中国普外基础与临床杂志

中国普外基础与临床杂志

伴巨大甲状腺 Graves 病的围手术期综合治疗

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目的 总结伴巨大甲状腺 Graves 病(GD)患者的围手术期综合治疗效果。 方法 回顾性分析北京协和医院于 2006 年 1 月至 2016 年 12 月期间收治的 8 例伴巨大甲状腺的 GD 患者的临床资料。患者术前均行综合措施准备,并接受甲状腺全切除术。总结围手术期经规范抗甲状腺药物治疗、碘准备及动脉栓塞后甲状腺的功能状况,以及术中出血、术后引流和随诊复发情况。 结果 所有患者经综合措施(复方碘溶液口服 3~4 周、抗甲状腺药物重叠使用 2~4 周及术前 24 h 内行甲状腺主要供血动脉栓塞)准备后效果满意。8 例患者的手术过程顺利,手术时间较短(2.5~4.5 h),术中出血较少(4 例≤ 100 mL),术后颈部引流量少。所有病例无严重或永久并发症(如甲状腺功能亢进危象、语音改变及甲状旁腺功能障碍)发生。8 例患者门诊随诊 18~133 个月,无远期并发症发生,无复发病例。 结论 伴巨大甲状腺 GD 病的围手术期处理十分重要,多学科综合措施可有效降低出血、甲状腺功能亢进危象等风险,术中精细操作可有效保护局部重要功能。

Objective To explore the effect of multi-disciplinary treatment of the Graves’ disease (GD) with huge-size thyroid during perioperative period. Methods Retrospectively analyzed the clinical data of 8 GD patients with huge-size thyroid who got treatment in Pekin Union Medical College Hospital during Jan. 2006 to Dec. 2016. All patients underwent comprehensive preparation before operation and underwent total thyroidectomy. To explore the changes of thyroid function and culture after anti-thyroid drug (ATD)/iodine preparation/arterial embolization before operation, and to summarize situation of the bleeding loss intraoperation, neck-drainage, thyroid function, and relapses after operation. Results All cases got a satisfactory operation result after standard ATD, iodine preparation (Lugol’s solution 10–15 drops for 3–4 weeks, combined with ATDs for 2–3 weeks ), and main arterial embolization of thyroid in 24 h preoperation. They got shorter operative time (2.5–4.5 h), less bleeding intraoperation (4 cases≤100 mL), less neck-drainage, and almost normal retention time. No severe or permanent complications, for example thyroid storm, abnormal voice, and hypoparathyroid occurred. They were followed as outpatients for 18–133 months, and were found a perfect long-term effect without complication and relapse. Conclusions Perioperative period management is very important to those GD patients with huge-sized thyroid, and multi-disciplinary treatment can decrease theintraoperation bleeding, as well as occurrence of thyroid storm effectively. In addition, operated subtly during surgery can protect the recurrent laryngeal nerve and parathyroid effectively.

关键词: Graves 病; 巨大甲状腺; 多学科综合治疗; 围手术期

Key words: Graves’ disease; huge-size thyroid; multi-disciplinary treatment; perioperative period

引用本文: 刘洪沨, 廖泉, 高维生, 谢勇, 杨宁, 连小兰, 朱慧娟, 李小毅, 刘跃武. 伴巨大甲状腺 Graves 病的围手术期综合治疗. 中国普外基础与临床杂志, 2018, 25(10): 1194-1200. doi: 10.7507/1007-9424.201806010 复制

