原发性甲状腺机能亢进症腔镜与开放手术的临床对比研究
摘要
目的：原发性甲状腺机能亢进症是一种常见内分泌疾病，多发于年轻女性病患，一般首选抗甲状腺药物治疗，但服用药物治疗仅对50％的患者有效；选择~(131)I放射治疗，创伤小，但适应症偏窄且易引起甲状腺功能低下；传统经颈部开放手术可使90～95％的患者获得治愈，但术后颈部会遗留疤痕，故多数患者要求在治愈疾病的同时兼顾美容，因此腔镜甲状腺美容手术应运而生。
实际上，腔镜手术和传统开放手术都是通过切除大部分腺体而达到治愈的目的，评估腺体也多是临床医师凭经验而定。由于腔镜手术缺乏术者对腺体的直接触摸及腔镜放大作用，切除腺体量较传统手术难以评估。我们分析比较两种不同术式各30例原发性甲亢患者的围手术期情况及短期随访，通过完善术前检查、术中测量、术后跟踪随访调查，探讨腔镜手术是否适用于原发性甲亢患者及术后相关并发症的发生情况。从对比术后并发症发生的角度，尽可能地探讨就原发性甲状腺机能亢进症而言，腔镜手术是否安全可靠。
方法：2005年4月至2006年12月在我院接受传统开放手术(OT)或腔镜手术(ET)的原发性甲状腺机能亢进症患者各30例，分析比较ET组与OT组的手术时间、术中出血量，术后疼痛评分、声嘶、呛咳等情况及术后4个月动态检查甲状腺激素水平。统计分析，计量资料数据以均数±标准差((?)±S)，采用两样本均数比较的t检验；其中，术后4个月甲状腺激素的动态检测，采用重复测量设计的方差分析。计数资料以频数n表示，采用χ~2检验。
结果：ET组和OT组在术中出血量(t=2.55，P=0.016＜0.05)，术后住院时间(t=5.08，P=0.000＜0.01)，切口美容满意度(t=-9.80，P=0.000＜0.05)，术后FT_4检测水平(F=6.22，P=0.015＜0.05)，切口引流量(t=-16.85，P=0.000＜0.01)及引流天数(t=-26.72，P=0.000＜0.01)方面有统计学意义；在手术时间(P=0.649)，术后疼痛(P=0.288)，呼吸困难，声嘶、呛咳等神经损伤(P=0.554)，手足麻木情况(P=0.301)，甲亢危象，复发，甲低(P=0.754)，术后甲状腺激素FT_3(P=0.553)、TSH(P=0.900)方面均无统计学意义。
结论：ET组较OT组术中出血量少，术后住院时间短，切口美容满意度高；ET组术后引流量多、引流天数长，且术后甲状腺激素FT_4水平较OT组低。经术后并发症对比及短期随访观察，腔镜手术对原发性甲亢患者为安全有效的手术方式，但其安全性的正确评价，需要中长期随访和更多的临床病例。
Objective: Primary hyperthyroidism is a common endocrine disease, most of patients are young female. It has three treatments, the first is antithyroid drug, cure rate of which is approximately50%; the second is ~(131)I which shows micro-invasive, but the indication is narrow and it can revoke hypothyroidism; open subtotal thyroidectomy cures 90%～95% patients, except for scar in neck. Some patients need a new treatment which not only cures disease but also conceals scar, endoscopic subtotal thyroidectomy gives into birth. In fact, endoscopic thyroidectomy and open thyroidectomy gain the effect through removing most glandular organ, surgeon evaluate glandular organ by touching. Because endoscopic thyroidectomy lacks of tactus, it is hard to evaluate glandular organ well. Through perfecting preoperative examination、measurement of operation and follow-up investigation, the topic is to compare the operative hemorrhage、complication after operation、satisfaction of incision of 60 patients who were done open thyroidectomy or endoscopic thyroidectomy. From a new direction, to discuss the safety of endoscopic thyroidectomy.
Methods: 60 patients were treated with open subtotal thyroidectomy (OT) or endoscopic thyroidectomy (ET) from April 2005 to December 2006, analyzing operation time、operative hemorrhage、soreness、nerve injury and the thyroid hormones of postoperation in 4 months etc. measurement data displayed by mean±standard deviation ((?)±S), used independent-samples T test; thyroid hormones of postopertion in 4months used repeated measure design. Enumeration count data displayed by frequency, used Chisquare test.
Result: In the group ET and OT, the statistics was significant difference in operative hemorrhage (t=2.55, P=0.016＜0.05), length of stay of postoperation (t=5.08, P=0.000＜0.01), the satisfaction of incision (t=-9.80, P=0.000＜0.05), FT_4 of postoperation in 4months (F=6.22, P=0.015＜0.05), the amount of drainage (t=-16.85, P=0.000＜0.01)and days of drainage(t=-26.72, P=0.000＜0.01); the statistics was similar in operation time(P=0.649), soreness(P=0.288 ), nerve injury(P=0.554), deadlimb (P=0.301 ), FT_3 and TSH of postoperation in 4months (P=0.553, P=0.900) etc.
