腔镜甲状腺次全切除治疗原发性甲状腺功能亢进

目的 探讨腔镜手术治疗原发性甲状腺功能亢进的安全性及有效性.方法 回顾性分析2003年1月至2007年1月腔镜手术治疗30例甲状腺功能亢进患者的临床资料,并与同期45例开放手术的甲状腺功能亢进患者进行对比研究.结果 所有手术均获成功,腔镜组无中转开放手术.腔镜组及开放组手术时间分别为(110.5±12.3)min与(98.8±15.5)min(t=3.46,P<0.05);术中出血量分别为(45.5±11.5)ml与(65.8±12.6)ml(t=7.07,P<0.05);住院总费用分别为(11128.5±358.8)元与(6500.9±231.9)元(t=67.92,P<0.05);引流总量分别为(125.9±10.7)ml与(46.5±9.4)ml(t=33.90,P<0.05);引流时间分别为(2.98±0.5)d与(1.75±0.3)d(t=13.31,P<0.05);止痛药使用率分别为20.0%(6/30)与42.2%(19/45)(χ~2=4.00,P<0.05);一过性声音嘶哑发生率分别为6.6%(2/30)与8.8%(4/45)(χ~2=0.12,P>0.05).所有患者均获随访18～61个月,平均47.8个月.腔镜组出现甲状腺功能低下1例,1例甲状腺功能亢进复发;开放组出现甲状腺功能低下1例,2例甲状腺功能亢进复发,两组差异无统计学意义(χ~2=0.08,P>0.05).结论 腔镜双侧甲状腺次全切除术治疗原发性甲状腺功能亢进是安全有效的,且具有颈部美容效果.     

Hypocalcaemia after subtotal thyroidectomy for thyrotoxicosis

Eighty-one patients who underwent subtotal thyroidectomy for thyrotoxicosis had a 10 per cent incidence of symptomatic hypocalcaemia (corrected calcium less than 2.0 mmol/l) but only a 1.2 per cent incidence of prolonged hypocalcaemia. In the same patients only one had a transient right sided recurrent laryngeal nerve palsy. These results would seem to confirm the wisdom of lateral ligation of the inferior thyroid arteries to protect the recurrent laryngeal nerve. They lend no support to the suggestion that in order to protect parathyroid function this teaching be abandoned in favour of a policy of ligation of the arteries on the surface of the gland. Nevertheless, injury, devascularization or inadvertent removal of parathyroid tissue must still be the first practical consideration.     

超声刀甲状腺大部分切除术的效果评估

目的探讨使用超声刀降低甲状腺大部分切除术患者术中损伤的效果。方法将92例接受甲状腺大部分切除术治疗的患者随机分为超声刀组和电刀组,超声刀组44例、电刀组48例。电刀组使用传统电刀进行手术,超声刀组使用超声刀进行手术。对比两组患者术中资料、术后恢复速度和术后并发症发生率。应用SPSS 19.0软件包进行数据处理,术中资料指标及术后资料指标等计量资料呈正态分布,以(x珋±s)表示,采用t检验;术后并发症发生率等计数资料采用χ2检验。P0.05为差异具有统计学意义。结果超声刀组手术时间(48.8±15.6)min、术中出血量(19.6±14.4)ml、切口长度(4.3±1.1)cm、线结个数(2.2±1.7)个显著少于电刀组的(59.1±16.3)min、(31.9±19.7)ml、(5.6±1.6)cm、(7.4±2.3)个,两组比较差异有统计学意义(t=3.096,3.438,4.572,12.399,P0.01)。超声刀组术后引流量为(29.7±18.7)ml显著低于电刀组的(54.1±33.5)ml(t=4.359,P0.01)。并发症总发生率:超声刀组为20.5%(9/44),电刀组56.3%(27/48),两组间差异有统计学意义(χ2=13.700,P0.01)。结论使用超声刀进行甲状腺大部分切除术操作更为简便且术中损伤较小、具有临床应用价值。     

The effect of subtotal thyroidectomy on Graves' ophthalmopathy

Nineteen unselected patients undergoing subtotal thyroidectomy (STT) for Graves' disease were submitted to thorough ophthalmologic assessment before and after (mean, 10 mo) thyroid surgery. All clinical examinations were performed by the same observer and findings were scored according to the American Thyroid Association (NOSPECS) classification. Orbital computed tomography (CT) scans were performed in all patients prior to surgery and again at follow-up if the initial scan was abnormal or if there was evidence of clinical deterioration; all CT scans were viewed by the same individual. There was evidence of infiltrative ophthalmopathy at some stage in the course of observation in 17 (89%) of the 19 patients. No predictable ocular response to STT was apparent. Ophthalmic status was noted to improve in 6 patients, to remain unchanged in 7 patients, and to progressively deteriorate in 6 patients. This unpredictable pattern was seen irrespective of the severity of preexisting ocular involvement. The absence of any consistent or predictable ocular response to STT strongly suggests that thyroidectomy does not influence the natural course of Graves' ophthalmopathy. We believe that the presence of evolving or stable ophthalmopathy, even if severe, should not be regarded as a contraindication to STT in Graves' disease.

