无充气经腋窝腔镜甲状腺乳头状癌侧颈部淋巴结清扫的临床应用

Clinical application of modified radical neck dissection by gasless unilateral axillary approach in papillary thyroid cancer

目的本研究旨在初步探讨无充气经腋窝腔镜改良根治性颈淋巴结清扫术(modified radical neck dissection by gasless unilateral axillary approach,GUA-MRND)在经过选择的甲状腺乳头状癌(papillary thyroid carcinoma,PTC)患者外科治疗中的有效性、安全性和优势。方法回顾性分析2019年1月至2021年6月浙江省人民医院头颈外科的48例PTC患者,根据患者意愿分为GUA-MRND(腔镜组n=16)和采用单侧传统开放改良根治性颈淋巴结清扫术(modified radical neck dissection,MRND)(开放组n=32)。腔镜组:男2例,女14例,年龄(30.56±9.82)岁;开放组:男14例,女18例,年龄(39.78±15.35)岁。比较分析腔镜组与开放组在手术效能、并发症发生率和切口满意度上的差异。应用SPSS 25.0软件进行统计学分析,组间比较采用独立样本t检验,构成比或率的比较采用χ^(2)检验或精确概率法检验。结果腔镜组患者年龄(P=0.050)显著小于开放组。在手术时间(P<0.001)、术后引流量(P=0.001)方面腔镜组显著高于开放组,两组在手术出血量方面差异无统计学意义(P>0.05)。腔镜组在颈前吞咽不适(P=0.018)及切口满意度(P=0.000)评估方面较开放组具有显著优势。在术后副神经运动功能异常、暂时性喉返神经损伤、术后出血、术后血肿、术后感染、术后淋巴漏或乳糜漏及术后3个月锁骨上区域麻木的发生率上腔镜组与开放组差异无统计学意义(P>0.05)。腔镜组Ⅱ区淋巴结清扫个数显著低于开放组(P=0.001),Ⅲ区淋巴结清扫个数显著高于开放组(P=0.004)。腔镜组区域清扫平均效能由高到低依次为levelⅢ(35.5%)、levelⅥ(28.59%)、levelⅣ(23.21%)、levelⅡ(7.18%)和levelⅤ(7.12%)。区域清扫平均效能值提示GUA-MRND对于levelⅢ、levelⅥ和levelⅣ组淋巴结的清扫具有较高的清扫效能。结论对经过选择的PTC单侧侧颈部淋巴结转移患者,初步研究认为应用GUA-MRND治疗安全、有效且具有较高美容满意度。

Objective To investigate the effectiveness,safety,and advantages of modified radical neck dissection by gasless unilateral axillary approach(GUA-MRND)in the surgical management of selected patients with papillary thyroid cancer.Methods We retrospectively analyzed patients with papillary thyroid cancer who underwent GUA-MRND(endoscopic group,n=16)versus unilateral open modified radical neck dissection(MRND)(open group,n=32)during the period from Jan.2019 to Jun.2021,including the differences in surgical efficiency,complication rate,and incisional satisfaction.Results Compared MRND with GUA-MRND,the patients were younger(P<0.05),operative time and postoperative drainage anterior(P<0.01)were slightly inferior in the latter,but it had obvious advantages in cervical swallowing discomfort and incision satisfaction evaluation(P<0.05).There was no significant difference in the incidence of temporary recurrent laryngeal nerve injury,intraoperative and postoperative bleeding,hematoma,infection,lymphatic or chylous leakage and supraclavicular numbness after surgery(P>0.05).The number of dissected lymph nodes in area II in the GUA-MRND was lower(P<0.05),but it was significantly higher(P<0.01)in area III.And the average regional cleaning efficiency in the GUA-MRND was levelⅢ(35.5%),levelⅥ(28.59%),levelⅣ(23.21%),levelⅡ(7.18%)and levelⅤ(7.12%),suggested that GUA-MRND had higher efficacy for level III,levelⅥand Level IV.Conclusion GUA-MRND is safe,effective,and has high cosmetic satisfaction in the treatment of selected patients with lateral cervical lymph node metastases from papillary thyroid cancer.