Conclusion: In the group ET, operative hemorrhage was few, length of stay of postoperation was short, the satisfaction of incision was high. In the group OT, the amount of drainage was few, the days of drainage was short, FT_4 of postoperation in 4months were low. Through comparing with postoperative complication and short-term follow-up, ET is a effect treatment, but we need long-term follow-up and more cases for safety appreciation.
实际上，腔镜手术和传统开放手术都是通过切除大部分腺体而达到治愈的目的，评估腺体也多是临床医师凭经验而定。由于腔镜手术缺乏术者对腺体的直接触摸及腔镜放大作用，切除腺体量较传统手术难以评估。我们分析比较两种不同术式各30例原发性甲亢患者的围手术期情况及短期随访，通过完善术前检查、术中测量、术后跟踪随访调查，探讨腔镜手术是否适用于原发性甲亢患者及术后相关并发症的发生情况。从对比术后并发症发生的角度，尽可能地探讨就原发性甲状腺机能亢进症而言，腔镜手术是否安全可靠。
方法：2005年4月至2006年12月在我院接受传统开放手术(OT)或腔镜手术(ET)的原发性甲状腺机能亢进症患者各30例，分析比较ET组与OT组的手术时间、术中出血量，术后疼痛评分、声嘶、呛咳等情况及术后4个月动态检查甲状腺激素水平。统计分析，计量资料数据以均数±标准差((?)±S)，采用两样本均数比较的t检验；其中，术后4个月甲状腺激素的动态检测，采用重复测量设计的方差分析。计数资料以频数n表示，采用χ~2检验。
结果：ET组和OT组在术中出血量(t=2.55，P=0.016＜0.05)，术后住院时间(t=5.08，P=0.000＜0.01)，切口美容满意度(t=-9.80，P=0.000＜0.05)，术后FT_4检测水平(F=6.22，P=0.015＜0.05)，切口引流量(t=-16.85，P=0.000＜0.01)及引流天数(t=-26.72，P=0.000＜0.01)方面有统计学意义；在手术时间(P=0.649)，术后疼痛(P=0.288)，呼吸困难，声嘶、呛咳等神经损伤(P=0.554)，手足麻木情况(P=0.301)，甲亢危象，复发，甲低(P=0.754)，术后甲状腺激素FT_3(P=0.553)、TSH(P=0.900)方面均无统计学意义。
结论：ET组较OT组术中出血量少，术后住院时间短，切口美容满意度高；ET组术后引流量多、引流天数长，且术后甲状腺激素FT_4水平较OT组低。经术后并发症对比及短期随访观察，腔镜手术对原发性甲亢患者为安全有效的手术方式，但其安全性的正确评价，需要中长期随访和更多的临床病例。
Objective: Primary hyperthyroidism is a common endocrine disease, most of patients are young female. It has three treatments, the first is antithyroid drug, cure rate of which is approximately50%; the second is ~(131)I which shows micro-invasive, but the indication is narrow and it can revoke hypothyroidism; open subtotal thyroidectomy cures 90%～95% patients, except for scar in neck. Some patients need a new treatment which not only cures disease but also conceals scar, endoscopic subtotal thyroidectomy gives into birth. In fact, endoscopic thyroidectomy and open thyroidectomy gain the effect through removing most glandular organ, surgeon evaluate glandular organ by touching. Because endoscopic thyroidectomy lacks of tactus, it is hard to evaluate glandular organ well. Through perfecting preoperative examination、measurement of operation and follow-up investigation, the topic is to compare the operative hemorrhage、complication after operation、satisfaction of incision of 60 patients who were done open thyroidectomy or endoscopic thyroidectomy. From a new direction, to discuss the safety of endoscopic thyroidectomy.
Methods: 60 patients were treated with open subtotal thyroidectomy (OT) or endoscopic thyroidectomy (ET) from April 2005 to December 2006, analyzing operation time、operative hemorrhage、soreness、nerve injury and the thyroid hormones of postoperation in 4 months etc. measurement data displayed by mean±standard deviation ((?)±S), used independent-samples T test; thyroid hormones of postopertion in 4months used repeated measure design. Enumeration count data displayed by frequency, used Chisquare test.
Result: In the group ET and OT, the statistics was significant difference in operative hemorrhage (t=2.55, P=0.016＜0.05), length of stay of postoperation (t=5.08, P=0.000＜0.01), the satisfaction of incision (t=-9.80, P=0.000＜0.05), FT_4 of postoperation in 4months (F=6.22, P=0.015＜0.05), the amount of drainage (t=-16.85, P=0.000＜0.01)and days of drainage(t=-26.72, P=0.000＜0.01); the statistics was similar in operation time(P=0.649), soreness(P=0.288 ), nerve injury(P=0.554), deadlimb (P=0.301 ), FT_3 and TSH of postoperation in 4months (P=0.553, P=0.900) etc.