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Resumen Diecinueve patientes no seleccionados sometidos a tiroidectomía subtotal (TST) por enfermedad de Graves fueron llevados a una completa valoración oftalmológica antes y después (promedio, 10 meses) de la cirugía tiroidea. Todos los exámenes clínicos fueron realizados por el mismo observador y los hallazgos fueron registrados de acuerdo con la clasificación de la Asociación Americana de Tiroides (NOSPECS). Se hicieron tomografías computadorizadas (TC) orbitales en todos los pacientes antes de la cirugía y en el período de seguimiento si la escanografía inicial era anormal o si había evidencia de deterioro clínico; todas las TC fueron interpretadas por la misma persona. Se halló evidencia de oftalmopatía infiltrativa en algún momento en el curso de la observación en 17 (89%) de los 19 pacientes.Ninguna respuesta ocular predecible a la TST se hizo aparente. El estado oftálmico mejoró en 6 pacientes, permaneció sin cambio en 7, y se deterioró en forma progresiva en 6. Este impredecible patrón fue observado con independencia de la gravedad de la afección ocular preexistente. La ausencia de una respuesta ocular predecible o consistente a la TST ciertamente sugiere que la tiroidectomía no influencia la evolutión natural de la oftalmopatía de Graves. Creemos que la presencia de una oftalmopatía estable o en evolución, aún si es severa, no debe ser considerada como contraindicatión para la TST en la enfermedad de Graves.

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Résumé Dix-neuf patients non sélectionnés ont eu une évaluation ophthalmologique avant et après (moyenne, 10 mois) une thyroïdectomie subtotale (TST) pour maladie de Basedow. Tous les examens ont été faits par le même médecin, et les résultats ont été notés selon la classification NOSPECS de l'American Thyroid Association. Une tomodensitométrie (TDM) orbitale a été effectuée chez tous les patients avant la thyroïdectomie et une fois encore après si l'examen initial était anormal, ou si l'état clinique s'aggravait. Tous les résultats de TDM orbitale ont été interprétés par le même médecin. Dix-sept (89%) des 19 patients avaient une ophtalmopathie infiltrative à un moment donné de l'évolution.On n'a pas mis en évidence de réponse oculaire à la TST. L'état ophtalmique s'est amélioré chez 6 patients, est resté inchangé chez 7, et s'est détérioré chez les 6 autres. L'évolution ophtalmique était imprévisible quelle que soit la sévérité de l'état ophtalmique préexistant. L'absence de réponse oculaire constante ou prévisible dans cette série suggère fortement que la thyroïdectomie n'influe pas sur l'évolution naturelle de l'ophtalmopathie de la maladie de Basedow. Nous croyons que la présence d'ophtalmopathie, stable ou pas, même si elle est sévère, ne devrait pas constituer une contre-indication à la TST dans la maladie de Basedow.

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Presented at the International Association of Endocrine Surgeons in Sydney, Australia, September, 1987.     

复发甲亢再次手术的探讨

目的：探讨甲亢术后复发原因,术后复发率,提高再次手术疗效和减少合并症的方法,方法：对12例术后复发甲亢行再手术治疗的资料进行了回顾性分析。结果：复发主要因首次手术保留腺体过多,椎状叶未切除或未切断甲状腺动脉,再手术的困难是解剖模糊,粘连严重,渗血明显,再手术前要控制好甲亢症状,防止损伤甲状旁腺和喉返神经及颈部动静脉,采用甲状腺前内侧和前外侧之间囊内切除可防止损伤,保留组织控制在4－8g,保证术后引流通畅,必要时预防性气管切开。结论：甲亢术后复发再手术是治疗的重要方法。     

Video-assisted subtotal or near-total thyroidectomy for Graves' disease

BACKGROUND: Surgery remains the treatment of choice for patients with Graves' disease. The purpose of the present study was to assess the usefulness and efficacy of video-assisted subtotal or near-total thyroidectomy in patients with Graves' disease. METHODS: Between March 2000 and December 2004, 63 patients with Graves' disease underwent video-assisted subtotal, near-total or total thyroidectomy. Fifty-three patients (84 per cent) were considered for surgery after failure of antithyroid drug and radioiodine therapy, whereas the other ten patients were initially selected for surgical treatment based on their own preference. Treatment outcome was evaluated, including surgical complications, thyroid function, quality of life and patient satisfaction with the surgical result. RESULTS: All patients were operated on using a video-assisted technique, with some modifications depending on time and experience. There were no conversions to open surgery. Three patients (5 per cent) had temporary recurrent laryngeal nerve palsy that recovered spontaneously. Most patients were satisfied with the surgical results, particularly regarding the placement of the surgical scars. CONCLUSION: Video-assisted subtotal or near-total thyroidectomy is a safe and effective procedure for treatment of Graves' disease.     

