双侧结节性甲状腺肿手术方式的探讨

目的 探讨双侧甲状腺全切除/近全切除术治疗双侧结节性甲状腺肿是否安全可行.方法 2003年1月至2006年12月311例拟诊双侧结节性甲状腺肿者分为A、B两组;A组130例行双甲全/近全切术;B组181例行双甲次全切或/和大部切除术.结果 A、B两组各有6例和2例术中冰冻报告良性,但术后石蜡切片报告为乳头状癌.A组不需再手术,B组需再手术;两组术后各3例(2.42%,3/124 vs.1.68%,3/179)有暂时性声嘶,差异无统计学意义(P=0.48).术后2月A组2例有音调改变,无法发高音,喉镜示双侧声带活动好;B组1例有声嘶,喉镜示一侧声带活动减弱.两组术后各有11(8.87%,11/124)和9例(5.03%,9/179)术后48 h内有低钙血症,差异无统计学意义(P=0.16).两组无永久性甲状旁腺功能减退.B组术后2例(1.12%,2/179)因出血需再手术.A组术后无结节性甲状腺肿复发,B组12例复发(6.70%,12/179),差异有统计学意义(P=0.02).结论 双甲全/近全切除术可减少结节性甲状腺肿术后复发率和再手术率,且并发症并无增加,是安全可行的.     

结节性甲状腺肿术后复发原因及防治

回顾性分析术后复发性结节性甲状腺肿76例的临床资料，其中首次手术后病理检查为结节性甲状腺肿58例，甲状腺腺瘤样改变l8例。首次手术行单纯结节切除l6例，腺叶部分切除34例，一侧次全切除加对侧结节摘除l8例，双侧腺叶次全切除8例。再次手术均行双侧甲状腺叶次全切除术。术后无严重并发症。再次术后病理检查均为结节性甲状腺肿。再次术后给予甲状腺素片治疗。随访2-10年，无l例复发。提示结节性甲状腺肿术后复发与病变性质、手术适应证的掌握及手术方式有密切关系。     

甲状腺全切除术的适应证及安全性分析

目的探讨甲状腺全切术的手术适应证以及并发症的防治。方法回顾性分析2009年1月至2011年12月期间在笔者所在医院接受甲状腺全切除术的85例患者的临床资料。85例中甲状腺癌46例,结节性甲状腺肿38例,桥本甲状腺炎1例。分析其手术过程以及术后并发症。结果术后病理检查提示46例甲状腺癌中9例（19.6%）为双侧癌;38例结节性甲状腺肿患者均为双侧多发结节。全部患者均解剖出2条喉返神经,有4例患者的喉返神经被肿瘤侵犯,其中1条喉返神经被切除。有5例患者术中未能明确看到并保留甲状旁腺,其余患者均保留了1枚或以上的甲状旁腺。有2例患者术后发生出血需再次手术止血;有6例患者术后出现声音嘶哑,除1例喉返神经被切除者之外,其余患者声音均恢复正常;33例（38.8%）患者出现一过性低钙血症症状;2例患者出现永久性甲状旁腺功能低下。结论甲状腺全切除术是治疗双侧结节性甲状腺肿和甲状腺癌的安全术式,术中显露喉返神经与鉴别甲状旁腺可有效防止相应并发症的发生。肿瘤侵犯喉返神经并不一定导致患者声音嘶哑。     

结节性甲状腺肿术后复发原因及防治

目的 分析结节性甲状腺肿术后复发的原因，并探讨防治其术后复发的有效方法。方法 回顾性分析1988～2000年我院收治的结节性甲状腺肿术后复发病人76例。结果 76例中首次手术表现为结节性甲状腺肿58例，甲状腺腺瘤样改变18例。行单纯结节切除16例，腺叶部分切除34例，一侧次全切除加对侧结节摘除18例，双侧腺叶次全切除8例。再次手术均行双侧甲状腺叶次全切除术。术后无严重并发症。再次术后给予甲状腺素片治疗。随访2～10年，无一例复发。结论 结节性甲状腺肿术后复发与病变性质，手术适应证的掌握以及手术方式密切相关。严格掌握手术指征，正确选择手术方式以及术后系统的服用甲状腺素，可以降低结节性甲状腺肿术后复发。     

