甲状腺手术不同术式对甲状旁腺功能影响的临床观察

背景与目的：手术是治疗甲状腺疾病的一种极为重要的方式,而甲状旁腺功能减退是甲状腺手术的常见并发症之一。由于各类甲状腺疾病采取的手术方式不同,对甲状旁腺功能的影响也可能不同。本研究探讨甲状腺不同术式对甲状旁腺功能影响的差异并分析原因。 方法：回顾性分析2017年8月—2019年3月收治的319例甲状腺手术患者的临床资料,其中,行甲状腺单侧腺叶切除111例（单侧切除组）、行甲状腺双侧腺叶切除107例（双侧切除组）、行甲状腺双侧腺叶切除+中央区淋巴清扫术71例（双侧切除+VI区清扫组）、行甲状腺双侧腺叶切除+中央区淋巴清扫术+侧颈区淋巴清扫术30例（双侧切除+II~VI区清扫组）。术中在患侧近峡部周围被膜选择1~2点,每点注射0.1~0.2 mL纳米炭混悬注射液,所有患者均采取精细被膜解剖法原位保留甲状旁腺,若术中发现甲状旁腺无法原位保留则立即将该甲状旁腺剪成薄片或匀浆移植包埋于胸锁乳突肌中。观察并比较各组手术前后甲状旁腺激素（PTH）与血钙水平的变化以及术后甲状旁腺功能减退与低钙血症发生率。 结果：各组术前一般资料及PTH与血钙水平均无统计学差异（均P>0.05）。各组术后PTH和血钙浓度均较术前明显降低（均P<0.01）,但两者的下降幅度在术后相同时间点随着手术范围扩大而明显增大,即单侧切除组<双侧切除组<双侧切除+VI区清扫组<双侧切除+II~VI区清扫组,差异均有统计学意义（均P<0.05）。甲状旁腺功能减退与低钙血症的发生率同样随着手术范围扩大而升高,单侧切除组、双侧切除组、双侧切除+VI区清扫组、双侧切除+II~VI区清扫组甲状旁腺功能减退发生率分别为9.9%、32.7%、56.3%、73.3%,低钙血症发生率分别为0、1.9%、19.7%、50.0%,组间差异均有统计学意义（均P<0.05）。所有患者随访至24周,无永久性甲状旁腺功能减退发生。 结论：各种甲状腺手术均对甲状旁腺功能有一定的影响,且手术范围越大,甲状旁腺受损的几率越大,发生甲状旁腺功能减退的风险越高。因此,无论何种术式术中均应对甲状旁腺实施保护,术中精细操作,减少对甲状旁腺血运影响,从而尽可能地降低甲状旁腺功能减退的发生率。     

Complications in the surgery of benign thyroid disease

Summary   Background: Thyroid surgery has developed from a life-threatening intervention in the last century to an efficient, wide-spread, and safe procedure for half a million goitre patients per year in Europe. The mortality of thyroid surgery has been reduced to a very low percentage due to progress in the control of bleeding and experience in the management of tracheal problems. It is the purpose of this report to review the actual problems in surgery of the benign thyroid. Methods: Data were collected from a large series (n = 5961 patients operated in our department between 1986 and 1998) and the literature. Results: The major specific complications in surgery of benign thyroid disease are palsy of the recurrent laryngeal nerve (RLN) at a rate of about 0.5–2.5 % in primary surgery, about 3 % in recurrent goitre, and 1.5–5 % in retrosternal and recurrent retrosternal goitre. Whereas temporary hypocalcaemia is observed in about 30 % of patients during the first postoperative days, temporary hypoparathyroidism necessitating substitution of calcium and active vitamin D is observed in about 6 % of patients, its frequency increasing in more extended procedures and recurrences. Permanent hypoparathyroidism occurs in 0.5–4.0 % of patients and may be reduced to below 1 % by meticulous surgical technique and deliberate autotransplantation of all parathyroid glands with potentially compromised blood supply. Damage to the superior laryngeal nerve is an important, annoying, avoidable, but insufficiently recognized feature of thyroid surgery that needs further work-up. Conclusions: The risk of complications depends on the extent of surgery, the nature of the underlying disease, and the experience of the surgeon. Particular surgical problems are raised by recurrent thyroid disease, large glands, thyroid autonomy, retrosternal or even mediastinal localisation, and previous damage to the RLN or parathyroids. In such instances the patient should be referred to a specialised centre since the surgeon’s experience can help to bring the rate of surgical complications down to those of ordinary procedures.      

