附加保留颈外静脉耳大神经和维持胸锁乳突肌连续性的功能性颈淋巴结清除术

附加保留颈外静脉耳大神经和维持胸锁乳突肌连续性的功能性颈淋巴结清除术湖北省肿瘤医院头颈科胡少南随着医疗技术的发展，六十年代提出了保留颈内静脉、副神经、胸锁乳突肌的功能性颈淋巴结清除术。近年来，我们在上述“三保留”的基础上，附加保留颈外静脉、耳大神经和...     

甲状腺癌功能性颈淋巴结清除术

自1963年采用功能性颈淋巴结清除术治疗甲状腺癌颈淋巴结转移102例。术式包括(1)保留胸锁乳突肌、颈内静脉及付神经的颈淋巴结清除术38例,(2)保留付神经的颈淋巴结清除术64例。102例的5年健在率为94.4%,10年健在率为63.6%,术后患侧颈部复发仅1例,本文对手术步骤,重点描述:仿领状切口,标本分两块切除。初步认为能够作到清除肿瘤,并可达到保留功能和兼顾外形的要求。     

多功能保留颈清术在治疗分化型甲状腺癌的应用

目的探讨多功能保留颈清术在分化型甲状腺癌治疗中的作用。方法回顾性分析15例(16侧)分化型甲状腺癌患者行多功能保留颈清术治疗的临床资料。结果15例(16侧)保留胸锁乳突肌、颈内静脉、副神经及耳大神经16例次，枕小神经15例次，锁骨上皮神经14例次，颈横动静脉14例次。所保留的神经功能一般3个月内均能恢复，上肢活动良好，无颈部肿瘤复发。结论多功能保留颈清术既能达治疗目的又能提高患者术后的生活质量，值得临床推广应用。     

传统改良颈清扫术对比多功能保留颈清扫术治疗甲状腺癌的临床效果差异性分析

目的研究传统改良颈清扫术和多功能保留颈清扫术治疗甲状腺癌的临床差异。方法选取甲状腺癌伴颈部淋巴结转移的患者150例,根据患者肿瘤原发灶的大小、局部的浸润度和转移程度,分别实施传统改良式颈清扫术(对照组,65例)和多功能保留颈清扫术(实验组,85例)。对照组保留颈清扫术为保留胸锁乳突肌、颈内静脉和副神经,而实验组则在对照组的基础上还保留了颈部浅静脉、颈丛皮神经和颈横血管。结果 2组的手术时间和出血量差异无统计学意义(P>0.05);2组中每例患者的平均淋巴结总数和阳性淋巴结数量对比,差异均无统计学意义(P>0.05)。实验组患者的耳部、颈肩部皮肤感觉基本上在术后3~5个月内可以恢复正常,并且其面部以及上颈部肿胀的发生率大大降低;实验组患者肩部疼痛麻木、锁骨下皮肤疼痛麻木、颈外疼痛麻木、枕部疼痛麻木、耳周疼痛麻木等并发症发生率显著低于对照组,差异有统计学意义(P<0.05)。结论多功能保留颈清扫术,没有增加手术时间和手术难度,却达到了治疗的目的,同时也提高了患者术后的生活质量,值得临床推广应用。     

功能性颈淋巴结清除术在头颈部恶性肿瘤治疗中的应用

本文作者总结功能性颈淋巴结清除术(FND)治疗19例头颈部恶性肿瘤(非甲状腺癌)的经验,并对颈淋巴结清除术后颈部标本、颈动脉鞘和胸锁乳突肌筋膜作前瞻性病理组织学检查。19例FND标本中,淋巴结阳性9例(47.4％),而颈动脉鞘和胸锁乳实肌筋膜全部无肿瘤残留。随诊8～24个月,全组病例无颈部淋巴结复发征。术后颈部外形和功能良好(作者认为FND适用于N_0,N_1,N_2和部分N_3病例,只要病例选择恰当,FND可望同RND一样,可达到根治颈部淋巴结的目的。     

多功能保留性颈淋巴结清除术

分化型甲状腺癌疗效好，对早、中期的病人多施行功能性颈淋巴结清除术，即保留胸颈乳突肌、颈内静脉和副神经，这就是通常所说的"三保留"手术。作者在长期的工作实践中摸索出其它功能的保留方法并积累了一些经验。自1991年8月至1997年10月共行多功能保留的颈淋巴结清除术105例（3例为双侧颈清术）。除上述三保留以外的保留内容有耳大神经108例次，枕小神经41例次，颈横动脉58例次，颈外静脉10例次和锁骨上皮神经的斜方肌支7例次。术中重点介绍了各功能器官的保留方法和技巧并讨论了耳大神经和枕小神经的功能恢复时间及影响神经功能恢复的因素，为开展此项工作的朋友提供些经验。     

