Graves病的手术前评估与准备（附126例报告）

doi:10.16139/j.1007-9610.2021.06.012

摘要/Abstract

摘要：

目的：回顾本院Graves病的外科治疗病例，总结术前评估与准备的临床经验。方法：分析2015年1月至2021年5月Graves病126例。收集病例的基础情况、术前准备情况、手术方式、术后病理检查结果和并发症发生资料。结果：病人男27例，女99例，平均年龄（42.4±14.3）岁。手术指征包括Graves病伴恶性肿瘤、气道受压狭窄、胸骨后甲状腺肿、药物治疗不耐受、甲状旁腺功能亢进等。恶性肿瘤中甲状腺乳头状癌75例，其中47例为乳头状微小癌;另2例滤泡状癌。术后近期并发症发生有声音嘶哑11例，其中1例为永久性;术后低血钙35例，其中1例为永久性。结论：Graves病的术前准备要求个体化、精细化。建议评估碘剂准备、气道和神经监测、甲状旁腺功能、喉返神经变异以及恶性结节。

关键词: Graves病, 甲状腺切除, 术前准备, 术后并发症

Abstract: Objective To analyze retrospectively preoperative evaluation and preparation in Graves′ disease patients with surgical treatment. Methods A total of 126 cases of Graves′ disease in our department from January 2015 to May 2021 were reviewed. Patient information including preoperative preparation, operative mode, postoperative pathological results and complications were collected. Results There were 27 males and 99 females with an average age of(42.4±14.3) years. Surgical indications were Graves′ disease with malignant tumour, airway compression and stenosis, retrosternal goiter, drug intolerance or hyperparathyroidism. There were 75 cases with thyroid papillary carcinoma including 47 cases with papillary microcarcinoma， and 2 cases with follicular carcinoma. Short-term postoperative complications were 11 cases with hoarseness among which 1 case was permanent, and 35 cases with hypocalcemia among which 1 case was permanent. Conclusions It is indicated that preoperative preparation for Graves′ disease requires individualization and refinement, which include iodine preparation, examination of airway condition and neural monitoring, the evaluation of parathyroid function, recurrent laryngeal nerve variation and malignant nodules.

Key words: Graves′ disease, Thyroidectomy, Preoperative preparation, Complication

中图分类号:

R736.1

孙寒星, 沈晓卉, 高浩基, 刘卓然, 陈曦, 邱伟华, 严佶祺. Graves病的手术前评估与准备（附126例报告）[J]. 外科理论与实践, 2021, 26(06): 517-521.

SUN Hanxing, SHEN Xiaohui, GAO Haoji, LIU Zhuoran, CHEN Xi, QIU Weihua, YAN Jiqi. Preoperative evaluation and preparation of Graves′ disease: a report of 126 cases[J]. Journal of Surgery Concepts & Practice, 2021, 26(06): 517-521.