甲状腺良性疾病再手术的并发症分析

目的　探讨甲状腺良性疾病再手术术后并发症的防治。方法　1992年6月至2 0 0 3年6月,我院共收治6 5例甲状腺良性疾病再手术患者,分别对6 5例患者手术方式、病理及术后并发症进行分析。结果　6 5例患者中首次手术行单侧腺叶手术2 7例(41 5 % ) ,双侧腺叶手术38例(5 8 5 % ) ,再手术后发现甲状腺癌8例(12 3% ) ,8例(12 3% )出现术后并发症,其中永久性并发症1例(1 5 % )。结论　甲状腺再手术并发症高于首次手术,但永久性并发症低于2 % ,甲状腺良性疾病再手术是安全的     

Surgical training and vocal-cord paralysis in benign thyroid disease

Introduction: Operations performed by a trainee surgeon should not result in a higher risk of complications. However, there is little information about identifying risk factors for primary surgery of benign, non-autoimmune goiter. Methods: This study correlates experience of the surgeon and other potential risk factors with palsy rates of the recurrent laryngeal nerve over an 18-month period. Radical removal of all nodular thyroid tissue and principal nerve identification were standard procedures. Results: Of a total of 405 operations per side, 55.8% were subtotal resections, 11.8% extended subtotal (near total) resections and 33.1% lobectomies. The overall initial and permanent palsy rates of “nerves at risk” were 8.9% and 1.2%, respectively. Patients' age, gender and weight, as well as endocrine activity of the thyroid gland were not associated with increased complications. Conclusion: The risk of nerve damage increased significantly and independently with size of goiter and extent of resection, but did not correlate with the surgical experience. In conclusion, the training of surgeons is safe if cases are carefully selected and the surgeons in training are supervised. Received: 30 January 1998     

Intact parathyroid hormone measurement 1 hour after thyroid surgery identifies individuals at high risk for the development of symptomatic hypocalcemia

Background

There is currently no consensus regarding the utilization of intact parathyroid hormone (iPTH) for predicting postthyroid surgery hypocalcemia. The objective of this study was to determine a threshold value for the 1-hour postoperative iPTH level that can identify those patients at significantly increased risk for the development of symptomatic hypocalcemia.

Methods

A prospective study of 21 individuals undergoing either total or completion thyroid operations was performed. One-hour postoperative iPTH levels were drawn along with ionized calcium at 6 hours postoperatively and at 7 am the following morning. Symptoms of hypocalcemia were recorded.

Results

Of the 21 patients recruited into the study cohort, there were 18 individuals that developed hypocalcemia (4 symptomatic and 14 asymptomatic) and 3 that remained normocalcemic. The mean iPTH level 1 hour postoperatively was significantly different when comparing the normocalcemic, asymptomatic hypocalcemic, and symptomatic hypocalcemic patient groups (6.50 pmol/L versus 3.76 pmol/L versus 0.7 pmol/L, respectively; P = .007). An iPTH level ≤2.5 pmol/L was 100% sensitive for predicting which individuals would go on to develop symptomatic hypocalcemia.

Conclusions

This study suggests that a 1-hour postoperative iPTH level ≤2.5 pmol/L can identify those individuals at risk for developing symptomatic hypocalcemia. Therefore, we recommend early calcium supplementation for these patients to decrease their postoperative morbidity from symptomatic hypocalcemia.     

甲状腺癌患者甲状腺全切手术安全性探讨

目的 探讨甲状腺癌患者行甲状腺全切除手术的安全性.方法 回顾性分析1986年1月至2006年12月因甲状腺癌行甲状腺全切除(全切组)以及次全或近全切除术(双叶手术组)的患者资料,比较两组间喉返神经损伤和继发性甲状旁腺功能低下的发生率.结果 双叶切除手术组433例:13例发生暂时性单侧喉返神经损伤,5例发生永久性单侧喉返神经损伤;11例发生暂时性甲状旁腺功能低下,无永久性甲状旁腺功能下病例.甲状腺全切手术组共70例:4例发生暂时性单侧喉返神经损伤(P>0.05),1例发生永久性单侧喉返神经损伤(P>0.05);7例发生暂时性甲状旁腺功能低下(P<0.01),2例永久性甲状旁腺功能低下(P<0.05).结论 甲状腺全切除术并不增加喉返神经损伤的概率,但手术后甲状旁腺功能低下发生率增加,因此应该有选择的施行甲状腺全切除手术.     

