巨大甲状腺肿合并胸骨后病变或气管软化的外科处理

目的:探讨巨大甲状腺肿合并胸骨后病变或气管软化的外科处理,以及开胸和气管悬吊的手术适应症。方法:回顾性分析1992年-2010年本院收治的66例巨大甲状腺肿患者的临床资料。其中24例为胸骨后甲状腺肿,42例合并气管软化,所有病例均在术前行米瓦试验摄片,以及颈部-上胸部CT。结果:胸骨后甲状腺肿常规做好开胸准备,24例中23例经颈部切口切除,1例术中冰冻证实为淋巴瘤仅行姑息性大部切除后续化疗;42例米瓦试验阳性患者,术中探查见局部受压处气管软骨环消失6例,气管软骨环变细、变薄、变软36例。36例甲状腺切除术后行单一气管悬吊患者获得临床治愈,6例气管悬吊加气管切开患者抢救成功,无手术死亡。52例获随访,随访时间3个月至18年,48例均无呼吸道梗阻症状,2例死于癌症复发转移,2例死于其他疾病。结论:绝大多数的胸骨后甲状腺肿可经颈部切口切除。术中探查有助于气管软化的确诊,气管悬吊是治疗巨大甲状腺肿合并气管软化的有效方法。

Surgical management of large goiter complicated by retrosternal lesion or tracheomalacia

Objective:To explore the surgical management of large goiter with retrosternal lesion or tracheomalacia,with an emphasis on the indications for sternotomy and tracheal suspension.Methods:Clinical data of 66 large goiters between 1992 and 2010 in Xijing Hospital were retrospectively analyzed.Among them,24 cases were retrosternal goiters,and 42 cases were complicated by tracheomalacia.Preoperative radiographic examinations,including Valsalva-Mueller(V-M) test and cervico-superthoracic CT were performed in all patients.Results:Sternotomy was routinely prepared for retrosternal goiters.Twenty-three of 24 retrosternal goiters were removed via cervical approach,while one patient was identified as lymphoma by frozen section analysis and received palliative resection plus subsequent chemotherapy.Among 42 patients with positive V-M test,the tracheal cartilage disappeared in 6 cases,and softened in other 36 cases.Thirty-six patients who underwent thyroidectomy and tracheal suspension recovered and six cases were rescued by tracheal suspension plus tracheostomy.No mortality was recorded.Forty-eight of 52 cases followed up from six months to eighteen years had no respiratory obstruction,and four cases died of distant metastases.Conclusion:Almost all retrosternal goiters could be removed via cervical approach.Surgical exploration was the key procedure to make a definite diagnosis of tracheomalacia.Tracheal suspension was the effective treatment for large goiters with tracheomalacia.