颈胸联合操作治疗胸骨后巨大甲状腺肿的体会  

Experience in treating giant substernal goiter through combined cervicothoracic approach

作　　者：贺梁[1] 王江[1] 王志文[1] 张永久[1] 

机构地区：[1]兰州军区乌鲁木齐总医院普外科,830000

出　　处：《临床外科杂志》2014年第8期556-558,共3页Journal of Clinical Surgery

摘　　要：目的：探讨胸骨后巨大甲状腺肿围手术期处理，手术方式选择及诊治要点。方法回顾分析2008年至2013年全部采用颈部低领式切口加胸骨劈开术式的11例患者资料，总结围手术期诊治要点。结果所有病例通过增强 CT、多面重建及三维重建等得到了完备的术前评估。所有病例肿瘤直径大于10 cm，胸骨后下坠位置超过主动脉弓平面，均出现气管压迫或移位；9例瓦米（Valsalva-Mueller，V-M）试验阳性；5例合并甲亢，术前准备超过1个月。术前评估均为高危。术中因肿瘤巨大及粘连而导致不同程度的操作困难。术后均送往外科 ICU 拔管并留观至少24 h。1例行气管切开；1例因创面渗血二次手术；气胸1例；所有病例出现不同程度暂时性喉返神经损伤；4例暂时性甲旁腺功能低下，永久性功能低下1例；未出现气管塌陷及呼吸困难。结论完善的术前影像检查尤其是 CT 扫描及三维重建对于巨大胸骨后甲状腺肿的诊治至关重要，对于肿瘤过大下坠位置超过主动脉弓平面者应果断选取颈部低领式切口加胸骨劈开术。开阔的术野更有利于操作，避免并发症。Objective To investigate the key points of perioperative management,surgery choices,diagnosis and treatment for giant substernal goiter.Methods A retrospective study on eleven pa-tients with giant substernal goiter who underwent sternotomy via low-collar incision was made for summari-zing the key points of diagnosis and treatment.Results All patients were completely evaluated with preop-erative enhanced CT scan,multiplanar reformation and three dimensional（3D）reconstruction.Tumor diam-eter in all cases was greater than 10 cm and the location was below the level of the aortic arch.All cases had tracheal compression or deviation,9 cases were positive in Valsalva-Mueller（V-M）test,and 5 cases were combined with hyperthyroidism.All cases were highly risky and experienced more than one month of preparation.The tumor size and tissue adhesion resulted in difficulties to a variable degree during the oper-ation.All cases were transferred to the surgical ICU for intubation and observed for at least 24 hours.One patient underwent tracheotomy during the operation,one patient received reoperation for hemorrhage and one patient suffered from pneumothorax.All patients showed variable degrees of temporary recurrent laryn-geal nerve injury.Four patients had temporary parathyroid gland hypofunction and 1 case had permanent hypofunction.No tracheal collapse and dyspnea occurred.Conclusion Complete preoperative imaging tests,especially CT scan and 3D reconstruction,are very important for the diagnosis and surgical treatment of giant substernal goiter.Sternotomy via low-collar incision should be decisively adopted when the tumor is too large and below the level of the aortic arch.Open surgical field contributes to the operation procedures and avoid complications.

关 键 词：胸骨后巨大甲状腺肿 外科治疗 低位领形切口 胸骨劈开术 并发症 

分 类 号：R653[医药卫生—外科学]