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1. Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid, 2016, 26(10): 1343-1421.
2. Ventrella S, Klein I. Beta-adrenergic receptor blocking drugs in the management of hyperthyroidism. Endocrinologist, 1994, 4: 391-399.
3. Tagami T, Yambe Y, Tanaka T, et al. Short-term effects of β-adrenergic antagonists and methimazole in new-onset thyrotoxicosis caused by Graves’ disease. Intern Med, 2012, 51(17): 2285-2290.
4. 朱预. 甲状腺功能亢进的外科治疗及展望. 中国实用外科杂志, 2006, 26(7): 485-486.
5. 吴维敏, 余书勇, 尹俊峰. Graves 病外科治疗应注意的几个问题. 中华内分泌外科杂志, 2009, 3(5): 332-335.
6. Erbil Y, Ozluk Y, Giriş M, et al. Effect of lugol solution on thyroid gland blood flow and microvessel density in the patients with Graves’ disease. J Clin Endocrinol Metab, 2007, 92(6): 2182-2189.
7. Ansaldo GL, Pretolesi F, Varaldo E, et al. Doppler evaluation of intrathyroid arterial resistances during preoperative treatment with Lugol’s iodide solution in patients with diffuse toxic goiter. J Am Coll Surg, 2000, 191(6): 607-612.
8. 苏国森, 何友钊. 甲状腺功能亢进症围手术期处理与 T3、T4 变化的临床观察. 中国普外基础与临床杂志, 2000, 7(1): 57.
9. Shinall MC Jr, Broome JT, Baker A, et al. Is potassium iodide solution necessary before total thyroidectomy for Graves disease? Ann Surg Oncol, 2013, 20(9): 2964-2967.
10. 王东, 乔天凤, 刘启榆, 等. 甲状腺功能亢进症的介入治疗. 中国普外基础与临床杂志, 2001, 8(3): 176-178.
11. Langley RW, Burch HB. Perioperative management of the thyrotoxic patient. Endocrinol Metab Clin North Am, 2003, 32(2): 519-534.
12. Erbil Y, Ozluk Y, Giriş M, et al. Effect of lugol solution on thyroid gland blood flow and microvessel density in the patients with Graves’ disease. J Clin Endocrinol Metab, 2007, 92(6): 2182-2189.
13. Ansaldo GL, Pretolesi F, Varaldo E, et al. Doppler evaluation of intrathyroid arterial resistances during preoperative treatment with Lugol’s iodide solution in patients with diffuse toxic goiter. J Am Coll Surg, 2000, 191(6): 607-612.
14. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am, 1993, 22(2): 263-277.
15. Akamizu T, Satoh T, Isozaki O, et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid, 2012, 22(7): 661-679.
16. Angell TE, Lechner MG, Nguyen CT, et al. Clinical features and hospital outcomes in thyroid storm: a retrospective cohort study. J Clin Endocrinol Metab, 2015, 100(2): 451-459.
17. Swee du S, Chng CL, Lim A. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am, 2006, 35(4): 663-686.
18. Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am, 2006, 35(4): 663-686.
19. 饶惠民, 孙羽, 邱堃. 76 例青少年原发性甲状腺功能亢进的外科治疗. 中国普外基础与临床杂志, 2008, 15(5): 327-328.
20. 闫利英, 李随勤, 施秉银, 等. 甲状腺功能亢进症的外科治疗. 中华耳鼻咽喉头颈外科杂志, 2006, 41(8): 595-598.
21. Palit TK, Miller CC 3rd, Miltenburg DM. The efficacy of thyroidectomy for Graves' disease: a meta-analysis. J Surg Res, 2000, 90(2): 161-165.
22. Guo Z, Yu P, Liu Z, et al. Total thyroidectomy vs bilateral subtotal thyroidectomy in patients with Graves’ diseases: a meta-analysis of randomized clinical trials. Clin Endocrinol (Oxf), 2013, 79(5): 739-746.
23. Sung TY, Lee YM, Yoon JH, et al. Long-term effect of surgery in Graves’ disease: 20 years experience in a single institution. Int J Endocrinol, 2015, 2015: 542641.
24. Wilhelm SM, McHenry CR. Total thyroidectomy is superior to subtotal thyroidectomy for management of Graves’ disease in the United States. World J Surg, 2010, 34(6): 1261-1264.
25. 黄初东, 胡明, 李志辉, 等. 甲亢手术后骨饥饿综合征. 中国普外基础与临床杂志, 2011, 18(10): 1098-1099.
26. 张金星, 周俊强, 蔺辉琦. 手术治疗甲状腺功能亢进症21例报告. 中国普外基础与临床杂志, 2003, 10(3): 214.