甲状腺癌根治术致甲状旁腺功能减退的危险因素及预防

目的:探讨甲状腺癌根治术中可能导致甲状旁腺功能减退的危险因素及预防措施。方法:回顾性分析首都医科大学附属北京同仁医院普通外科2014年全年由同一外科医师实施的75例甲状腺癌手术的临床资料。结果:全组术后发生甲状旁腺功能减退20例(26.67%),其中暂时性甲状旁腺功能减退19例(25.33%),永久性甲状旁腺功能减退1例(1.33%)。甲状腺全切术患者甲状旁腺功能减退发生率明显高于甲状腺近全切除术患者(46.88%vs.11.63%,P0.05);行VI区淋巴结清扫患者甲状旁腺功能减退发生率明显高于未行VI区淋巴结清扫患者(45.71%vs.10.00%,P0.05);同时行自体甲状旁腺移植术患者甲状旁腺功能减退发生率高于未行甲状旁腺移植患者,但差异无统计学意义(50.00%vs.22.22%,P0.05)。结论:甲状腺全切和Ⅵ区淋巴结清扫是导致甲状旁腺功能减退的危险因素。术中精细解剖甲状腺后被膜,尤其是尽可能保留下甲状旁腺血运,术后应用预防性药物可能有助于甲状旁腺功能的保护。     

甲状腺再次手术分析(附110例报告)

目的:回顾分析甲状腺癌再次手术的指征和方式,以及手术并发症的发生。方法:收集2014年1月至2017年12月在我院外科同组医师完成的所有甲状腺再次手术,共110例。分析其再次手术原因、病理检查结果、手术时间间隔和术后并发症。结果:110例甲状腺再次手术都是因为甲状腺癌复发、转移。两次手术中位间隔时间11.5(2～336)个月,其中<12个月54例(49.1%)。30例因甲状腺癌复发再次手术,双侧癌17例(56.7%),多灶癌10例(33.3%)。再次手术清扫中央区淋巴结50例中,诊断中央区淋巴结转移7例,术后病理检查阳性6例(85.7%)。诊断中央区和侧方淋巴结同时转移6例,术后病理检查阳性4例(66.7%)。其余37例为甲状腺手术规范清扫中央区淋巴结,术后病理检查阳性18例(48.6%)。诊断侧方淋巴结转移再次手术73例,术后病理检查阳性91.8%(67/73)。区域侧方淋巴结清扫27.4%(20/73)。分析再次手术后并发症,包括甲状腺切除、中央区淋巴结切除和侧方淋巴结清扫。再次手术甲状腺切除52例。单侧甲状腺切除48例中,35例甲状腺切除发生术后并发症8例(22.9%),13例残留甲状腺切除发生术后并发症6例(46.2%),4例双侧甲状腺切除均出现并发症。再次手术中行中央区淋巴结清扫的并发症发生率30.0%(15/50),其中单侧再次手术的发生率为20.0%(2/10),单侧为首次手术的并发症发生率为18.5%(5/27),再次手术行双侧中央区淋巴结清扫术的并发症发生率61.5%(8/13)。再次手术行侧方淋巴结清扫73例,其中46例单侧清扫发生并发症15例(32.6%),7例双侧清扫发生2例(28.6%),20例区域淋巴结清扫发生3例(15.0%)。结论:再次手术从心理和生理上都对病人造成了再次创伤,手术并发症发生增加。应规范首次手术的指征和范围,再次手术前明确诊断和定位,尽可能避免再次手术。     

Which criterion of intraoperative iPTH assay is the most accurate in prediction of true serum calcium levels after thyroid surgery?

