临床路径管理在结节性甲状腺肿治疗中的效果评价

目的 探讨临床路径在我院普通外科结节性甲状腺肿治疗中的实施效果.方法 调查2009 年11 月-2010 年8 月临床路径实施前后我院普通外科结节性甲状腺肿治疗情况.将165 份病例按是否实施临床路径分为非路径组87 例和路径组78 例,根据手术方式不同,又将两组各分为单侧甲状腺手术组和双侧甲状腺手术组,评价临床路径的实施效果.结果 路径组单侧手术患者的住院时间较非路径组由(7.79±2.69)d 下降到(6.55±1.36)d ;术前住院时间由(4.04±2.69)d 下降到(3.03±1.11)d.双侧手术患者住院时间由(8.00±2.62)d 下降到(7.17±1.61)d,术前住院时间由(3.84±2.19)d 下降到(3.33±1.48)d.路径组单侧手术患者较路径组药品费用由(4 965.8±1 796.7) 元下降到(3 716.6±1 668.1) 元;住院费用由(10 366.1±3 509.7) 元下降到(10 080.1±3 436.3) 元;双侧手术患者药品费用由(5 149.7±2 174.14) 元下降到(4 428.2±1 558.2) 元,住院费用由(11 533.7±4 006.1) 元下降到(11 283.5±2 716.9) 元.术后不良反应和并发症发生率也从14.94% 下降到6.41%.结论 实施临床路径可有效缩短患者住院日,减少患者住院费用,降低术后不良反应和并发症发生率,可在临床上推广应用.     

肝结节性再生性增生1例

肝结节性再生性增生(Noducar regenerative hyperplasia of liver,NRHL)是一种临床少见的肝脏疾病,临床主要表现为非肝硬化性肝源性门静脉高压症,因对其临床病理特征缺乏认识,易引起漏诊或误诊,我院收治1例,现报道如下。     

钙化在甲状腺结节CT鉴别诊断中的价值

目的:探讨CT图像中钙化与其他特征在鉴别甲状腺良恶性病变中的价值。方法:收集我院2007年1月～2009年12月间经病理证实并有完整CT检查资料、病灶内有钙化甲状腺结节的病例35例,将甲状腺内钙化按照大小分为细颗粒(≤2 mm)、粗颗粒(>2 mm)和混合性钙化(细颗粒与粗颗粒均出现);按照数量分为单发和多发钙化;按照钙化边缘情况分为光滑、毛糙。同时观察钙化甲状腺结节平扫密度及增强扫描后强化程度。结果:35例中,男7例,女28例,良性病变20例,恶性病变15例,良、恶性病变男女比例分别为1:19,6:9,良、恶性病变边缘光滑与毛糙比例为6:14,12:3,差异具有统计学意义。病灶内钙化位置及多少、钙化伴发结节密度及强化幅度在良恶性病变中差异无统计学意义。结论:甲状腺结节伴发钙化出现在男性,并且钙化边缘光滑时提示恶性病变。     

Surgical Management of Tracheal Compression Caused by Mediastinal Goiter: Is Extracorporeal Circulation Requisite?

Objective

To investigate the surgical and anesthetic management strategy of tracheal compression caused by mediastinal goiter.

Methods

We retrospectively analyzed a patient with an anterior mediastinal mass in whom cardiopulmonary bypass was kept on standby via femoral vessels before induction of anesthesia. Bronchoscope guided tracheal intubation was done and tumor was removed via a cervical approach. Relative literature was reviewed.

Results

CPB via femoral vessels before induction of anesthesia help the patient recover from the perioperative period safely. While bronchoscope slipped beyond the obstruction smoothly and spent less time. The apparently narrow trachea easily distended and did not impair passage of the tube into the trachea opposed to being predicted preoperatively. The histopathological diagnosis confirmed the tumor as a nodular goiter with the formation of hematoma.

Conclusions

CPB via femoral vessels before induction of anesthesia during surgical management of tracheal compression caused by mediastinal goiter is justified while bronchoscope guided tracheal intubation to establish the tracheal patency is a safe and feasible alternative.     

