cN0期甲状腺乳头状癌经腋窝与经锁骨下入路腔镜手术临床对比研究

Clinical comparison of transaxillary and transsubclavian endoscopic surgery for cNo papillary thyroid carcinoma

目的比较改良免充气经腋窝和经锁骨下人路腔镜甲状腺手术治疗cN0期甲状腺乳头状癌(papillary thyroid carcinoma,PTC)的临床效果。方法回顾性分析2020年10月至2022年10月于吉林大学第一医院普通外科中心甲状腺外科接受单侧甲状腺癌根治术的190例cN0期单侧PTC患者的资料,男38例,女152例,年龄(39.88±9.35)岁。经腋窝入路腔镜手术(腋窝组)65例,经锁骨下入路腔镜手术(锁骨下组)43例,传统开放手术(开放组)82例。将腋窝组和锁骨下组合称为腔镜组。对3组在手术时间、中央区完全显露率、术后住院时间、引流量、住院费用、清扫淋巴结个数及术后相关并发症等方面进行比较。同时将腔镜组和开放组进行比较。采用t检验、Wilcoxon秩和检验、x^(2)检验或Fisher确切概率法比较每两组之间的手术结果。结果所有腔镜手术均顺利完成,无中转开放手术。①腔镜组(腋窝组+锁骨下组)与开放组相比,手术时间更长(开放组74.5min,范围65~87min;腔镜组102min,范围89~121min;P<0.001),中央区完全显露率更低(开放组100%,腔镜组89.8%,P=0.008),引流量更多(开放组60ml,范围45~76ml;腔镜组100ml,范围80~130ml;P<0.001),住院费用更高(开放组23638元,范围22158~25901元;腔镜组26967元,范围25572~28284元;P<0.001),甲状旁腺自体移植率更高(开放组4.9%,腔镜组50.9%;P<0.001),两组在清扫淋巴结个数、淋巴结转移个数、术前术后甲状旁腺激素(parathyroidhormone,PTH)等差异无统计学意义(P>0.05)。②胶腋窝组与锁骨下组相比:腋窝组手术时间更长(腋窝组110min,范围97~127min;锁骨下组89min,范围80~111min;P<0.001),中央区完全显露率更低(腋窝组83.1%,锁骨下组100%;P=0.012),术后住院天数更长(腋窝组3d,3~4d;锁骨下组3d,3~3d;P=0.002),引流量更多(腋窝组110ml,范围82~140ml;锁骨下组95ml,范围65~120ml;P=0.046),住院费用高(腋窝组27510±2578元,锁骨下组26609±1878元;P=0.038),两组在清扫淋巴结个数、淋巴结转移个数、术前术后PTH、甲状旁腺自体移植等方面差异无统计学意义(P>0.05)。结论经腋窝/锁骨下入路腔镜甲状腺手术治疗cN0期PTC安全可行,清扫中央区淋巴结个数与传统开放手术无明显差异,切口隐蔽性好。相比较而言,经锁骨下腔镜甲状腺手术时间更短,中央区完全显露率更高,术后恢复更快,有较好的临床运用价值。

Objective To compare the clinical effects of endoscopic thyroidectomy using the modified gasless transaxillary approach(TA group)and transsubclavian approach(TS group)in the treatment of cNO papil-lary thyroid carcinoma(PTC).Methods A total of 190 PTC patients(mean age 39.88+9.35 years,38 males,152 females),who underwent unilateral thyroidectomy in the Department of Thyroid Surgery,the First Hospital of Jilin University from Oct.2020 to Oct.2022 were retrospectively analyzed,including 65 cases in TA group,43 cases in TS group and 82 cases through traditional neck approach(TN group).The endoscopic group(TA+TS)consists of the TA group and the TS group.Comparative analyses were performed on operation time,full exposure rate of central compartment,postoperative hospitalization time,postoperative drainage,hospitalization costs,the number of dissected lymph nodes and postoperative complications.The t-test or Wilcoxon rank sum test,the x^(2) test or the exact probability method were used for statistical analysis.Results All endoscopic operations were successfully completed without conversion to traditional neck approach.Compared with the TN group,the endoscopic group(TA+TS)had longer operation time[TN group=74.5(65-87)min,(TA+TS)group=102(89-121)min,P<0.001],lower full exposure rate of central compartment(TN group=100%,(TA+TS)group=89.8%,P=0.008),more postoperative drainage[TN group=60(45-76)ml,(TA+TS)group=100(80-130)ml,P<0.001],higher hospitalization costs[TN group=￥23638(22158-25901),(TA+TS)group=￥26967(25572-28284),P<0.001],and higher parathyroid autotransplantation rate(TN group=4.9%,(TA+TS)group=50.9%,P<0.001).There were no significant differences in the number of dissected lymph nodes,the number of metastatic lymph nodes,preoperative and postoperative parathyroid hormone(PTH)(P>0.05).②Compared with the TS group,the TA group had longer operation time[TA group=110(97-127)min,TS group=89(80-111)min,P<0.001],lower full exposure rate of central compartment(TA group=83.1%,TS group=100%,P=0.012),longer postoperative hospitalization time[TA group=3(3-4)d,TS group=3(3-3)d,P=0.002],more postoperative drainage[TA group=110(82-140)ml,TS group=95(65~120)ml,P=0.046]and higher hospitalization costs(TA group=￥27510±2578,TS group=￥26609±1878,P=0.038).There were no significant differences in the number of dissected lymph nodes,the number of metastatic lymph nodes,preoperative and postoperative PTH,and parathyroid autotransplantation between the two groups(P>0.05).Conclusions Endoscopic thyroidectomy through axillary/subclavian approach is safe and feasible for the treatment of cNO PTC.There was no significant difference in the number of dissected central lymph nodes compared with conventional surgery,and the incision was well concealed.In comparison,transsubclavian endoscopic surgery has beter clinical application value,with shorter operation time,higher full exposure rate of central compartment and faster postoperative recovery.