甲状腺峡部乳头状癌手术切除范围探讨

目的 探讨甲状腺峡部乳头状癌手术切除的范围。方法 回顾性分析上海交通大学医学院附属瑞金医院和远洋分院自2007年1月至2011年12月收治的28例甲状腺峡部乳头状癌的临床资料。结果 28例中20例（71.43%）双侧中央区淋巴结均发现转移,8例（28.57%）双侧中央区淋巴结未发现转移。13例术前伴双侧甲状腺多发结节者,9例结节性甲状腺肿,4例慢性淋巴细胞性甲状腺炎伴结节性甲状腺肿,其中1例发现微小癌。3例术前伴一侧多发结节者,为结节性甲状腺肿。术后有3例出现暂时性声嘶,7例发生暂时性低钙血症。结论　甲状腺峡部乳头状癌行双侧中央区淋巴结清扫是必要的;对伴双侧甲状腺多发结节者,同时行甲状腺全切除术;但对仅峡部单发癌结节或一侧腺叶多发结节者,行双侧甲状腺次全切或结节侧腺叶切除及对侧无结节侧腺叶次全切,以减少术后并发症。     

结节性甲状腺肿合并甲状腺癌的诊断与治疗

目的探讨结节性甲状腺肿合并甲状腺癌的临床特点和诊治原则。方法回顾性分析2005年1月—2007年12月期间收治的40例结节性甲状腺肿合并甲状腺癌患者的临床病例资料。结果结节性甲状腺肿合并甲状腺癌中结节钙化的发生率(42.5%)明显高于单纯结节性甲状腺肿(16.7%)(P0.05);甲状腺单个结节癌变发生率(20.8%)显著高于一侧多个结节者(4.66%)(P0.01)。仅4例术前诊断为结节性甲状腺肿合并甲状腺癌。40例患者均行手术治疗,术中常规快速冷冻病理检查,并根据病理检查结果采取不同的手术方式,包括一侧全切4例,一侧全切一侧次全切除27例,双侧次全切1例,双侧全切8例。40例患者中行一侧颈部淋巴结清扫术11例。术后未发生明显声嘶,3例术后出现抽搐或手足麻木。孤立性结节的癌变率显著高于多发性结节(P0.05)。结论对单侧孤立结节或有钙化的甲状腺结节,应高度警惕结节恶变可能,需积极手术治疗;对结节性甲状腺肿术中必须行快速冷冻切片病理检查,以明确诊断。结节性甲状腺肿合并甲状腺癌需按甲状腺癌的处理原则进行。     

复发性结节性甲状腺肿再次手术方式的选择

目的探讨正确选择复发性结节性甲状腺肿再次手术的方式,以降低手术并发症发生率。方法回顾性的分析手术治疗的68例复发性结节性甲状腺肿患者的临床资料。其中1次术后复发者56例,2次术后复发者10例,3次术后复发者2例。结果一侧全切或近全切 对侧次全切或大部切12例,一侧次全切 对侧次全切或大部切28例,一侧次全切20例,一侧大部切8例。平均手术时间136.43 min,术中出血平均212.33 mL。术中有54例显露喉返神经;有2例患者术后出现声带麻痹,其中1例双侧麻痹者行气管切开;3个月后拔除气管导管。4例患者出现一过性的四肢麻木。结论再次手术时,首选一侧腺叶的全切除,至少应行次全或近全切除,应当摒弃大部切除术。     

Dunhill手术治疗双侧结节性甲状腺肿的临床疗效分析

目的:探讨Dunhill手术(一侧甲状腺全切加对侧次全切除术)治疗双侧结节性甲状腺肿的临床效果。方法:收集哈尔滨医科大学附属第四医院2011年1月—2017年1月间开展的58例Dunhill手术与60例双侧甲状腺次全切除术的患者临床资料进行回顾性分析,所有患者术中病理均证实为双侧结节性甲状腺肿。结果:两组患者术前一般资料均无统计学差异(均P0.05)。与双侧次全切除术组比较,Dunhill手术组的平均手术时间明显延长(95.41minvs.52.48min,P=0.000),术后第1天低血钙发生率明显升高(12.1%vs.1.7%,P=0.031),两组术中出血量、甲状旁腺移植例数、喉返神经损伤发生率、术后第3天低钙血症发生率、甲状旁腺功能低下发生率均无统计学差异(P=1.000)。随访期间,Dunhill手术组患者复发率明显低于双侧甲状腺次全切除术组患者(P=0.027)。结论:Dunhill手术治疗双侧结节性甲状腺肿安全、有效,且能有效降低术后复发,推荐其临床应用。     