结节性甲状腺肿术后复发的临床分析

目的：分析结节性甲状腺肿术后复发的原因。方法：对84例结节性甲状腺肿术后患者进行2～10年的随访,使用B超、CT等检查手段,回顾性分析、研究相关病历资料。结果：84例结节性甲状腺肿患者术后1～10年中,共有26例复发,复发率为30.95%,复发患者经再次手术及辅助治疗后,除2例因局部癌变,最终死亡外,其余患者甲状腺功能均恢复正常,未出现结节性甲状腺肿的复发病例。结论：结节性甲状腺肿术后复发一直是临床中普遍存在的问题,预防结节性甲状腺肿术后复发只有严格把关治疗的各个环节,术前仔细定位,控制手术指征,术中操作力争做到精细,才能有效地杜绝结节性甲状腺肿术后复发。     

Is fine-needle aspiration (FNA) of multiple thyroid nodules justified?

Background: The clinical management of patients with solitary thyroid nodule is well established; however, the evaluation of patients with multiple thyroid nodules is controversial. The aim of this study was to assess if there is a correlation between the risk of malignancy and number of thyroid nodules. Design: The study cohort included 2884 patients (2410 females and 474 males) with 3274 thyroid nodules that underwent FNA under ultrasound guidance between November 1997 and April 2004. Multiple thyroid nodules were aspirated in 360 patients; 2 in 332 (291 females, 41 males), 3 nodules in 26 (23 females, 3 males), and 4 nodules in 2 patients (1 female, 1 male). Subsequent information regarding the histological diagnosis was obtained in the cases that underwent surgical excision. Results: The average age for patients with single or multiple nodules was the same (51 yr). The FNA specimens were diagnosed as benign (n=1663, 51%), neoplasm (n=880, 27%), suspicious for neoplasm or papillary carcinoma (n=234, 7%), malignant (n=187, 6%), and non-diagnostic (n=310, 9%). Surgical excision was performed in 1135 patients: 993 patients with single nodules and 142 patients with multiple nodules. The surgical pathology diagnosis was benign in 656 nodules (52%) and malignant in 596 nodules (48%). In the malignant category 153 tumors were papillary microcarcinoma (<1 cm). Excluding these cases, the malignancy rate was 39% in patients with single nodules, 41% with two nodules, and 21% with three nodules. Conclusions: The cancer risk is similar for patients with one or two nodules over 1 cm and decreases with three or more thyroid nodules.     

血清TSH浓度与结节性甲状腺肿癌变关系的临床研究

目的探讨血清TSH（thyroid-stimulating hormone,促甲状腺激素）浓度与结节性甲状腺肿癌变的关系。方法回顾性分析我院2003-2006年428例初诊结节性甲状腺肿患者临床资料和血清TSH浓度,以及手术切除标本病理切片情况,其中43例为结节性甲状腺肿局部癌变患者。结果结节性甲状腺肿局部癌变患者血清TSH浓度高于无癌变患者（P〈0.05）,结节性甲状腺肿癌变率与血清TSH浓度1组（rs=0.384,P〈0.05）、2组（rs=0.265,P〈0.05）、3组（rs=0.314,P〈0.05）均呈正相关,且结节性甲状腺肿癌变率随着血清TSH浓度升高而增加。结论血清TSH浓度的升高增加结节性甲状腺肿癌变的风险,手术前血清TSH浓度的评估有助提高对结节性甲状腺肿癌变的早期诊断。     

Monosomy and ring chromosome 13 in a thyroid nodular goiter-do we underestimate its relevance in benign thyroid lesions?

Classical cytogenetic examination of a thyroid nodular goiter revealed the existence of two different cytogenetically aberrant cell clones. They were characterized by monosomy 13 as the sole abnormality in one clone, and loss of one chromosome 13 and a ring chromosome that was found to consist of chromosome 13 material by fluorescence in situ hybridization in the other clone. We have concluded that during the course of karyotypic evolution, the instability of the ring chromosome has led to its loss and subsequent monosomy 13. In the literature, two cases of partial monosomy 13 have been reported in adenomatous goiters, suggesting that this abnormality characterizes a rare but distinct subgroup of benign thyroid lesions histologically presenting as adenomatous goiters. Possible target genes of these deletions are the retinoblastoma (RB1) gene locus and the MIR16-1/15A cluster. Based on similar changes in other tumors, it seems reasonable to also analyze a large number of adenomatous goiters for submicroscopic deletions of the long arm of chromosome?13.