甲状腺癌的功能性颈清术

甲状腺癌的传统颈清术因切除胸锁乳突肌、颈内静脉和副神经,术后可致颈部凹陷变形、斜方肌瘫痪、上臂运动功能受限等后遗症,因此,在不影响手术彻底切除的前提下施行保留胸锁乳突肌、颈内静脉和副神经的功能性颈清术,得到较多人的赞同,尤其对儿童及青少年女性患者更为适宜。     

甲状腺切除联合同期双侧颈淋巴结清扫术治疗分化型甲状腺癌

目的 探讨分化型甲状腺癌行甲状腺切除联合同期双侧颈淋巴结清扫（颈清）术的安全性、适应证和手术难点。方法对1991年1月至2004年6月我科收治的分化型甲状腺癌行甲状腺切除联合同期双侧颈清术患者36例作回顾性分析,手术切口选择根据原发癌灶的位置及颈淋巴结可疑转移情况,选择相应的H型、L型或衣领式,甲状腺组织行近全切或全切,双侧颈清术原则上按保留颈内静脉、副神经、胸锁乳突肌改良颈清术式进行。结果全组36例患者无一例手术死亡,术后并发症为创口出血2例,一侧喉返神经损伤4例,一侧喉上神经内支损伤2例,一侧喉上神经外支损伤9例,一侧副神经损伤3例,一侧颈交感神经损伤5例,一侧膈神经损伤2例,一侧乳糜瘘6例,暂时性甲状旁腺功能减退13例,永久性甲状旁腺功能减退3例。淋巴结阳性数0-21个,平均8．3个／例,双侧淋巴结均阳性31／36,一侧淋巴结阳性,另一侧淋巴结阴性3／36,双侧淋巴结均阴性2／36。经1-13年随访,4例死亡,7例失访,25例存活,3例复发。结论分化型甲状腺癌行甲状腺切除联合同期双侧颈清术是安全的,关键是至少保留一侧颈内静脉,不要同时损伤双侧喉返神经和膈神经;对双侧颈淋巴结病理证实转移或临床判断转移（淋巴结明显肿大、质地偏硬或淋巴结为典型的紫葡萄颜色）的分化型甲状腺癌,均应行甲状腺切除联合同期双侧颈清;至少保留一个有血供的甲状旁腺;尽可能将甲状腺组织近全切或全切;应兼顾手术彻底性和机体功能保留。     

多功能保留颈清扫术治疗分化型甲状腺癌35例的临床分析

目的探讨多功能保留性颈淋巴结清扫术治疗甲状腺癌的可行性及意义。方法回顾性分析35例施行保留颈丛、肩胛舌骨肌及颈外静脉的多功能保留性颈淋巴结清扫术的甲状腺癌患者的临床资料。结果无手术死亡者,术后恢复良好,随访期间无复发。颈部外观无塌陷,所保留的神经功能从术后第1天开始逐渐恢复,表现为神经支配区域麻木感逐渐消失,术后3个月内均恢复。上肢活动良好,无臂丛神经和膈神经损伤。耳廓感觉恢复,下颈部及肩部无麻木感,颈部外观无改变。术后上颈及耳周疼痛或肩胛区疼痛明显17例,1~6周后好转。结论多功能保留性颈淋巴结清扫术既可达到根治肿瘤的目的,又能有效保留耳廓区、颈部、锁骨上区的感觉,合理、可行,但部分患者术后疼痛感明显。     

经胸锁乳突肌肌间入路甲状腺癌根治手术的临床观察

目的:探讨颈侧切口经胸锁乳突肌肌间入路（腔镜辅助）实施甲状腺癌根治手术的可行性和安全性。方法:选择2018年1月-2019 年9月我院普外科收治的甲状腺恶性结节患者共60例。按照随机数字表法分为两组,每组各30 例。观察组采用颈侧切口经胸锁乳突肌肌间入路（腔镜辅助）实施甲状腺癌根治手术。对照组采用颈前切口颈白线入路实施甲状腺癌根治手术。比较两组手术时间、术中出血量、术后切口疼痛评分、美容满意度、术后住院时间、并发症等指标。结果:观察组在美容满意度、术后疼痛评分、并发症方面要明显优于对照组,其差异有统计学意义。两组在手术时间、术中出血量、术后住院时间方面的比较无明显统计学意义。结论:颈侧切口经胸锁乳突肌肌间入路（腔镜辅助）实施甲状腺癌根治手术要明显优于传统的颈前切口颈白线入路,更值得在临床上推广及实施。     

Value of neck dissection in patients with squamous cell carcinoma of unknown primary.

