改良Miccoli术式与新型开放术式治疗Graves病的比较

Comparison Between Improved Miccoli Procedure and Novel Open Surgery for Graves' Disease

目的比较改良Miccoli术式与新型开放术式行双侧甲状腺次全切除术治疗Graves病的优缺点。方法2012年10月~2014年10月我院甲状腺外科收治Graves病151例,按患者意愿行改良Miccoli手术（n=82,A组）或新型开放手术（n=69,B组）。改良Miccoli术式行颈部低衣领3 cm小切口,使用腔镜及超声刀完成;新型开放术式行常规甲状腺手术切口,使用常规手术器械及超声刀完成。比较2组切口长度、出血量、手术时间、并发症、术后疼痛视觉模拟评分（VAS）、术后住院时间、住院费用、治疗效果、病人对切口满意度调查评分。结果 151例Graves病均顺利完成双侧甲状腺次全切除术。与B组相比,A组切口短[（3.08±0.10）cm vs.（8.05±0.84）cm,t=-52.826,P=0.000],出血少[（42.3±10.1）ml vs.（82.0±15.9）ml,t=-18.627,P=0.000],2组手术时间差异无显著性[（84.4±6.7）min vs.（83.0±8.9）min,t=1.128,P=0.261]。A组术后24 h VAS疼痛评分低[（1.8±0.6）分vs.（2.7±0.6）分,t=-8.401,P=0.000],术后住院时间短[（3.9±1.0）d vs.（4.8±0.7）d,t=-6.627,P=0.000],但住院费用高[（8894.8±269.2）元vs.（7278.9±150.0）元,t=44.371,P=0.000]。2组均无甲状腺危象、永久性声嘶及肢体抽搐等严重并发症。A组并发症发生率（0/82）明显低于B组[5.8%（4/69）]（P=0.042）。随访3~6个月,2组各有1例轻症复发（χ2=0.000,P=1.000）,甲状腺功能减退A组11例,B组8例（χ2=0.113,P=0.737）。切口美观满意度调查评分A组（8.1±0.8）高于B组（6.7±1.3）（t=8.188,P=0.000）。结论改良Miccoli术式与新型开放术式行双侧甲状腺次全切除治疗Graves病的手术时间、治疗效果无明显差异,均能达到治疗目的。同样使用超声刀的情况下,改良Miccoli术式安全性、微创性及切口美观效果优于新型开放术式。新型开放术式不使用腔镜,节省了手术费用。

Objective To compare advantages and disadvantages between improved Miccoli procedure and novel open surgery of thyroid bilateral subtotal resection for Graves＇ disease. Methods A total of 151 patients with Graves＇ disease were admitted in our hospital between October 2012 and October 2014. According to patients ＇willingness,they were given either improved Miccoli procedure（ A group,n = 82） or novel open surgical procedure（ B group,n = 69）. The improved Miccoli procedure was carried out through a low neck collar 3-cm small incision,by using of endoscopic and ultrasonic knife. The novel open surgery was performed via a conventional thyroid surgery incision,by using of conventional surgical instruments and ultrasonic knife. Comparative analyses on incision length,blood loss,operative time,complications,postoperative pain,hospitalization time,cost of hospitalization,treatment outcomes,and patient satisfaction with the surgical incision were made between the two groups. Results The surgery was successfully operated in all the 151 cases. As compared to the B group,the A group had shorter incision length [（ 3. 08 ± 0. 10） cm vs.（ 8. 05 ± 0. 84） cm,t =- 52. 826,P = 0. 000] and less blood loss [（ 42. 3 ± 10. 1） ml vs.（ 82. 0 ± 15. 9） ml,t =- 18. 627,P = 0. 000]. No significant difference was seen in operative time between the A group and the B group [（ 84. 4 ± 6. 7） min vs.（ 83. 0 ± 8. 9） min,t = 1. 128,P = 0. 261]. Pathological findings showed Graves＇ disease in all the cases. The VAS pain score of the A group was lower than the B group [（ 1. 8 ± 0. 6） points vs.（ 2. 7 ± 0. 6） points,t =- 8. 401,P = 0. 000]. The hospitalization time after operation in the A group was significantly less than the B group [（ 3. 9 ± 1. 0） d vs.（ 4. 8 ± 0. 7） d,t =- 6. 627,P = 0. 000].The cost of hospitalization in the A group was higher than that in the B group [（ 8894. 8 ± 269. 2） yuan vs.（ 7278. 9 ± 150. 0） yuan,t = 44. 371,P = 0. 000]. There were no serious complications such as thyroid crisis,permanent hoarseness,or limbs twitching. The complication rate in the A group was significantly lower than that in the B group [0（ 0 /82） vs. 5. 8%（ 4 /69）,P = 0. 042]. All the patients were followed up for 3- 6 months. Each group had one case of relapse of mild symptoms（ χ2= 0. 000,P = 1. 000）. There were 11 cases of hypothyroidism symptoms in the A group,and 8 cases in the B group（ χ2= 0. 113,P = 0. 737）. The patients＇ satisfaction with surgical incision score in the A group was higher than that in the B group [（ 8. 1 ± 0. 9） points vs.（ 6. 7 ± 1. 3）points,t = 8. 188,P = 0. 000]. Conclusion Both improved Miccoli procedure and novel open surgery are suitable for thyroid bilateral subtotal resection to treat Graves＇ disease. There is no significant difference between the two types in operative time and treatment outcomes. By using the ultrasonic scalpel,the improved Miccoli procedure is superior to novel open surgery in safety,minimal invasion,and cosmetic results. However,the cost of novel open surgery is less because of no requirement of endoscopy.