complication rates after operations for benign thyroid disease

Controversy persists concerning the use of total thyroidectomy in benign thyroid disease and varying complication rates have been reported. We evaluated the safety of total thyroidectomy or lobectomy in benign thyroid disease. During a 5-year period, 102 patients were operated on for benign thyroid disease, including multinodular goiter (n = 55), solitary nodule (n = 18), toxic nodular goiter (n = 22) and Hashimoto's thyroiditis (n = 7). Recurrent laryngeal nerves were routinely investigated during dissection. Total thyroidectomy was performed in 27 cases, unilateral total lobectomy with isthmectomy in 38 and unilateral total, contralateral subtotal lobectomy in 37. One (0.9%) temporary superior laryngeal nerve palsy, 1 (0.9%) temporary recurrent nerve palsy and 1 (0.9%) temporary hypoparathyroidism occurred. Wound seroma developed in 2 patients (1.9%). There were no deaths or permanent complications. This study shows that total thyroidectomy or lobectomy can be done with minimal morbidity in cases of benign thyroid disease affecting the whole gland.     

Risk factors for permanent laryngeal nerve paralysis in patients with thyroid carcinoma.

OBJECTIVES: This study investigated the incidence of and risk factors for permanent recurrent laryngeal nerve paralysis for patients with thyroid malignancy. DESIGN: Retrospective chart review. SETTING: Tertiary oncology referral centre. PARTICIPANTS: Records of 290 consecutive patients treated between 1997 and 2001 were reviewed. All patients who have had one or more operations. Patients with preoperative recurrent laryngeal nerve paralysis and patients who underwent thyroidectomy in conjunction with laryngectomy were excluded. The incidence of postoperative permanent cord palsy was calculated in relation to the number of patients. MAIN OUTCOME MEASURES: Age, gender, thyroid functions, tumour localisations and size, multicentricity, thyroid capsule invasion, extrathyroidal soft tissue invasion, differentiation, histological type, co-existence of lymphocytic thyroiditis, total number of dissected and metastatic nodes, type of surgery, the place of surgery and number of operations were the risk factors investigated for permanent recurrent laryngeal nerve paralysis. Univariate and multivariate analyses were performed. RESULTS: Permanent recurrent laryngeal nerve paralysis developed in 27 (9%) of 290 patients with thyroid carcinoma. Transient and permanent paralysis rates in total or subtotal thyroidectomy, completion thyroidectomy and neck dissection groups were 5/3%, 7/3% and 24/17% respectively. Cox regression analysis identified the type of surgery [adjusted relative risk (RR) = 2.1, 95% confidence interval (CI) = 1.1-4.0, P = 0.01], extrathyroidal soft tissue invasion (RR = 5.7, 95% CI = 2.0-15.7, P = 0.001) and number of metastatic nodes (RR = 1.6, 95% CI = 1.1-2.5 P = 0.01). CONCLUSIONS: The factors related with recurrent laryngeal nerve paralysis post-thyroid carcinoma surgery are linked to special features of the tumour and to the type of surgery.     

Morbidity following central compartment reoperation for recurrent or persistent thyroid cancer