甲状腺良性结节手术后复发的再治疗

目的 探讨甲状腺良性结节手术后复发的相关因素和再治疗原则。方法 对我院18年中51例甲状腺良性结节手术后临床复发者的病理、手术适应证、术式以及再治疗进行回顾性分析。结果 甲状腺良性结节手术后复发与病变性质、单发或多发、手术适应证的掌握及术式的选择密切相关。51例复发者中结节性甲状腺肿29例,甲状腺瘤22例;其中行结节摘除21例,腺叶部分切除16例,一侧腺叶次全切除9例,一侧腺叶切除5例。再手术38例,行一侧腺叶切除19例,一侧叶切加对侧次全切除3例,一侧次全切除7例,双侧次全切除9例;无严重手术并发症。随访32例再手术者,平均7年,仅1例结节性甲状腺肿再复发。结论 对甲状腺瘤和结节性甲状腺肿的正确诊断、明确病变的单发或多发,严格掌握多发性结节性甲状腺肿的手术适应证,并废弃结节摘除和腺叶部分切除术可降低复发率和再手术率。     

经纤维喉镜连续钳夹法治疗声带息肉临床疗效分析

目的探讨经纤维喉镜连续钳夹法摘除声带息肉的疗效。方法在表面麻醉下经纤维喉镜使用连续钳夹法摘除声带息肉80例，与同期全麻支撑喉镜下85例声带息肉摘除患者比较手术时间、术后并发症及术后2个月时疗效，所得数据采用SPSS15．0软件包进行统计学分析。结果两绀患者术后2个月疗效比较无明湿差异（P〉0．05），化表面麻醉下经纤维喉镜连续钳央法组平均手术时间明显缩短（P〈0．05），且患者并发症少于支撑喉镜组患者（P〈0．05），结论相较于伞麻支撑喉镜下声带肿物切除术，对较小声带良性肿物更适于在表面麻醉下经纤维喉镜连续钳央法进行切除。     

经乳晕入路腔镜甲状腺切除术26例报道

目的探讨经乳晕入路腔镜甲状腺切除术的可行性。方法2003年3月-2005年9月，采用经乳晕入路腔镜甲状腺切除术26例。结节位于甲状腺右叶13例，左叶10例，双侧叶结节1例，原发性甲状腺功能亢进（Ⅰ度）2例；单发结节9例，多发结节15例；囊性结节5例，实性结节13例，囊实混合性6例；结节直径1-4cm。术前诊断甲状腺腺瘤9例，结节性甲状腺肿15例，原发性甲状腺功能亢进2例，无临床诊断甲状腺癌。结果镜下手术成功25例，手术时间50-210min，平均112min，行甲状腺肿瘤摘除4例，单侧甲状腺大部分切除10例，双侧甲状腺大部分切除8例，甲状腺双叶次全切除加峡部切除3例；中转开放手术1例，为术中发现甲状腺癌并侵犯气管。病理诊断甲状腺腺瘤4例，结节性甲状腺肿18例，原发性甲状腺功能亢进2例，甲状腺癌2例。术后24—48h拔除引流管，无神经或甲状旁腺损伤等并发症。26例术后住院3—6d，平均4．2d。25例随访3～33个月，平均13个月，无局部复发，美容效果满意。2例甲状腺癌随访9、11个月，无复发转移。结论经乳晕入路腔镜甲状腺手术可行，近期效果满意，切口隐蔽。     

Total versus subtotal thyroidectomy for multiple node goiter: experience with 350 surgically treated cases

The surgical treatment of benign thyroid pathology and in particular the multinodular form is controversial. This controversy exists and one must choose either perform conservative surgical therapy such as lobectomy or sub-total thyroidectomy or total thyroidectomy. From January 1985 to July 1999, the Authors observed 534 cases of benign thyroid pathology. Of these 534, 330 were diagnosed with primitive goiter, and 20 with recurrent goiter; 13 cases of the primitive goiter type were found to have microfoci of carcinoma inside the goiter on the definitive histologic exam. There were 275 patients who underwent total thyroidectomy and the remaining 75 cases with ultrasound proven multinodular goiter were treated with lobectomy or sub-total thyroidectomy, depending on the appearance at the time of the operation as well as the macroscopic and microscopic exams of the integrity of the glandular parenchyma performed while in the operating room. The Authors demonstrated that in multinodular goiter there is a high percentage of cases with disease involving the entire gland. Many areas of apparently healthy tissue are found to be microscopically involved with a variable grade of chronic lymphocytic thyroiditis or follicular hyperplasia or even lobular dysplasia with the tendency to form nodules. These signs of disease of this organ tend to recur if not treated.     

