常规暴露与神经监测喉上神经在甲状腺癌切除术中的应用效果比较

Efficacy of routine exposure versus neuromonitoring of superior laryngeal nerve in thyroid cancer surgery

目的:比较常规暴露与神经监测喉上神经外支(EBSLN)在甲状腺癌切除术中的应用效果。方法:回顾性分析衢州市人民医院乳甲外科2017年7月至2020年6月收治的行开放甲状腺癌手术患者500例的临床资料,根据术中是否进行神经监测,将其分为监测组(n=300)和未监测组(对照组)(n=200),对照组患者术中常规暴露EBSLN,肉眼观察;监测组患者术中给予EBSLN监测。比较两组手术前、后嗓音障碍指数量表简版(VHI-10)评分、声带功能及血清甲状旁腺素(PTH)、钙离子(Ca^(2+))水平变化。术后随访1年,观察两组患者EBSLN损伤、甲状旁腺损伤及低钙血症等并发症发生情况。结果:监测组手术时间[(112.32±10.42)min]、术中出血量[(10.58±5.04)mL]、引流管拔管时间[(2.07±0.54)d]、术后第1天引流量[(10.55±3.58)mL]、术后住院时间[(3.03±1.03)d]均明显短于、少于对照组(t=18.68、15.09、15.24、32.98、27.37,均P<0.001)。与术前相比,两组患者术后标准化噪音能量(NNE)、振幅微扰、基频微扰、基频值均明显降低,谐波噪声比(HNR)值、VHI-10评分明显升高,且监测组术后上述指标较对照组改善均更为显著(t=43.31、27.10、46.45、37.11、8.97,均P<0.001)。与术前相比,两组患者术后血清PTH、Ca^(2+)水平均明显降低,且对照组患者术后血清PTH、Ca^(2+)水平降低更显著(t=41.14、5.99,均P<0.001)。监测组并发症发生率[低钙血症4例(1.33%)、甲状旁腺损伤0例(0.00%)、EBSLN损伤8例(2.67%)]明显低于对照组(χ^(2)=73.41、74.17、76.29,均P<0.001)。结论:开放甲状腺癌术中监测EBSLN,可有效改善患者嗓音及声带功能,降低EBSLN损伤率,具有一定的临床应用价值。

Objective:To investigate the efficacy of routine exposure versus neuromonitoring of the external branch of the superior laryngeal nerve(EBSLN)in thyroid cancer surgery.Methods:The clinical data of 500 patients who underwent open thyroid cancer surgery in the Department of Breast and Thyroid Surgery,People's Hospital of Quzhou from July 2017 to June 2020 were retrospectively analyzed.These patients were divided into a monitoring group(n=300)and an unmonitored group(control group)(n=200)according to whether neuromonitoring was performed during surgery.In the control group,the EBSLN was routinely exposed during the surgery for naked observation.In the monitoring group,the EBSLN was monitored.The Voice Handicap Index score,vocal cord function,and serum levels of parathyroid hormone and calcium ion were compared between the two groups before and after surgery.All patients were followed up for 1 year to observe injury to the EBSLN,parathyroid gland injury,and hypocalcemia.Results:In the monitoring group,operative time(112.32±10.42)minutes,intraoperative blood loss(10.58±5.04)mL,time to extubation(2.07±0.54)days,postoperative drainage flow(10.55±3.58)mL,and postoperative hospital stay(3.03±1.03)days were significantly shorter and less compared with the control group(t=18.68,15.09,15.24,32.98,27.37,all P<0.001).Compared with before surgery,normalized noise energy,amplitude perturbation,fundamental frequency perturbation,and fundamental frequency value in each group were significantly decreased after surgery,harmonic to noise ratio and the Voice Handicap Index were significantly increased after surgery.These indices were more obviously improved in the monitoring group compared with the control group(t=43.31,27.10,46.45,37.11,8.97,all P<0.001).Compared with before surgery,serum levels of parathyroid hormone and calcium ion in each group were significantly decreased after surgery.After surgery,serum levels of parathyroid hormone and calcium ion in the control group were significantly lower than those in the monitoring group(t=41.14,5.99,both P<0.001).The incidence of complications in the monitoring group[4 cases of hypocalcemia(1.33%),0 cases of parathyroid injury(0.00%),8 cases of injury to the EBSLN]was significantly lower than that in the control group(χ^(2)=73.41,74.17,76.29,all P<0.001).Conclusion:Neuromonitoring of the EBSLN during open thyroid cancer surgery can effectively improve patient voice and vocal cord function,reduce the rate of injury to the EBSLN,and has a clinical application value.