Conclusion: In the group ET, operative hemorrhage was few, length of stay of postoperation was short, the satisfaction of incision was high. In the group OT, the amount of drainage was few, the days of drainage was short, FT_4 of postoperation in 4months were low. Through comparing with postoperative complication and short-term follow-up, ET is a effect treatment, but we need long-term follow-up and more cases for safety appreciation.
引文
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2．吴在德，主编，外科学，北京，人民卫生出版社，2001：336
3．朱玲锦、管昌田，编著，甲状腺功能亢进症，北京，中医古籍出版社，2003：156-183
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5．中华人民共和国卫生部医政司主编，核医学诊断与治疗规范，北京，科学出版社，1997：286
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11. Yeh TS, Jan YY, Hsu BR. Video—assisted endoscopic thyroidectomy. Am J Surg, 2000, 180 (2): 82—85
12. Mccoli P, Berti P, Raffaelli M. Minimally invasive video—assisted thyroidectomy. Am J Surg, 2001, 181 (6): 567—570
13. Bellantone R, Lombardi CP, Raffaelli M, et al. Video—assisted thyroidectomy. J Am Coll Surg, 2002, 194 (5): 610—614
14. Yamamoto M, Sasaki A, Asahi H. Endoscopic subtotal thyroidectomy for patients with Grave's disease. Surg Today, 2001, 31 (1): 1—4
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2．吴在德，主编，外科学，北京，人民卫生出版社，2001：336
3．朱玲锦、管昌田，编著，甲状腺功能亢进症，北京，中医古籍出版社，2003：156-183
4. Hamilton JG, Lawrence JH. Recent clinical developments in the therapeutic application of radiophosphorus and radioiodine. J Clin Invest, 1942, 21: 624
5．中华人民共和国卫生部医政司主编，核医学诊断与治疗规范，北京，科学出版社，1997：286
6. Ron E, Doody MM, Becker SV, et al. Cancer mortality following treatment for abult hyperthyroidism[J]. JAMA, 1998, 280: 347-355
7．吴阶平、裘法祖，主编，黄家驷外科学(第六版)，北京，人民卫生出版社，1999：815
8．王树峰，刘津，黎国屏，王树良．甲状腺手术与颈部美容．河北医药，1997，19(5)：306
9. Huscher CSG, Chiodini S, Napolitano C, et al. Endoscopic right thyroid lobectomy[J]. Surg Endosc, 1997, 11 (8): 877
10. Miccoli P, Berti P, Raffaelli M, et al. Minimally invasive video—assisted thyroidectomy. Am J Surg, 2001, 181 (6): 567—570
11. Yeh TS, Jan YY, Hsu BR. Video—assisted endoscopic thyroidectomy. Am J Surg, 2000, 180 (2): 82—85
12. Mccoli P, Berti P, Raffaelli M. Minimally invasive video—assisted thyroidectomy. Am J Surg, 2001, 181 (6): 567—570
13. Bellantone R, Lombardi CP, Raffaelli M, et al. Video—assisted thyroidectomy. J Am Coll Surg, 2002, 194 (5): 610—614
14. Yamamoto M, Sasaki A, Asahi H. Endoscopic subtotal thyroidectomy for patients with Grave's disease. Surg Today, 2001, 31 (1): 1—4
15．王存川，段立纪，陈鋆等．腔镜下甲状腺部分切除术．中国内镜杂志，2002．8(7)：19-21
16. Yamashita H, Watanabe S, Koike E, et al. Video-assisted thyroid lobectomy through a samall wound in the submandibular area [J]. Am J Surg, 2002, 183 (3): 286-289
17．Gagner M，Inabnet W，朱江帆．内镜甲状腺切除术16例分析[J]．中华普通外科杂志，2001，16(9)：530-531
18. Bellantone R, Lombardi CP, Raffaelli M, et al. Minimally invasive, totally gasless video-assisted thyroid lobectomy[J]. Am J Surg, 1999, 177 (4): 342-343
19. Shimizu K, Akira S, asmi AY, et al. Video-assisted neck surgery: endoscopic resection of thyroid tumors with a very minimal neck wound[J]. J Am Coll Surg, 1999, 188 (6): 697-703
20. Ishii S, Ohgami M, Arisawa Y, et al. Endoscopic thyroidectomy with anterior chest wall approach[J]. Surg Endosc, 1998, 12 (6): 611-613
21. Ikeda Y, Takami H, Niimi M, et al. Endoscopic thyroidectomy and parathyroidectomy by the axillary approach: a preliminary report[J]. Surg Endosc, 2002, 16 (1): 92-95
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