Total thyroidectomy replaces subtotal thyroidectomy as the preferred surgical treatment for Graves' disease

BACKGROUND: Total thyroidectomy is increasingly being adopted for patients requiring surgical treatment for Graves' disease based on a comparable surgical risk and the lack of recurrence, as well as the questionable ability of subtotal thyroidectomy to maintain euthyroidism. The purpose of the present paper was to evaluate its safety and efficiency. METHODS: Total thyroidectomy was adopted as part of the routine surgical treatment for Graves' disease from 2000. Patients who underwent subtotal thyroidectomy (STT) from 1995 to 1999 (n = 119) were compared with those who underwent total thyroidectomy (TT) from 2000 to 2003 (n = 98) with respect to immediate postoperative morbidity and long-term outcome. RESULTS: Fourteen (11.8%) and 22 patients (22.4%) required calcium supplement on discharge in the STT and TT groups, respectively (P < 0.05). One (0.8%) and three patients (3.1%) developed permanent hypocalcaemia, respectively. Transient recurrent laryngeal nerve palsy occurred in 9.2% (n = 11) and 5.1% (n = 5) of patients or 5.0% and 2.6% of nerves at risk after STT and TT, respectively. None of the patients had permanent nerve palsy. The estimated blood loss was less and hospital stay shorter after TT. During a mean follow up of 64 months, 86 patients (72.3%) in the STT group required thyroxine replacement and seven patients (5.9%) developed relapse. CONCLUSION: Subtotal thyroidectomy was associated with relapse as well as hypothyroidism in a significant proportion of patients during long-term follow up. Total thyroidectomy can be performed as safely as STT and should be recommended as the procedure of choice for patients requiring surgical treatment for Graves' disease.     

保留上极的甲状腺次全切除术

目的 探讨保留上极的改良甲状腺次全切除术的可行性。方法 应用保留上极的改良甲状腺次全切除术治疗甲状腺良性疾病332(保留上极组），常规手术治疗360例（常规组），比较两组的并发症发生率、出血量和手术时间。结果 保留上极组的手术时间较常规组短，有显著性差异（P＜0．001）。常规组23例（6．39％）发生喉上神经损伤，保留上极组无此并发症发生。两组均无明显喉返神经损伤。出血量无明显差别。结论 保留上极的改良甲状腺次全切除术是一种操作简便、并发症少的术式。     

甲状腺次全切除术1437例报告

目的 探讨甲状腺功能亢进手术病人术后并发症的发生原因和预防措施。方法 回顾总结１９７９年１月至１９９８年１２月间１４３７例甲状腺次全切除术的临床资料。结果 术后出现并发症６例,占０．４２％,复发１５例,占１．０４％。结论 严格作好术前准备,术中操作轻柔,彻底止血,囊内结扎甲状腺上、下极血管,并根据临床中毒症状、病程长短、年龄、腺体的大小决定保留腺体的量,有助于进一步减少并发症,提高治愈率。     

甲状腺机能亢进性心脏病手术风险的防范

目的 探讨在甲状同能亢进（甲亢）合并心脏病的情况下，如何安全、有效地手术治疗甲亢，防范手术风险，并使其所致的心脏损害得以恢复。方法 对１３８例甲亢合并心脏病患者，术前应用甲亢性心脏病危险指数评分表进行手术耐受性评估，并进行综合治疗、监护，使全组安全进行手术。结果 原发性甲亢手术治愈率１００％，心脏损害治愈率８９．２％，术后均无心衰发生，无围手术期死亡。结论 通过各种防范措施，甲亢性心脏病施行手术治     

Long term follow-up of hyperthyroid patients treated by subtotal thyroidectomy

The early and long term complications of subtotal thyroidectomy in 306 hyperthyroid patients (multinodular goitre and diffuse hyperplasia) followed for up to 30 yr are reviewed. There were no perioperative deaths. Sixteen patients (5.2 per cent) had transient symptomatic hypocalcaemia, while 9 (2.9 per cent) had permanent hypocalcaemia. Permanent unilateral vocal cord paralysis occurred in 11 (3.6 per cent) patients (1.8 per cent of nerves at risk). Cumulative per cent (+/- s.e.m.) relapse and hypothyroid rates at 30 yr (life-table analysis) were 15.6 +/- 2.4 per cent and 20.5 +/- 2.1 per cent, respectively. Lifelong follow-up of post-thyroidectomy patients is mandatory because of the risk of relapse of hypothyroidism.