Total thyroidectomy. The preferred option for multinodular goiter.

Total thyroidectomy is an operation that has generally been reserved for the management of differentiated thyroid carcinoma. Over the last decade total thyroidectomy has become used increasingly and is now the preferred option in the authors' unit for the management of multinodular goiter affecting the entire gland. Over the period from 1975 to 1985, 853 thyroidectomies have been performed for multinodular goiter; of these, 115 have been total thyroidectomies. During that time, the incidence of total thyroidectomy for multinodular goiter has increased in percentage terms from 9% in 1975 to 50% in 1985. There have been two cases of permanent hypoparathyroidism and one case of permanent recurrent laryngeal nerve injury, and these occurred in patients who had less than total thyroidectomy. Total thyroidectomy is an appropriate operation for the management of diffuse multinodular goiter where the entire gland is involved because it precludes patients from requiring further surgery for recurrent disease, with its high associated risks. It must be emphasized, however, that protection of the recurrent laryngeal nerve and parathyroid glands must still be paramount in dealing with benign thyroid disease.     

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??Total or near-total bilateral thyroidectomy after subtotal bilateral thyroidectomy YANG Wei-ping, SHAO Tang-lei,CHEN Wei-gou, et al.Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, China. Corresponding author:SHAO Tang-lei,E-mail:shaotl_03@hotmail.com Abstract Objective To evaluate the safety of total or near-total bilateral thyroidectomy after subtotal bilateral thyroidectomy. Methods Thirty-four cases of subtotal bilateral thyroidectomy because of benign thyroid disease were performed total or near-total bilateral thyroidectomy because of the recurrence of nodules between June 1995 and June 2008 at Ruijin Hospital of Shanghai Jiaotong University School of Medicine. The clinical data of all the cases were analyzed. Results Partial fibers of right recurrent laryngeal nerves were cut at their entrance to the larynges in 2 cases.But the mobility of the vocal cord return to normal and the hoarseness were disappeared 6 months after operation. Hypocalcaemia was occurred in 6 cases.The hypocalcaemia disappeared by calcium supplementing through oral or/and intravenously in 5 of 6 cases 2 weeks after operation. But the righr superior parathyroid was cut inadvertently in one thyroid papillary cancer case, and the case underwent parathyroid autotransplantation. Hypocalcaemia was alleviated gradually 1 year after operation in the case. The levels of calcaemia and PTH were still under the normal until 14 months after operation. Conclusion If choosing the right way to expose the remnant gland and being familiar with the anatomical position of bilateral recurrent laryngeal nerves and parathyroids, it is safety to perform total or near-total bilateral thyroidectomy after subtotal bilateral thyroidectomy.     

The advantage of total thyroidectomy to avoid reoperation for incidental thyroid cancer in multinodular goiter

HYPOTHESIS: To investigate the impact of total thyroidectomy on the rate of completion thyroidectomy for incidentally found thyroid cancer in euthyroid multinodular goiter. DESIGN: A randomized, prospective clinical trial. SETTING: A tertiary referral center. PATIENTS: Patients with euthyroid multinodular goiter without any preoperative suspicion of malignancy, history of familial thyroid cancer, or previous exposure to radiation were randomized (according to a random table) to total or near-total thyroidectomy leaving no remnant tissue or less than 1 g (group 1; n = 109) or bilateral subtotal thyroidectomy leaving 5 g or more of remnant tissue (group 2; n = 109). Patients with preoperative or perioperative suspicion of malignancy were excluded. MAIN OUTCOME MEASURES: We compared the complication rates and the incidence of thyroid cancer requiring radioactive iodine ablation and completion thyroidectomy between groups. RESULTS: There were no permanent complications. The rates of temporary unilateral vocal cord dysfunction and hypoparathyroidism showed no significant difference between groups 1 and 2 (0.9% vs 0.9% and 1.8% vs 0.9%, respectively; P>.05). Papillary cancer was found in 10 group 1 patients (9.2%) and 8 group 2 patients (7.3%) (P =.80). Of the 9 patients requiring radioactive iodine ablation, reoperation was avoided in 5 group 1 patients; the remaining 4 group 2 patients underwent completion thyroidectomy (P =.007). CONCLUSION: We recommend total or near-total thyroidectomy in multinodular goiter to eliminate the necessity for early completion thyroidectomy in case of a final diagnosis of thyroid cancer.     

