甲状腺再次手术分析（附110例报告）

doi:10.16139/j.1007-9610.2019.01.017

摘要/Abstract

摘要： 目的: 回顾分析甲状腺癌再次手术的指征和方式,以及手术并发症的发生。方法: 收集2014年1月至2017年12月在我院外科同组医师完成的所有甲状腺再次手术,共110例。分析其再次手术原因、病理检查结果、手术时间间隔和术后并发症。结果: 110例甲状腺再次手术都是因为甲状腺癌复发、转移。两次手术中位间隔时间11.5（2~336）个月,其中<12个月54例（49.1%）。30例因甲状腺癌复发再次手术,双侧癌17例（56.7%),多灶癌10例（33.3%）。再次手术清扫中央区淋巴结50例中,诊断中央区淋巴结转移7例,术后病理检查阳性6例（85.7%）。诊断中央区和侧方淋巴结同时转移6例,术后病理检查阳性4例（66.7%）。其余37例为甲状腺手术规范清扫中央区淋巴结,术后病理检查阳性18例（48.6%）。诊断侧方淋巴结转移再次手术73例,术后病理检查阳性91.8%（67/73）。区域侧方淋巴结清扫27.4%（20/73）。分析再次手术后并发症,包括甲状腺切除、中央区淋巴结切除和侧方淋巴结清扫。再次手术甲状腺切除52例。单侧甲状腺切除48例中,35例甲状腺切除发生术后并发症8例（22.9%）,13例残留甲状腺切除发生术后并发症6例（46.2%）,4例双侧甲状腺切除均出现并发症。再次手术中行中央区淋巴结清扫的并发症发生率30.0%（15/50）,其中单侧再次手术的发生率为20.0%（2/10）,单侧为首次手术的并发症发生率为18.5%（5/27）,再次手术行双侧中央区淋巴结清扫术的并发症发生率61.5%（8/13）。再次手术行侧方淋巴结清扫73例,其中46例单侧清扫发生并发症15例（32.6%）,7例双侧清扫发生2例（28.6%）,20例区域淋巴结清扫发生3例（15.0%）。结论: 再次手术从心理和生理上都对病人造成了再次创伤,手术并发症发生增加。应规范首次手术的指征和范围,再次手术前明确诊断和定位,尽可能避免再次手术。

关键词: 甲状腺癌, 再次手术, 甲状腺多灶癌, 甲状腺癌复发

Abstract: Objective To analyze the surgical indication and type and postoperative complication of reoperation for thyroid carcinoma retrospectively. Methods A total of 110 cases with thyroid reoperations performed by same thyroid surgeon group in our hospital were studied between January 2014 and December 2017. The indication of reoperation and postoperative complication, pathological diagnosis and interval duration between two operations were analyzed. Results The indications of reoperation of all 110 cases were recurrent thyroid carcinoma. The median interval between two operations was 11.5 (2-336) months with 54 cases (49.1%) less than 12 months. Thirty cases with recurrent thyroid carcinoma, of which 17 cases (56.7%) were bilateral and 10 cases (33.3%) were multifocal, had reoperation. There were 50 cases with thyroid reoperation for central lymph node dissection including 7 cases diagnosed as central lymph nodes metastasis and 6 cases as both central and lateral lymph nodes metastasis, in which 6 cases (85.7%) and 4 cases (66.7%) were confirmed by postoperative pathology respectively. The other 37 cases had usual central lymph node dissection for recurrent thyroid carcinoma in which 18 cases (48.6%) were found lymph node metastasis by postoperative pathology. A total of 73 cases were diagnosed as lateral lymph node metastasis and had lateral lymph node dissection, in which 67 cases (91.8%) were confirmed by postoperative pathology. Twenty cases (27.4%) in 73 cases had supplemented lateral lymph node dissection for metastasis. Post-reoperation complication was analyzed including thyroidectomy, central lymph node dissection and lateral lymph node dissection. There were 52 cases with thyroidectomy during reoperation including 48 cases with unilateral resection and 4 cases with bilateral resection. Eight cases (22.9%) in 35 cases with thyroidectomy and 6 case (46.2%) in 13 cases with residual thyroid resection were found postoperative complications. Postoperative complication was present in all 4 cases with bilateral resection. Fifteen cases (30.0%) in 50 cases with central lymph node dissection had postoperative complication including 2 cases (20.0%) in 10 cases with unilateral re-dissection and 5 cases (18.5%) in 27 cases in unilateral dissection without previous lymph node dissection and 8 cases (61.5%) in 13 cases with bilateral central lymph node dissection. As to 73 cases with lateral lymph node dissection, postoperative complication was seen in 15 cases (32.6%) of 46 cases with unilateral lymph node dissection and 2 cases (28.6%) of 7 cases with bilateral lymph node dissection and 3 cases (15.0%) of 20 cases with supplemented lateral lymph node dissection. Conclusions Reoperation would be secondary injury to the patients with thyroid carcinoma both psychologically and physically and risk of postoperative complication increases. The first operation for thyroid carcinoma should be standardized. The diagnosis and localization of pre-reoperation could be clear and reoperation might be avoided as less as possible.