Lymph node metastases of cancer of an unknown primary (CUP syndrome) are responsible for 3-5% of the malignant diseases in the head and neck area. More than 70% of these patients show lymph node metastases of an unknown squamous cell carcinoma. The survival depends immediately on number and location of lymph node metastases. For a curative approach modified radical neck dissection combined with postoperative radiation therapy with or without chemotherapy should be considered in N1-N3 lymph node status. A radical neck dissection with postoperative radiation therapy should only be approved in cases of infiltration of the internal jugular vein, the accessory nerve and/or the sternocleidomastoid muscle. The different prognosis of patients with upper cervical and lower cervical lymph nodes should influence the indication and the extent of a neck dissection in the contralateral N0 neck.     

Radical neck dissection: preserving the distal spinal accessory nerve based on its cervical plexus contribution

In an effort to overcome shoulder morbidity from the classical radical neck dissection, modifications preserving the entire spinal accessory nerve, were described. When there are metastatic upper jugular nodes with potential extracapsular spread, modifications that preserve the entire XI nerve may be oncologically unsafe. We describe a technique wherein the XI nerve is preserved based on the contribution from the cervical plexus, while allowing resection of the proximal part of the nerve en bloc with the specimen. This modification may preserve useful trapezius function without compromising oncological safety.     

The X-pointer: A forgotten anatomical relationship of spinal accessory nerve and great auricular nerve

IntroductionThe preservation of the spinal accessory nerve cannot be overlooked in neck dissection. Injury to the nerve results in shoulder dysfunction and other related morbidities. In this article, we describe a unique constant relationship between spinal accessory nerve and great auricular nerve, at the junction of the anterior and posterior triangles of the neck, eponymously labelled the X- pointer.MethodologyThis was an observational study conducted at a tertiary care cancer centre that runs a comprehensive surgical training program. A 100 cases of modified radical neck dissection performed for oral cavity squamous cell carcinoma from January 2017 to January 2019 in were included. The relationship was analyzed in 100 cases of neck dissection for its constancy.ResultIn all the 100 cases, the X-pointer was demonstrated as a constant anatomical relationship between the spinal accessory nerve and great auricular nerve. The crossing over of the nerve on the undersurface of the sternocleidomastoid muscle is constant and independent of the patient's body proportions.ConclusionsThe relationship between the spinal accessory nerve and great auricular nerve remains constant irrespective of the technique of neck dissection and body habitus of the patient. In our view, this relationship can be used as an additional confirmatory landmark to prevent inadvertent injury to the spinal accessory nerve.     

颈丛阻滞加浅全麻应用于甲状腺癌根治术

目的探讨颈丛阻滞加浅全麻同用于甲状腺癌根治术的临床价值。（方法〕选择30例具有可比性的病例随机分成全麻组和颈丛浅全麻组，比较其手术开始前，切皮时，结扎甲状腺上极动脉前5分钟、结扎时、结扎后5分钟的血压心率值，用t检验进行统计学分析。同时观察手术结束至拔管时间，术毕清醒评分达1分所需时间及静脉麻醉药用量。结果颈丛加浅全麻组的血压心率变化与全麻组对照有显著性差异（P＜0．05），且术毕苏醒时间短，麻醉药用量少。〔结论）颈丛阻滞加浅全麻值得进一步用于甲状腺癌根治术。     

Modified radical neck dissection via extra-thyroideal space (MRND vets) in papillary thyroid carcinoma

The purpose of this study was to describe an alternative lateral neck access to perform lymph nodes sampling and/or neck dissection via extra-thyroideal space (MRND vets) in papillary thyroid carcinoma with lymph nodes involvment. Twenty-four consecutive patients with papillary thyroid carcinoma were included. Lymph nodes sampling and modified radical neck dissection, unilateral or bilateral, were performed acceding via a lateral dissection through a traditional Kocher incision, running along the medial fascia of the neck, posteriorly to the sterno-cleido-mastoideus muscle (SCM). Mean age was 39.04 +/- 13.69 years. Twenty patients were women, and 4 were men. Mean tumor size was 2.5 +/- 1 cm.. Total thyroidectomy with lymph nodes dissection of the central compartment associated to modified radical neck dissection was performed in 17 patients: among these, nine patients had a preoperative diagnosis of the latero-cervical lymph nodes metastases, and eight had a perioperative diagnosis of metastases of the extensive sampling of the lower third of the jugular chain. Metastatic lymph nodes were found in 107 out of 615 lymph nodes dissected. The MNRD vets access for modified lateral neck dissection seems to carry a lower risk in terms of specific morbility and allows a quicker recovery and a better cosmetic result. This access has to be considered as a less invasive procedure compared to other surgical accesses for the radical modified lateral neck dissection.     

