胸骨后甲状腺肿外科手术治疗体会

目的 总结胸骨后甲状腺外科手术治疗体会。方法 回顾分析50例胸骨后甲状腺肿患者的手术治疗资料,其中48例患者采用胸骨上1cm低位领形切口,2例行颈部低位领形切口+胸骨切开切除胸骨后甲状腺肿。术中常规显露喉返神经。结果 50例患者手术均获成功,结节性甲状腺肿41例,滤泡性甲状腺腺瘤7例,桥本病2例。术后并发症包括4例短暂的低钙血症、甲状腺功能减退症。结论 胸骨后甲状腺肿患者采用颈部低位领形切口是可行的,术中常规显露喉返神经全程对于减少喉返神经损伤具有重要意义。     

胸骨后甲状腺肿外科手术治疗体会

目的 总结胸骨后甲状腺肿外科手术治疗体会.方法 回顾分析50例胸骨后甲状腺肿患者的诊断治疗资料,其中48例患者采用胸骨上1 cm低位领形切口,2例行颈部低位领形切口+胸骨切开切除胸骨后甲状腺肿.术中常规显露喉返神经.结果 50例患者手术均获成功,结节性甲状腺肿41例,滤泡性甲状腺腺瘤7例,桥本病2例.术后4例并发短暂的...     

胸骨后甲状腺疾病的诊断和外科治疗

目的探讨胸骨后甲状腺病变的临床表现、诊断方法和手术治疗。方法回顾性分析我院1999年1月至2005年6月收治的47例胸骨后甲状腺肿的临床资料。结果46例为Ⅰ°坠人性胸骨后甲状腺肿,均为部分型,1例为Ⅱ°异位胸内甲状腺肿。良性病变45例,恶性病变2例。均行手术治疗,43例采用颈部低领式切口,3例采用颈部低领式切口+部分胸骨劈开,1例行胸骨劈开。行甲状腺大部切除术31例,双侧甲状腺次全切除术14例,甲状腺癌根治术1例,甲状腺癌姑息切除术1例。全组无手术及住院死亡,声嘶恢复正常5例,声嘶无改善2例,一过性手足抽搐4例,1例甲状腺鳞状细胞癌术后一月因肿瘤局部复发堵塞气管窒息死亡。结论绝大多数胸骨后甲状腺病变是颈部病变向下延续所致。CT扫描是最佳的术前检查手段。绝大多数患者的手术可经颈部低领式切口完成,必要时附加胸骨部分劈开。     

胸骨后甲状腺肿切除术的临床体会（附8例报告）

目的探讨胸骨后甲状腺肿的诊断和手术方式：方法收集1993-2004年间手术及病理证实为胸骨后甲状腺肿8例的临床资料。结果均以颈部低领状切口人路顺利完成手术，术后发生甲状腺危象2例，甲状腺功能减退1例，无喉返神经损伤及其他产重并发症，均临床治愈出院。结论(1)认识腺肿压迫气管引起气管痉挛等继发临床表现，并在围手术期加以控制，包括服碘、抗炎、解痉等药物治疗；(2)颈部低领状切口完全可满足本组胸骨后甲状腺肿切除术的需要。     

86例胸骨后甲状腺肿手术治疗分析

目的总结胸骨后甲状腺肿手术治疗经验及疗效。方法胸骨后甲状腺肿86例均行手术切除,其中颈低领式切口83例,颈部切口＋胸骨部分劈开3例。结果均获治愈,术后声嘶4例,除1例为肿瘤侵犯喉返神经所致外,余3例在术后1月内恢复;发生一过性手足抽搐3例,均在2月内恢复。86例均获随访,平均13（6-36）个月,无复发病例。结论经颈部切口切除胸骨后甲状腺肿适合绝大多数患者,术前CT扫描对手术方式的选择具有指导意义。     

