甲状腺癌术后复发再手术难点与对策

Difficulties and countermeasures in reoperation of postoperative recurrence of thyroid cancer

分化型甲状腺癌预后良好。甲状腺癌复发需行以再次手术为主的综合治疗。与初次手术相比,再次手术风险明显增大,并发症发生率和严重程度均升高。因此,再次手术前应进行充分的检查评估,并做好充分的知情同意。中央区的再次手术,难点在于把握手术指征、术中复发淋巴结的定位、术中喉返神经和甲状旁腺的保护以及周围器官结构受侵的处理。术前超声引导下纳米炭注射能够可靠帮助术中定位。术中神经监测技术可以帮助喉返神经的辨认。如需要切除喉返神经,尽可能同期修复。术中对于上位甲状旁腺区减少扰动、仔细在标本中辨认寻找甲状旁腺、必要时甲状旁腺自体移植可以尽量保护甲状旁腺。而侵犯气管、喉、食管时,则需要部分喉切除、气管切除和重建等技术。颈侧区的再次手术,难点在于颈淋巴结清扫容易遗漏部位的再次切除、咽旁等少见复发位置的处理,以及神经和大血管受侵的处理。颈侧区复发的转移淋巴结仍以规范的区域淋巴结清扫为主要治疗方法。对于少见部位的复发应熟悉局部解剖,减少副损伤。神经受侵时,尽量保留有功能的神经。必要时可以切除颈内静脉。上纵隔位置的复发主要通过上纵隔淋巴结清扫完成。胸骨劈开的开放入路显露较好,可切除范围较大,相对比较安全,但创伤较大。腔镜辅助的上纵隔淋巴结清扫创伤较小,需要一定技术储备。复发甲状腺癌经积极治疗预后较好。再次手术建议由经验丰富的专科医师来完成。术后辅助多学科综合治疗能提高再次手术的疗效。

Differentiated thyroid cancer has a good prognosis.Recurrence of thyroid cancer requires comprehensive treatment based on reoperation.Compared with the initial surgery,the risk of reoperation is significantly increased,and the incidence and severity of complications are elevated.Therefore,adequate evaluation and well-informed consent should be carried out before the reoperation.The difficulty of reoperation in the central compartment lies in grasping the surgical indications,intraoperative localization of the recurrent lymph nodes,intraoperative protection of the recurrent laryngeal nerve and parathyroid glands,and the treatment of invasion of surrounding organ structures.Preoperative ultrasound-guided nanocarbon injection can be reliably helpful in intraoperative localization.Intraoperative nerve monitoring techniques can be helpful in the identification of the recurrent laryngeal nerve.If the recurrent laryngeal nerve needs to be removed,repair it at the same time as possible.During the operation,reducing the disturbance of the superior parathyroid area,carefully identifying the parathyroid glands in the specimen,and if necessary,parathyroid autotransoplantation can protect the parathyroid gland as much as possible.When the trachea,larynx,and esophagus involved,techniques such as partial laryngectomy,trachelectomy,and reconstruction are required.The difficulty of reoperation in the lateral cervical region lies in the reexcision of easily missed sites in initical neck dissection,the treatment of some rare recurrent sites such as parapharyngeal,and the treatment of nerve and large vessel invasions.Standardized zone dissection is still the main treatment for recurrent metastatic lymph nodes in the lateral cervical region.For the recurrence of rare sites,we should be familiar with local anatomy to reduce secondary injury.Functional nerves should be preserved whenever possible.The internal jugular vein can be removed if necessary.Recurrence in the superior mediastinal region is mainly accomplished by superior mediastinal dissection.The open access with sternal splitting provides better exposure,which makes a wide resection possible,and is relatively safe but larger traumatic.The endoscopic superior mediastinum dissection is less invasive and requires relative trainings.The prognosis of recurrent thyroid cancer is quite good with active treatment.Reoperation is recommended to be performed by experienced specialists.Postoperative adjuvant multidisciplinary treatment can improve the efficacy of reoperation.