筋膜保留喉返神经解剖法右Ⅵ区淋巴结清扫对神经保护作用的初步分析

Preliminary analysis of neuroprotective effects of capillary fascia preservation recurrent laryngeal nerve anatomical method in right level Ⅵ dissection

目的探讨甲状腺乳头状癌右Ⅵ区淋巴结清扫时保留右喉返神经与颈总动脉之间筋膜毛细血管层(简称筋膜保留法)的可行性与神经保护效果。方法回顾性队列研究。纳入2021年3月至2022年8月北京同仁医院耳鼻咽喉头颈外科甲状腺乳头状癌手术行右Ⅵ区淋巴结清扫的195例患者临床资料,其中研究组按筋膜保留法解剖喉返神经,对照组采用常规方法,统计术中喉返神经监测电位数值及术后淋巴结数量,并观察并发症发生情况。结果共纳入甲状腺乳头状癌患者195例,研究组94例,对照组101例;其中男71例,女124例,年龄M(Q 1,Q 3)32(39,51)岁。研究组右Ⅵ区清扫总淋巴结数多于单纯右Ⅵa区清扫[8(6,11)比6(4,8)个,P<0.001]。研究组和对照组Ⅵa区淋巴结数[6(4,8)比5(3,7)个,P=0.373]及转移率[51.1%(48/94)比52.5%(53/101),P=0.844]、Ⅵb区淋巴结数[3(1,4)比2(1,4)个,P=0.337]及转移率[12.8%(12/94)比15.8%(16/101),P=0.541]差异均无统计学意义。研究组Ⅵ区下界R2/入喉点R2肌电信号振幅比值高于对照组(P<0.001)。研究组和对照组喉返神经暂时性麻痹率分别为1.1%(1/94)和2.0%(2/101),差异无统计学意义(P=1.000)。结论筋膜保留法既能保证淋巴结清扫的彻底性,又可减少喉返神经的物理及电刺激,从而明显减少喉返神经刺激损伤的风险。

Objective To investigate the application and effect of capillary fascia preservation between the recurrent laryngeal nerve(RLN)and common carotid artery(fascia preservation method)in nerve protection when dissecting right levelⅥlymph nodes for patients with papillary thyroid carcinoma.Methods A retrospective cohort study enrolling 195 patients with papillary thyroid carcinoma undergoing right levelⅥlymph node dissection in Beijing Tongren Hospital from March 2021 to August 2022 was carried out.The RLN was dissected by fascia preservation method in study group and by routine method in control group.The intraoperative electrical signal amplitude of the RLN,the number of dissected lymph nodes,and the postoperative complications were recorded and analyzed.Results A total of 195 patients(study group:94 cases,control group:101 cases)were collected.There were 71 males and 124 females,with the median age of 32(39,51)years.In the study group,the total number of right levelⅥlymph nodes was significantly larger than the number of rightⅥa level lymph nodes[8(6,11)vs 6(4,8),P<0.001].There were no significant differences between the two groups in the number of levelⅥa or levelⅥb lymph nodes[Ⅵa:6(4,8)vs 5(3,7),P=0.373;Ⅵb:3(1,4)vs 2(1,4),P=0.337]and metastasis rate[Ⅵa:51.1%(48/94)vs 52.5%(53/101),P=0.844;Ⅵb:12.8%(12/94)vs 15.8%(16/101),P=0.541].The ratio of electromyography(EMG)amplitude R2 in lower levelⅥand entry into larynx(grouped as>90%,50%~90%,<50%)in the study group was significantly higher than that in the control group(P<0.001).No significant differences were detected between the two groups in temporary RLN paralysis[1.1%(1/94)vs 2.0%(2/101),P=1.000].Conclusions Fascia preservation method can decrease the stimulus and traction to RLN and preserve the capillary network serving RLN.It can thoroughly dissect lymph nodes and decrease the injury of RLN.