超声刀在胸骨后甲状腺肿手术中应用的临床研究

目的探讨超声刀在胸骨后甲状腺肿手术中的临床意义。方法回顾性分析2007年4月～2010年2月在笔者所在医院行手术治疗的21例胸骨后甲状腺肿患者的临床资料。结果 21例患者均在超声刀配合下经颈部切口切除胸骨后甲状腺肿,均痊愈出院,无一例死亡。并发喉返神经暂时性损伤及暂时性甲状旁腺功能低下者各1例,无术后出血、呼吸困难等严重并发症。结论应用超声刀行经颈部切口入路胸骨后甲状腺肿切除术,可以降低手术难度,减少术中出血量,术后并发症少,是安全、有效的手术方法。     

巨大甲状腺肿腺叶切除术18例

目的:探讨巨大甲状腺肿腺叶切除术的手术技巧。方法:对巨大甲状腺肿18例患者采用颈部弧形切口、胸锁乳突肌前缘切开、颈白线切开双入路联合增加术野显露,直视下逐支切断上极血管分支,主动解剖喉返神经,视气管壁软化程度酌情悬吊气管。结果:18例均顺利完成手术,术野暴露充分,无1例切断颈前舌骨下肌群,无术中大出血,无喉返神经及喉上神经损伤,无甲状旁腺损伤,无术后大出血、窒息。结论:巨大甲状腺肿行腺叶切除术采用颈部弧形切口、胸锁乳突肌前缘切开、颈白线切开双入路联合术野暴露充分,组织损伤小;直视下逐支切断上极血管分支、解剖喉返神经、视气管壁软化程度酌情悬吊气管有助于避免相关手术并发症。     

双极电凝镊联合超声刀经颈部入路切除胸骨后甲状腺肿34例临床分析

目的探讨双极电凝镊联合超声刀经颈部入路切除胸骨后甲状腺肿治疗经验。 方法回顾性分析2013年7月至2020年12月收治的34例胸骨后甲状腺肿患者的病例资料。 结果根据术前分型，其中Ⅰ型9例，Ⅱ型17例，Ⅲ型8例。34例患者中，无明显临床症状者23例，表现为怕热多汗者1例，表现为吞咽困难、呼吸困难、声音嘶哑等压迫症状者10例。术后病理显示：良性31例，甲状腺乳头状癌1例，甲状腺滤泡性癌1例，甲状腺神经鞘瘤1例。患者均首选经颈部入路手术，其中有4例联合了胸骨劈开术。术后并发症发生率8.8%（3/34），均为术后暂时性四肢麻木，补钙治疗后症状消失，均顺利出院。 结论经过充分的术前评估和准备，双极电凝镊联合超声刀经颈部入路切除胸骨后甲状腺肿是安全有效的，能在手术过程中实施“精细化解剖”，最大限度地保护甲状旁腺、喉返神经等甲状腺周围组织器官。     

胸骨后甲状腺肿18例手术治疗分析

目的探讨胸骨后甲状腺肿的外科手术治疗。方法回顾1995年1月至2006年12月期间手术治疗胸骨后甲状腺肿患者18例，其中16例行颈部低领式切口、2例行颈部低领式切口＋胸骨劈开入路切除胸骨后甲状腺肿。结果18例患者接受手术均获得成功，结节性甲状腺肿10例，甲状腺腺瘤5例，甲状腺炎3例，术后并发症发生率11．11％（2／18），无死亡。结论经颈部低领式切口切除胸骨后甲状腺肿是可行的，具有损伤小，操作简单，并发症少的优点。     

30例胸骨后甲状腺肿的外科治疗

目的 探讨胸骨后甲状腺肿的诊断、治疗和术后并发症.方法 回顾性分析我院1989年至2008年收治30例胸骨后甲状腺肿患者的诊断、治疗资料.结果 30例患者中,多结节性甲状腺肿24例,滤泡性甲状腺瘤2例,复发性甲状腺肿3例,亚急性甲状腺炎1例.28例手术可以通过颈部低位领形切口手术完成,2例需要劈开胸骨.主要的临床症状包括呼吸困难18例,吞咽困难5例,多汗症2例;术后并发症包括4例暂时的喉返神经损伤,血肿2例,短暂的低钙血症2例,2例声音嘶哑.结论 绝大多数胸骨后甲状腺肿患者完全可以选择用颈部低位领形切口手术,术中辨明并保护甲状旁腺和喉返神经对于减少术后并发症具有重要的意义.     

