腔镜下甲状腺切除术颈部入路与颈外入路的系统比较

Systematic comparison of cervical and extra-cervical approaches for endoscopic thyroidectomy

目的评价腔镜下甲状腺切除术经颈部和颈外两种不同手术入路的治疗效果,为进一步规范腔镜下甲状腺切除术提供更合理、科学的治疗依据。方法制定原始文献的纳入标准、排除标准及完善的检索策略。文献检索国内外各数据库,收集其中有关腔镜下甲状腺切除术的随机对照试验(RCT)、临床对照试验(CCT)、临床试验等比较研究的文献,并手工检索相关全文文献,按照Cochrane协作网推荐的方法对现有资料进行系统分析。结果搜索得到相关文献共500余篇,最后纳入系统分析的文献共13篇。其中颈部组7篇,颈外组6篇,纳入的研究病例分别为503例和415例。文献提供的颈部入路和颈外入路的手术时间分别为(78.3±19.5)和(69.5±27.1)min(P>0.10),术中中转开放率分别为17/470和1/415(P<0.001)。颈部组术后低钙血症发生例数为14例,而颈外组未见低钙血症的病例(P<0.01),两组喉返神经损伤发生率、术后切口感染及术后出血发生率均较低,且差异无显著性。根据语言反应量表评定的术后美容效果颈部组3.84±0.29,而颈外组为3.4±0.6(P<0.01)。结论根据目前的资料分析,腔镜下甲状腺切除术颈部组的术后并发症发生率比颈外组稍高,且术中中转开放手术比例较高。手术时间和其他并发症如喉返神经损伤、术后出血等并没有显著差异。美容效果有待进一步评价。但是,由于缺乏主要比较颈部组和颈外组的随机对照试验,本文结论的可靠程度降低,所以需要更多更高质量的RCT文献来提升腔镜下甲状腺切除术临床应用的证据级别。

【Objective】 To evaluate clinical application of the different operative approaches of endoscopic thyroidectomy and provide a more rational and scientific treatment measures for endoscopic thyroidectomy.【Methods】 A consummate search strategy,and the inclusion criteria and exclusion criteria of the original literatures were set up.The related literatures in the domestic and foreign databases.Collect all the randomized controlled trials（RCT）,clinical controlled trials（CCT）,clinical trials were gathered and other comparative study of literatures about endoscopic thyroidectomy were carried out and systematically reviewed.【Results】 More than 500 literatures were searched,13 of which were selected for analysis.There was 7 literatures included in cervical group（Group A,n =503） and 6 literatures in extra-cervical group（Group B,n =415）.Mean operative times were（78.3±19.5） minutes for group A and（69.5±27.1） minutes for group B（P 0.10）.Conversion to open surgery happened in 17 patients in group A and only 1 in group B（P 0.001）.Postoperative hypocalcaemia occurred in 14 cases in group A but no cases in group B（P 0.01）.other complications such as recurrent laryngeal nerve injury,postoperative wound infection and postoperative bleeding had no significant differences between the two groups.The cosmetic results,evaluated by verbal response scales respectively as follows： group A（3.84±0.29） and group B（3.4±0.6）（P 0.01）.【Conclusion】 With the information analyzed until the present,the evidences of the different operative approaches of endoscopic thyroidectomy show that the incidence rates of hypocalcemia and conversion to open surgery are a little higher in cervical group.Operative time and other complications such as RLN injury,postoperative bleeding have no significant difference between two groups.Cosmetic results need to be further evaluated.But because of the absence of RCTs comparison between the cervical group and extra-cervical group,the reliability of the conclusions step down,the better RCTs are necessarily designed to update the information to improve clinical application of endoscopic thyroidectomy.