OBJECTIVE: To determine the incidence of recurrent laryngeal nerve injury and hypoparathyroidism, we reviewed our experience with central compartment reoperation. DESIGN: Patients underwent preoperative ultrasonography and magnetic resonance imaging of the neck. Ultrasound-guided fine-needle aspiration biopsy was performed and demonstrated evidence of tumor in 15 patients. At the time of surgery, hook wire electrodes were placed endoscopically into 1 or both vocal cords to monitor the integrity of the recurrent laryngeal nerve. PATIENTS: The study population comprised 20 patients who had undergone reoperative central compartment dissections between the years 1997 and 2001. There were 15 women and 5 men whose mean age was 49.4 years. All of the patients had prior total or subtotal thyroidectomy, and 4 patients had prior neck dissections. A primary thyroid cancer recurrence in the thyroid bed was present in 7 patients, and the remainder of the patients had cytological evidence of paratracheal or mediastinal metastases. A single patient had evidence of distant metastases involving the lung. MAIN OUTCOME MEASURE: Short- and long-term postoperative morbidity. RESULTS: Of the 20 patients, 18 had histologic evidence of metastases to the paratracheal lymph nodes, whereas 8 patients had metastases involving the anterior mediastinal lymph nodes. The mean number of lymph nodes removed was 6.5, and the mean number of positive lymph nodes was 4.7. None of the patients with normal preoperative laryngeal function had postoperative recurrent laryngeal nerve paresis or paralysis. There were 18 patients with normal preoperative parathyroid function. Four patients developed transient postoperative hypocalcemia. All 4 patients with transient postoperative hypocalcemia are currently eucalcemic. A single patient continues to receive calcium and calcitriol supplementation 1 month following her third central compartment dissection for recurrent thyroid cancer. CONCLUSIONS: Reoperation for recurrent or persistent thyroid cancer presents a significant challenge. However, intraoperative recurrent laryngeal nerve monitoring and preservation of the vascular pedicle of the parathyroid glands has reduced the morbidity of reoperative central compartment dissections to acceptable levels. Revision surgery in the central compartment of the neck is compatible with successful eradication of recurrent thyroid cancers and acceptable morbidity.     

经口腔前庭入路腔镜甲状腺手术在甲状腺乳头状癌中的安全效用分析

目的 探究经口腔前庭入路腔镜甲状腺手术在甲状腺乳头状癌中的安全性及效用。 方法 回顾性分析2017年06月~2020年01月期间青岛大学附属烟台毓璜顶医院行经口腔镜甲状腺手术患者146例,将139例PTC患者纳入研究,总结建腔经验、术后视觉疼痛评分、住院时间、清扫淋巴结数目、并发症及术后随访情况。 结果 完成经口腔前庭入路单侧甲状腺癌手术135例,平均手术时间(132±34.9)min;经口腔前庭入路双侧甲状腺癌4例,平均手术时间(168±38.5)min。平均中央区淋巴结清扫数目(7.1±4.6)枚,中央区淋巴结转移率47.5%(66/139),术后平均住院天数(1.9±0.7)d。暂时性喉返神经损伤率1.4%,暂时性甲状旁腺功能低下为0.7%。颏神经损伤7例(5.0%),暂时性下唇运动功能障碍9例,暂时性面神经下颌缘支分损伤2例。 结论 经口腔镜前庭入路腔镜手术可以进行标准的加速康复外科理念管理,在单侧甲状腺乳头状癌中具有良好的肿瘤治疗效果及手术安全性。     

Clinical implementation of endoscopic thyroidectomy in selected patients

OBJECTIVES: Systematic investigation of minimal access thyroid compartment surgery combined with the advent of several key new technologies has culminated in the implementation of endoscopic thyroidectomy in specific clinical situations. STUDY DESIGN:: The authors conducted a prospective, nonrandomized analysis of a consecutive cohort of surgical patients from the Medical College of Georgia Thyroid Center. METHODS AND MATERIALS: A series of patients meeting specific criteria underwent thyroid surgery with the intention of performing endoscopic thyroidectomy. Demographic and clinical data were prospectively collected and included age, gender, indications for surgery, length of incision, need for conversion, and pathology. RESULTS: Thirty-five patients successfully underwent 36 endoscopic thyroidectomies between February 2005 and March 2006 (representing 28.8% of the 125 thyroidectomies done during that period of time). There were 32 females and three males with a mean age of 45.3 +/- 13.9 years. There were five total thyroidectomies and 31 hemithyroidectomies. The mean incision length was 24.2 +/- 0.5 mm. There were no cases of permanent hypocalcemia or recurrent laryngeal nerve paralysis. Factors that increased the difficulty of endoscopic surgery included obesity, the presence of thyroiditis, and nodules >2.5 cm. CONCLUSIONS: The combination of new technology and careful experimental investigation has spawned a new era of thyroidectomy in which definitive management of thyroid pathology may be accomplished through an incision of <1 inch. This approach is feasible in the hands of surgeons with high-volume thyroidectomy practices who are comfortable with endoscopic principles. The cosmetic advantages are self-evident.