Surgical treatment of substernal goiter: An analysis of 59 patients

PURPOSE: Substernal goiter is defined as a thyroid mass of which more than 50% is located below the thoracic inlet. In this article we report the diagnosis, symptoms, thyroid function, treatment, and postoperative complications of 59 patients with substernal goiter. METHODS: Between 1992 and 2005, 59 patients underwent surgery for substernal goiter at our institution. The indications for surgery were multinodular goiter in 46 cases, follicular adenoma in two cases, and Hashimoto's thyroiditis in one case. Ten patients were operated on for recurrent thyroid disease. RESULTS: The leading preoperative symptoms were dyspnea (49.2%), dysphagia (13.6%), hyperhidrosis (10.2%), and cardiac dysfunction (6.8%). All but two thyroid glands could be removed through a Kocher transverse collar incision. The most common postoperative complications were persistent (5.1%) or temporary (3.4%) paresis of the recurrent laryngeal nerve, transient hypocalcemia (3.4%), and hematoma (3.4%). A tracheotomy was required in one patient with bilateral vocal cord paresis (1.7%). CONCLUSIONS: (1) We conclude that a subtotal thyroidectomy is also the treatment of choice for asymptomatic benign substernal goiter. (2) Transverse collar incision should be the standard approach for most patients. (3) The visual identification of at least two parathyroid glands is essential to prevent permanent postoperative hypoparathyroidism.     

显露喉返神经在甲状腺切除术中的临床意义

目的探讨甲状腺手术中显露喉返神经对防止喉返神经损伤的价值。方法回顾性分析2 481例甲状腺手术患者的临床资料,其中术中显露喉返神经组1 425例和非显露喉返神经组1 056例,比较两组间并发喉返神经损伤的几率。结果显露喉返神经组喉返神经暂时性损伤31例,损伤率为2.18%,无永久损伤病例;非显露喉返神经组喉返神经损伤44例,损伤率为4.17%,其中暂时损伤39例,永久损伤为5例。两组喉返神经损伤率比较差异有统计学意义(P<0.01)。结论甲状腺手术术中显露喉返神经对保护喉返神经是安全和有效的,对预防或避免医源性喉返神经损伤有重要意义。     

Substernal goiter. Report of 212 cases

AIM OF THE STUDY: The aim of this retrospective study was to report the results of the surgical treatment in a series of 210 patients operated on for substernal goiters. PATIENTS AND METHOD: From 1982 to 1996, 210 patients with substernal goiters, including 80% of women, were operated on via a cervical approach in 208 cases, via a sternotomy in two cases. Two patients with operative contra-indications were not operated on. Twenty-five were operated on for a substernal recurrence of a goiter. In 160 cases, extraction of the substernal portion was easy. In 48 cases, removal of the substernal portion was facilitated by the discovery of the recurrent nerve at its entering into the larynx and a downward dissection of the tracheal attachments of the lobe. The complete dissection of the cervical portion made easier the ascension of the substernal portion even in very large substernal components. RESULTS: Three papillary carcinomas were diagnosed. A transient laryngeal nerve palsy occurred in 7.2% of the patients and a transient hypoparathyroidism in 13.4%, A definitive laryngeal nerve palsy occurred in 1.2% of the patients, and a persistent hypoparathyroidism in 2.1%. Of the 25 patients who underwent surgery for recurrence of a goiter, three (12%) developed a transient laryngeal nerve palsy, one (4%) a permanent nerve palsy, four (20%) a transient hypoparathyroidism and one (4%) a persistent hypocalcemia. CONCLUSION: CT scan and MRI are the best explorations to evaluate intrathoracic extension of substernal goiters. Thyroidectomy was performed via a cervical incision in 208 patients and via a sternotomy in two patients only. The complete dissection of the cervical portion with discovery of the recurrent nerve at its entering into the larynx, facilitates the ascension of the substernal portion even in very large substernal goiters.     