Key words: Thyroid carcinoma, Reoperation, Multifocal thyroid carcinoma, Thyroid carcinoma recurrence

中图分类号:

R736.1

沈晓卉, 丁家增, 陈海珍, 崔昂, 陈曦. 甲状腺再次手术分析（附110例报告）[J]. 外科理论与实践, 2019, 24(01): 79-84.

SHEN Xiaohui, DING Jiazeng, CHEN Haizhen, CUI Ang, CHEN Xi. Reoperative thyroid surgery: a report of 110 cases[J]. Journal of Surgery Concepts & Practice, 2019, 24(01): 79-84.

参考文献

[1] McGuire S. World cancer report 2014. Geneva, Switzerland: World Health Organization, international agency for research on cancer, WHO press, 2015[J]. Adv Nutr,2016, 7(2):418-419.
[2] Tedla M, Chakrabarti S, Suchankova M, et al.Voice outcomes after thyroidectomy without superior and recurrent laryngeal nerve injury: VoiSS questionnaire and GRBAS tool assessment[J]. Eur Arch Otorhinolaryngol,2016,273(12):4543-4547.
[3] Zhao C, Jiang W, Gao Y, et al.Risk factors for lymph node metastasis (LNM) in patients with papillary thyroid microcarcinoma (PTMC): role of preoperative ultrasound[J]. J Int Med Res,2017,45(3):1221-1230.
[4] Zheng W, Wang K, Wu J, et al.Multifocality is associated with central neck lymph node metastases in papillary thyroid microcarcinoma[J]. Cancer Manag Res,2018,10:1527-1533.
[5] Kim KJ, Kim SM, Lee YS, et al.Prognostic significance of tumor multifocality in papillary thyroid carcinoma and its relationship with primary tumor size: a retrospective study of 2,309 consecutive patients[J]. Ann Surg Oncol,2015,22(1):125-131.
[6] Kuo EJ, Thi WJ, Zheng F, et al.Individualizing surgery in papillary thyroid carcinoma based on a detailed sonographic assessment of extrathyroidal extension[J]. Thyroid,2017,27(12):1544-1549.
[7] Park JS, Son KR, Na DG, et al.Performance of preoperative sonographic staging of papillary thyroid carcinoma based on the sixth edition of the AJCC/UICC TNM classification system[J]. AJR Am J Roentgenol,2009,192(1):66-72.
[8] Roh JL, Kim JM, Park CI.Central lymph node metastasis of unilateral papillary thyroid carcinoma: patterns and factors predictive of nodal metastasis, morbidity, and recurrence[J]. Ann Surg Oncol,2011,18(8):2245-2250.
[9] Liang J, Li Z, Fang F, et al.Is prophylactic central neck dissection necessary for cN0 differentiated thyroid cancer patients at initial treatment? A meta-analysis of the literature[J]. Acta Otorhinolaryngol Ital,2017,37(1):1-8.
[10] Ma B, Wang Y, Yang S, et al.Predictive factors for central lymph node metastasis in patients with CN0 papillary thyroid carcinoma: a systematic review and Meta-analysis[J]. Surgery,2012,151(2):192-198.
[11] 陈诚, 陈海珍, 吕春晖, 等. 最大径≤5 mm甲状腺乳头状微小癌487例临床特点分析[J]. 中华外科杂志,2016, 54(11):870-874.
[12] Haugen BR, Alexander EK, Bible KC, et al.2015 Ame-rican Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: The Amercan Thyroid Association Guidelines Task Force on thyroid nodules and differentiated thyroid cancer[J]. Thyroid,2016,26(1):1-133.
[13] Musacchio MJ, Kim AW, Vijungco JD, et al.Greater local recurrence occurs with “berry-picking” than neck dissection in thyroid cancer[J]. Am Surg,2003,69(3):191-196.
[14] Stack BC Jr, Ferris RL, Goldenberg DM, et al.American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for late-ral neck dissection in differentiated thyroid cancer[J]. Thyroid,2012,22(5):501-508.
[15] Hartl DM, Al Ghuzlan A, Borget I, et al.Prophylactic level Ⅱ neck dissection guided by frozen section for clinically node-negative papillary thyroid carcinoma: is it useful?[J]. World J Surg,2014,38(3):667-672.
[16] Wang JB, Wu K, Shi LH, et al.In situ preservation of the inferior parathyroid gland during central neck dissection for papillary thyroid carcinoma[J]. Br J Surg,2017,104(11):1514-1522.
[17] Lee HS, Roh JL, Gong G,et al.Risk factors for re-recurrence after first reoperative surgery for locoregional recurrent/persistent papillary thyroid carcinoma[J]. World J Surg,2015,39(8):1943-1950.
[18] Madenci AL, Caragacianu D, Boeckmann JO, et al.La-teral neck dissection for well-differentiated thyroid carcinoma: A systematic review[J]. Laryngoscope,2014,124(7):1724-1734.