Background and aims Intraoperative quick intact parathyroid hormone (iPTH) assay (IOPTH) has become a valuable adjunct in parathyroid surgery reliably predicting cure from hyperparathyroid state. Similarly to parathyroid surgery, the accuracy of the assay in predicting postoperative calcemia after thyroid surgery is related to blood sample timing and the criteria applied with no guidelines widely accepted, so far. This study compares different IOPTH criteria in predicting hypoparathyroidism-related hypocalcemia after thyroid surgery. Materials and methods The study included 200 consecutive patients undergoing total thyroidectomy. Three blood samples for IOPTH were taken in each patient: preoperatively—baseline (BL), at the end of surgery—skin closure (SC), and at 4 h postoperatively (4H). Serum calcium was routinely monitored at 4, 12, 24, 48, and 72 h postoperatively. The incidence and severity of hypocalcemia and related symptoms were matched to IOPTH results. The following criteria were tested: A, greater than 50% drop from BL at SC; B, greater than 70% drop from BL at SC; C, greater than 50% drop from BL at 4H; D, greater than 70% drop from BL at 4H; E, serum iPTH less than 15 pg/ml at SC; F, serum iPTH less than 10 pg/ml at SC; G, serum iPTH less than 15 pg/ml at 4H; H, serum iPTH less than 10 pg/ml at 4H. The accuracy of the tested criteria was calculated in predicting serum calcium level less than 2.0 mmol/l at any point after thyroidectomy. Results Tested criteria had the following value in predicting serum calcium level less than 2.0 mmol/l after thyroidectomy (sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy, respectively): A (60, 89, 38, 95, and 86%), B (80, 93, 57, 98, and 92%), C (70, 90, 44, 96, and 88%), D (85, 95, 65, 98, and 94%), E (80, 91, 50, 98, and 90%), F (90, 95, 69, 99, and 95%), G (90, 95, 70, 99, and 95%), H (95, 99, 90, 99, and 98%). Conclusions The criterion of iPTH serum level less than 10 pg/ml at 4 h postoperatively has the highest accuracy in predicting serum calcium level below 2.0 mmol/l after total thyroidectomy when compared with the other criteria. Presented at the 2nd Biennial Congress of the ESES, May 2006, Krakow, Poland.     

甲状腺术后甲状旁腺功能低下的恢复和治疗

甲状旁腺功能低下引起的低钙血症是甲状腺手术后的常见并发症,严重影响患者的生活质量。手术因素、术后处理以及患者和疾病自身因素与术后低血钙发生密切有关。促进术后甲状旁腺功能的恢复对防止永久性甲状旁腺功能低下具有重要意义。补充钙剂和维生素D制剂是治疗术后低血钙的主要方法,同时应注意防治长期使用钙剂导致的并发症。甲状旁腺激素替代治疗将来有望成为治疗甲状旁腺功能低下的重要方法。     

Surgical treatment of thyroid diseases in elderly patients

Background

We evaluated the safety of thyroid surgery in elderly patients, in whom surgical procedures usually are considered more hazardous than in younger patients.

Methods

The medical records of all the patients who were aged 70 years or older who had undergone thyroid surgery between January 1998 and June 2008 were reviewed.

Results

A total of 320 patients were included. The preoperative diagnosis was multinodular goiter in 171 cases, toxic goiter in 59 cases, suspicious or indeterminate thyroid nodule in 60 cases, and thyroid carcinoma in 30 patients. Total thyroidectomy was performed in 283 patients, thyroid lobectomy in 15 patients, and a completion thyroidectomy was performed in 22 patients. The final histology showed thyroid cancer in 86 patients and benign disease in 234.

Conclusions

Thyroid surgery in patients aged 70 years or older is safe and the relatively high rate of thyroid carcinoma and toxic goiter may justify an aggressive approach.     

显露喉返神经在甲状腺手术中预防喉返神经损伤的作用

目的探讨显露喉返神经在甲状腺手术中预防喉返神经损伤的作用。方法随机将100例接受甲状腺手术的患者分为对照组和观察组,各50例。对照组术中不显露喉返神经,观察组在术中解剖、显露喉返神经。对比两组患者喉返神经损伤情况。结果对照组有3例患者出现了同程度喉返神经损伤,观察组患者无1例发生喉返神经损伤。结论在甲状腺手术过程中解剖显露喉返神经,可有效减少对喉返神经的损伤。     

Reoperative surgery for nonresponders and complicated sleeve gastrectomy operations in patients with severe obesity. An international expert panel consensus statement to define best practice guidelines

Background

Laparoscopic sleeve gastrectomy (SG) has rapidly become the most commonly performed bariatric procedure in the United States as well as other countries, with approximately 120,000 procedures being performed annually in the United States. Reoperative interventions after SG have become more prevalent in the past few years since the initial development of SG as a primary operation. Given the expected rapid growth of these reinterventions, an expert consensus conference was held with some of the most experienced bariatric surgeons in the world to better understand, discuss, and provide consensus on the reasons, indications, contraindications, and surgical options for nonresponders and complicated SG operations.