Is Total Thyroidectomy the Surgical Procedure of Choice for Benign Multinodular Goiter? An Evidence-Based Review

BACKGROUND: Benign multinodular goiter is one of the most common endocrine surgical problems. The appropriate surgical procedure for its effective and safe management is a matter of debate. Though seen by some as an overly hazardous procedure because of the risk of recurrent laryngeal nerve injury and damage to parathyroid function, total thyroidectomy has replaced subtotal thyroidectomy as the procedure of choice, as the latter is associated with significant recurrences. METHODS: A systemic literature review was undertaken of all available medical literature to evaluate whether total thyroidectomy is the appropriate, safe and effective surgical procedure for benign multinodular goiter. RESULTS: There is consistent level II-IV evidence that subtotal thyroidectomy results in recurrence in up to 50% patients. Incidental thyroid cancers are detected in 3%-16.6% of apparently benign goiters in numerous studies, mostly providing level IV evidence, one third of which would need further surgical treatment after subtotal thyroidectomy. Studies comparing subtotal thyroidectomy and total thyroidectomy, including two each of prospective randomized and prospective nonrandomized ones, provide level II-IV evidence that permanent complication rates associated with subtotal thyroidectomy and total thyroidectomy are not different, although the rate of transient hypocalcemia is higher with total thyroidectomy. On basis of these findings, a grade B recommendation can be made that subtotal thyroidectomy is associated with significant recurrence of goiter, leaves a small number of incidentally detected thyroid cancers inadequately treated, and provides little significant safety advantage over total thyroidectomy. Grade C recommendations can also be made about total thyroidectomy being a safe and effective procedure for benign multinodular goiters in the hands of expert surgeons, based on the extensive level IV evidence, and limited level II and level III evidence, which show that the risk of permanent vocal cord palsy and hypoparathyroidism associated with total thyroidectomy is below the acceptable 2% rate, but not without exceptions. CONCLUSION: Total thyroidectomy is the procedure of choice for the surgical management of benign multinodular goiter.     

Total versus subtotal thyroidectomy for the management of benign multinodular goiter in an endemic region

BACKGROUND: Because controversy still continuous to surround use of total thyroidectomy for the management of benign multinodular goiter, the present study aims to prospectively compare the safety and efficacy of total thyroidectomy with subtotal thyroidectomy. METHODS: A total of 200 consecutive patients with benign multinodular goiter were assigned to have either total thyroidectomy (n = 105) or subtotal thyroidectomy (n = 95) based on preoperative evaluation, intraoperative macroscopic findings and nodular dissemination. The patients with no healthy tissue or nodules localized in the dorsal part of the gland, which are usually left during normal subtotal resection, were assigned to the total thyroidectomy group. Demographic details, biochemical findings, indications for operation, operating time, specimen weight, complications and hospital stay were noted. RESULTS: There was no significant difference in the sex, hormonal status or duration of goiter between the two groups (P = 0.74, P = 0.59 and P = 0.59, respectively). The mean operating time was longer (148.52 min +/- 51.10 vs 135.10 min +/- 32.47, P = 0.03), and the mean weight of the specimens was greater (228.40 g +/- 229.91 vs 157.01 g +/- 151.23, P = 0.01) for total rather than subtotal thyroidectomy. Either temporary recurrent laryngeal nerve (RLN) palsy or hypoparathyroidism occurred in 10 (9.3%) or 12 (11.4%) of the patients undergoing total compared with six (6.3%) or nine (9.5%) of the patients undergoing subtotal thyroidectomy (P = 0.40 and P = 0.65, respectively). Either permanent RLN palsy or hypoparathyroidism was observed in one patient undergoing total thyroidectomy (P = 0.34 for each comparison). The mean hospital stay was longer in the total thyroidectomy group (2.24 days +/- 1.18 vs 1.89 days +/- 0.72 for subtotal thyroidectomy, P = 0.01). CONCLUSIONS: The present study shows that total thyroidectomy can be performed without increasing risk of complication, and it is an acceptable alternative for benign multinodular goiter, especially in endemic regions, where patients present with a huge multinodular goiter.