胸骨后甲状腺肿的手术径路

Surgical approach for intrathoracic goiter

目的探讨胸骨后甲状腺肿外科治疗和手术入路选择原则。方法回顾1990年初至2004年底期间手术治疗胸骨后甲状腺肿患者70例,男26例,女44例;年龄23—71岁,中位年龄55岁。甲状腺良性肿物60例,恶性肿瘤10例。根据甲状腺肿物延伸入胸骨后的胸部X线片、CT影像及临床征象,将胸骨后甲状腺肿分为Ⅰ型:颈部甲状腺肿一半以上进入胸骨后,下端极达主动脉弓上缘水平;Ⅱ型:甲状腺肿几乎全部进入胸骨后方,下极可达主动脉弓后方,或进入后纵隔;Ⅲ型:巨大的胸内甲状腺肿突入胸腔,或伴有上腔静脉压迫综合征体征。观察手术方法和手术入路、治疗效果的关系。结果Ⅰ、Ⅱ、Ⅲ型分别有41、24、5例。单独经颈部切口入路62例(Ⅰ型41例,Ⅱ型21例),颈胸联合入路切除8例(Ⅱ型3例,Ⅲ型5例)。胸内甲状腺的良性肿瘤与恶性肿瘤经颈部入路切除率分别为95％(57／60)及50％(5／10)。从颈部人路与颈胸联合入路并发症发生率分别8．1％和37．5％(P<0．01)。结论经颈部切口切除肿瘤的适应证包括所有Ⅰ型胸内甲状腺肿和Ⅱ型所有良性及部分分化型恶性胸内甲状腺肿,Ⅲ型均应是颈胸联合入路的手术指征。

Objective To explore the Surgical approach and management of intrathoracic goiter. Methods Seventy patients were operated on for thyromegaly extending to the thorax in an 15-year period at the department of Head and Neck surgery, Cancer Hospital, Chinese Academy of Medical Sciences. The median age of the 70 patients（44 women and 26 men） was 55 years, with a range of 23 to 71 years. Sixty cases were benign intrathoracic goiter and ten cases were malignancy. To help choice of operative approach, the intrathoracic goiter was divided into three types to based on chest film, computed tomography or magnetic resonance imaging and clinical symptom. Ⅰ type： the inferior extremity of goiter is on the aortic arch, Ⅱ type is the goiter to enter intrathoracic and portion located behind aortic arch, or the goiter enter posterior mediastinum. For Ⅲ type, intrathoracic goiter intrude thoracic cavity, or accompany superior vena caval syndrome. Operative method, surgical access and treatment effect were discussed in this essay. Results A cervical incision alone was performed in 62 cases （ Ⅰ type 41 cases, Ⅱ type 21 cases） ,and sternotomy in 8 （ Ⅱ type 3 cases, Ⅲ type 5 cases）. There was low morbidity and no deaths. Removal rate by cervical approach for intrathoracic benign and malignant goiter were 95% （ 57/60 ） and 50% （ 5/10 ） respectively. The Complication rate of cervical approach was significantly lower （8. 1% ） than that sternotomy approach （37. 5%, P 〈 0. 01 ）. Conclusions Most cases of intrathoracic goiter can be managed by cervical incision alone. Only a few cases, a median sternotomy approach may be needed when adhesions or an anomalous blood supply are present or carcinoma is suspected.