The clinical presentation and operative management of nodular and diffuse substernal thyroid disease

Patients with substernal thyroid disease, defined by the presence of enlarged thyroid tissue below the plane of the thoracic inlet, were identified from a prospective database maintained for patients who have undergone thyroidectomy at our institution since 1990. Substernal thyroid disease was present in 116 (30%) of 381 patients, anterior mediastinal in 109 (94%), and posterior mediastinal in seven (6%). Indications for surgery included compressive symptoms in 75 (65%) patients, an abnormal fine-needle biopsy in 45 (39%), progressive thyroid enlargement in 41 (35%), thyrotoxicosis in 11 (10%), and superior vena cava syndrome in two (1.7%). A median sternotomy and thoracotomy were performed in one patient each for a primary intrathoracic goiter. In all other patients thyroidectomy was accomplished through a cervical incision. Parathyroid autotransplantation was performed in 41 (37%) patients with retrosternal disease compared with 57 (22%) with disease confined to the neck (P < 0.01). Twenty-five patients (22%) had malignancy; four of these had unresectable disease. Postoperative complications included transient hypocalcemia (n = 46), transient hoarseness (n = 7), recurrent laryngeal nerve injury (n = 1), and wound infection (n = 1). One patient died from aspiration pneumonia. In summary, substernal thyroid disease is typically present in the anterior mediastinum and with rare exceptions can be resected through a cervical incision. Parathyroid devascularization is more common with resection of a substernal goiter and autotransplantation can prevent permanent hypoparathyroidism.     

腔镜甲状腺切除术中喉返神经的显露

目的探讨腔镜甲状腺切除术中喉返神经的显露技巧,避免因显露而造成的喉返神经医源性损伤。方法2011年4月～2012年4月,行胸乳晕人路腔镜下甲状腺切除术17例。于乳腺前皮下置入troear,注入CO2（压力6mmHg）建立操作空间,用超声刀显露喉返神经。结果17例均顺利完成喉返神经显露,其中7例行腔镜双侧甲状腺腺叶手术（6例双侧叶结节和1例甲状腺癌）,5例行一侧甲状腺叶切除术（一侧腺叶多发结节）,5例行一侧腺叶次全切除术。喉返神经主干位于甲状腺下动脉之前、之后和动脉分叉之间的比例分别为17．6％（3／17）、47．1％（8／17）和35．3％（6／17）,术后未见声音嘶哑等发生。结论尽管甲状腺下动脉与喉返神经的关系不固定,应用甲状腺囊外解剖和上翻技术,在切除腺体的同时可以显露喉返神经,减少喉返神经损伤。     

120例巨大甲状腺肿的外科治疗

目的：探讨巨大甲状腺肿外科治疗的特点与治疗要点。方法：收集我院17年间收治的甲状腺肿物患者3200例,并将重量在500g以上、肿块直径8cm以上的巨大甲状腺肿患者120例进行回顾研究。结果：巨大甲状腺肿占同期病例的3.8%。其中102例行一侧甲状腺叶切除加对侧次全切除,18例行甲状腺全切术,其中12例行甲状腺全切加颈部淋巴结清扫术。病理诊断105例为结节性甲状腺肿,甲状腺癌15例（12.5%）,继发甲亢者20例（16.2%）。术后出现并发症者44例,其中包括术后甲状腺功能低下30例,甲状旁腺功能低下5例,单侧喉返神经损伤7例,双侧喉返神经损伤1例,气管软化塌陷1例,无死亡病例。结论：巨大甲状腺肿可合并胸骨后甲状腺肿,可压迫气管,使气管移位变窄,手术操作难度大,风险较高,并发症多。应选择合适的麻醉方法,根据不同情况作不同处理,避免大血管和喉返神经的损伤。     

巨大甲状腺肿手术治疗的进展

巨大甲状腺肿多由结节性甲状腺肿、甲状腺瘤引起，少数也可由甲状腺功能亢进、甲状腺癌引起。近年来，巨大甲状腺肿的发病率有所下降，临床上仍可见到。甲状腺肿可使颈部大血管、气管受压移位及变窄，故手术操作难度较大、风险较高和并发症较多。文中着重从术前检查、麻醉的选择、切口及引流的选择、手术方式、纤支镜在气管移位的应用、胸骨后甲状腺肿的处理、避免喉返和喉上神经损伤八个方面，对国内外近几年手术治疗进展情况进行综述。