Complications of thyroid surgery

Background: The morbidity of thyroid surgery is low. Despite this, some authors advocate a subtotal thyroidectomy instead of a total thyroidectomy, to avoid the higher morbidity associated with a total thyroidectomy. Methods: We retrospectively evaluated the complications of thyroid surgery in Leiden between January 1, 1982 and October 1, 1990. Three hundred forty-one patients—261 women and 80 men—had 356 operations; 15 patients were operated on twice; there were 152 total hemithyroidectomies, 3 subtotal hemithyroidectomies, 33 total thyroidectomies, 122 bilateral subtotal hemithyroidectomies, 12 combinations of total and subtotal hemithyroidectomies, and 34 other operations. Results: Calculated for the nerves at risk (n=489), the percentage of permanent recurrent nerve lesions was 3.1 (in the 5 most recent years it was 1.2%). There was no significant difference between total or subtotal (hemi)thyroidectomies. Initial symptomatic hypocalcemia necessitating supplementation was encountered 42 times (12.5%). The occurrence of permanent symptomatic hypocalcemia (6%) was not significantly different between total and subtotal (hemi)thyroidectomies (p=0.06). The duration of surgery was 137.8 min for bilateral subtotal thyroidectomies and 182.9 min for bilateral total thyroidectomies (p<0.0001). There was no difference in blood loss between total and subtotal (hemi)thyroidectomies. Conclusions: Because total thyroidectomy carries a risk of complications similar to that for subtotal thyroidectomy, it is not logical to avoid total resections. If the number of total resections were increased, it is anticipated that fewer reoperations, which involve a relatively high morbidity rate, would have to be performed.Results of this work were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, March 18–21, 1993.     

显露喉返神经在甲状腺手术中的应用价值及预防其损伤的对策

【摘要】〓目的〓探讨常规显露喉返神经在甲状腺手术中的应用价值以及预防其损伤的对策。方法〓回顾性分析本科近5年来336例在初次行甲状腺手术患者的临床资料,根据术中是否显露喉返神经将其分为显露喉返神经组205例和未显露喉返神经组131例。根据喉返神经损伤的判断标准,比较两组患者术后喉返神经损伤情况。结果〓显露喉返神经组205例中有2例(0.98%)出现暂时性声音嘶哑,1个月未经特殊处理后声音恢复,无永久性损伤病例。未显露喉返神经组131例中有6例(4.58%)出现喉返神经损伤,其中4例为暂时性损伤,2例为永久性损伤。组间比较差异有统计学意义(P<0.05)。结论〓在甲状腺手术中规范化显露并保护喉返神经可有效预防与减少喉返神经的损伤。     

Intraoperative neuromonitoring of surgery for benign goiter

BACKGROUND: Recurrent laryngeal nerve (RLN) palsy is one of the most serious complications in thyroid surgery. No prospective studies are available that evaluate if the additional use of intraoperative neuromonitoring reduces the rate of RLN palsy. METHODS: Between January 1 and December 31, 1998, surgery for histologically benign goiter with intraoperative identification with and without additional intraoperative RLN neuromonitoring was performed on 4,382 patients in 45 hospitals. Data were collected prospectively by questionnaire. RESULTS: The rate of transient and permanent RLN palsy based on nerves at risk were 1.4% and 0.4% with intraoperative neuromonitoring. These rates were significantly lower (P <0.05) compared with intraoperative visual RLN identification without intraoperative neuromonitoring which resulted in rates of 2.1% and 0.8%, respectively. A multivariate logistic regression analysis confirmed that the use of intraoperative neuromonitoring decreases the rate of postoperative transient (P <0.008) and permanent (P <0.004) RLN palsies as an independent factor by 0.58 and 0.30, respectively. CONCLUSIONS: Intraoperative neuromonitoring of the RLN in thyroid surgery is recommended because of significantly lower rates of transient and permanent RLN palsy rates in comparison with conventional RLN identification.