Risk of bilateral cervical lymph node metastases in papillary thyroid cancer

We evaluated the risk of bilateral or contralateral cervical lymph node metastases in 135 patients with papillary thyroid cancer who underwent bilateral neck dissection. We confirmed that bilateral jugular lymph node metastases were frequent in patients with obvious carcinoma in both lobes of the gland, in those with cancers arising in the isthmus, in those with clinically detectable bilateral lymphadenopathy, and in those with recurrent thyroid cancer. However, only 24% of the patients who had cancer clinically confined to one lobe with no bilateral or contralateral lymphadenopathy had histologically detected bilateral or contralateral jugular lymph node metastases. But the occurrence of contralateral jugular lymph node metastases was significantly correlated with both clinical lymphadenopathy in the ipsilateral neck and contralateral paratracheal lymph node metastases. Bilateral lymph dissection might be beneficial for these patients. © 1993 Wiley-Liss, Inc.     

喉返神经显露技术在甲状腺癌手术中的应用

目的：探讨喉返神经显露技术在甲状腺癌手术中应用的意义。方法：对2009年8月至2012年8月本科收治的甲状腺癌患者112例,术中常规探查双侧喉返神经后行甲状腺全切术并行患侧Ⅵ区淋巴结廓清术,探讨手术治疗效果及防止喉返神经损伤的方法。结果：所有患者均成功探查双侧喉返神经,共224条,甲状腺腺体及癌肿包块完整切除。术后7例出现单侧声带活动障碍,5例患者1年内恢复正常,2例未恢复正常,无肿瘤复发病例。结论：甲状腺癌术中探查喉返神经有助于腺体及癌肿的完整切除,是防止术后喉返神经麻痹的有效方法,对保证患者术后生活质量具有重要意义。     

Lymph node metastasis in suprasternal space in pathological node–positive papillary thyroid carcinoma

BackgroundThe objective of the current study was to investigate the clinical significance of the suprasternal space lymph node (SSLN) in pathological node-positive (pN+) papillary thyroid carcinoma (PTC) patients.MethodOne hundred and forty patients with pN + PTC who underwent neck dissection were enrolled into this study. SSLN was resected and used as a specimen to investigate the relationship of SSLN with several clinicopathological parameters.ResultsThe metastasis rate of SSLN was 20.7%. On univariate analysis, we found that SSLN metastasis was significantly associated with primary cancer site (inferior portion), strap muscle invasion, level III metastasis, Level IV metastasis and lymph node metastasis between sternocleidomastoid and sternohyoid muscles. On multivariate analysis, primary cancer site (inferior portion), strap muscle invasion, Level IV metastasis and lymph node metastasis between sternocleidomastoid and sternohyoid muscles were independent risk factors for SSLN metastasis of PTC.ConclusionFor pN + PTC patients, special attention should be paid to the issue of SSLN metastasis.     

喉返神经旁淋巴结切除在cNo甲状腺乳头状癌手术中的价值

目的：探讨喉返神经旁淋巴结清除在临床无可触及转移淋巴结甲状腺乳头状癌手术中的意义，以及在选择术式中的价值。方法：复习186例cNo甲状腺乳头状癌的临床病理资料，分析喉返神经旁淋巴结转移同侧颈淋巴结转移的关系。结果：186例cNo甲状腺乳头状癌中喉返神经旁淋巴结转移阳性者占42．5％(79／186)。在有喉返神经旁淋巴结转移的病例中，63．2％同期或术后发生侧颈部淋巴结或远处转移，而喉返神经旁淋巴结阴性病例中仅8例发生转移。结论：喉返神经旁淋巴结转移阳性的cNo甲状腺乳头状癌，其颈部其他区域发生转移的机会明显增加。喉返神经旁淋巴结清除及术中冰冻病理检查可作为cNo甲状腺乳头状癌手术时是否施行选择性颈廓清术的参考依据。