图/表 4

表1

图1

图2

表2

参考文献 20

[1]	Davies TF, Andersen S, Latif R, et al. Graves′ disease[J]. Nat Rev Dis Primers, 2020, 6(1):52.
[2]	中国医师协会外科医师分会甲状腺外科医师委员会, 中国研究型医院学会甲状腺疾病专业委员会, 中国医疗保健国际交流促进会临床实用技术分会. 甲状腺功能亢进症外科治疗中国专家共识(2020版)[J]. 中国实用外科杂志, 2020, 40(11):1229-1233.
[3]	Rubio GA, Koru-Sengul T, Vaghaiwalla TM, et al. Postoperative outcomes in Graves′ disease patients: results from the nationwide inpatient sample database[J]. Thyroid, 2017, 27(6):825-831.
[4]	Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis[J]. Thyroid, 2016, 26(10):1343-1421.
[5]	Randle RW, Bates MF, Long KL, et al. Impact of potas-sium iodide on thyroidectomy for Graves′ disease: implications for safety and operative difficulty[J]. Surgery, 2018, 163(1):68-72.
[6]	Lindner K, Kuβmann J, Fendrich V. Preoperative potassium iodide treatment in patients undergoing thyroidectomy for Graves′ disease-perspective of a European high-volume center[J]. World J Surg, 2020, 44(10):3405-3409.
[7]	中国医师协会外科医师分会甲状腺外科医师委员会. 甲状腺及甲状旁腺手术中神经电生理监测临床指南(中国版)[J]. 中国实用外科杂志, 2013, 33(6):470-474.
[8]	邵堂雷, 杨卫平, 王海, 等. 甲状腺外科手术中喉不返神经的解剖研究[J]. 中华普通外科杂志, 2009, 24(12):963-965.
[9]	Iacobone M, Citton M, Pagura G, et al. Increased and safer detection of nonrecurrent inferior laryngeal nerve after preoperative ultrasonography[J]. Laryngoscope, 2015, 125(7):1743-1747.
[10]	Watanabe A, Taniguchi M, Kimura Y, et al. Efficient, effective, safe procedure to identify nonrecurrent inferior laryngeal nerve during thyroid surgery[J]. Head Neck, 2016, 38(4):573-577.
[11]	孙辉, 刘晓莉, 赵涛, 等. 术中神经监测识别非返性喉返神经6例经验[J]. 中华内分泌外科杂志, 2010, 4(6):402-404.
[12]	Kazaure HS, Zambeli-Ljepovic A, Oyekunle T, et al. Severe hypocalcemia after thyroidectomy: an analysis of 7366 patients[J]. Ann Surg,2019-12-05[online ahead of print].
[13]	Giovanella L, Suriano S, Ceriani L. Graves′ disease, thymus enlargement, and hypercalcemia[J]. N Engl J Med, 2008, 358(10):1078-1079.
[14]	Wei S, Baloch ZW, LiVolsi VA. Parathyroid adenoma in patients with Graves′ disease: a report of 21 cases[J]. Endocr Pathol, 2015, 26(1):71-74.
[15]	Staniforth JUL, Erdirimanne S, Eslick GD. Thyroid carcinoma in Graves′ disease: a meta-analysis[J]. Int J Surg, 2016, 27:118-125.
[16]	Wei S, Baloch ZW, LiVolsi VA. Thyroid carcinoma in patients with Graves′ disease: an institutional experience[J]. Endocr Pathol, 2015, 26(1):48-53.
[17]	Mekraksakit P, Rattanawong P, Karnchanasorn R, et al. Prognosis of differentiated thyroid carcinoma in patients with Graves disease: a systematic review and meta-analysis[J]. Endocr Pract, 2019, 25(12):1323-1337.
[18]	Song Y, Fu L, Wang P, et al. Effect of Graves′disease on the prognosis of differentiated thyroid carcinoma: a meta-analysis[J]. Endocrine, 2020, 67(3):516-525.
[19]	黄海燕, 匡洁, 应夏洋, 等. Graves病合并甲状腺癌(附47例报告)[J]. 外科理论与实践, 2018, 23(6):519-522.
[20]	Kwon H, Moon BI. Prognosis of papillary thyroid cancer in patients with Graves′ disease: a propensity score-matched analysis[J]. World J Surg Oncol, 2020, 18(1):266.

基本情况	病例数
男/女	27/99
年龄（岁）	42.4±14.3
手术指征
恶性肿瘤	77
气道受压狭窄	23
胸骨后甲状腺肿	9
药物治疗不耐受	7
合并甲状旁腺功能亢进	1
其他	9
术前特殊准备
口服碘剂准备	42
术中神经监测	28
手术方式
甲状腺全切除	21
甲状腺近全切除	12
甲状腺全切除+中央组淋巴结清扫	74
甲状腺次全切除+中央组淋巴结清扫	11
甲状腺全切除+（中央组+颈侧区）淋巴结清扫	8
恶性肿瘤术后病理诊断
乳头状癌（直径<1 cm/≥1 cm）	47/28
滤泡状癌	2
中央区淋巴结转移	28
颈侧区淋巴结转移	8

术后并发症	病例数（%）（n=126）	恶性肿瘤组（%）（n=77）	非恶性肿瘤组（%）（n=49）	P值
术后声音嘶哑	11（8.7）	8（10.4）	3（6.1）	0.408
暂时	10（7.9）	8（10.4）	2（4.1）
永久	1（0.8）	0	1（2.0）
术后低血钙	35（27.8）	23（29.9）	12（24.5）	0.511
暂时	34（27.0）	22（28.6）	12（24.5）
永久	1（0.8）	1（1.3）	0
术后出血（二次手术）	1（0.8）	1（1.3）	0
术区积液	8（6.3）	4（5.2）	4（8.2）	0.505^a)