晚期甲状腺癌的外科处理

张小盒 · 发表于 2014-12-10 17:18

摘要
目的：探讨晚期甲状腺癌的诊断、手术、术后处理及疗效。
方法：对22例该类患者的诊治情况进行回顾性的总结。其中，并发Ⅳ级心衰的4例。手术在切除原发灶和颈淋巴清扫术的同时,对喉、气管、食管、下咽的受侵程度分3种类型分别处理。Ⅰ甲状腺癌仅侵及气管环软骨膜、下咽食管外膜，未侵及气管软骨、下咽食管肌层，采用电刀剔除术（6例）；Ⅱ甲状腺癌侵及气管软骨、环间组织或气管内膜固有层，范围较小者（<1.5cm），采用气管开窗术（1例）；肿瘤侵及下咽食管肌层或黏膜范围较小者，采用局部拉拢缝合（3例）；Ⅲ对喉、气管、食管、下咽全层受累者，切除受累部分的器官，根据缺损范围采用气管端端吻合（8例），胸锁乳突肌锁骨肌骨（骨膜）瓣（3例），胸大肌折叠皮瓣（1例），带状肌修复半喉（1例）等方法重建上气道及上消化道。对不能保留喉功能者采用永久性气管造口。
结果：22例患者随访1.5-5.0年，3例死亡，其余存活。术后出现咽瘘2例，换药后愈合。2例出现一过性误咽。3例双侧喉返神经受侵切除的病人中2例戴气管套管发音，1例拔管。4例术前有心衰的病人，3例术后心衰明显好转。
结论：按照肿瘤外科的原则完整切除肿瘤的同时尽量保留和修复重建喉、气管、下咽、食管的功能，能提高了患者的生存率和生存质量。
关键词：甲状腺癌　外科治疗分期

Surgery Management of Advanced Stage Thyroid Carcinoma
Chenli  Wuhao  Huangqi
Department of Otolaryngology-Head and Neck Surgery, XinHua Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai 200092
[Abstract] Objective: To discuss diagnose, operation, and post-operation surgery management methods and treatment effect of the advanced stage thyroid carcinoma Methods: To summarize retrospectively diagnose and treatment information of the 22 patients. Among the total, four patients had congestive heart failure of four stage. The total patients primary thyroid lesions were resected and neck dissection were completed in operation, the level of thyroid carcinoma invading larynx, trachea, esophagus and hypopharynx was divided three types. TypeⅠ: The six cases invading the annulus tracheae perichondrium and the outer-wall of esophagus and hypopharynx, but not invading the cartilagines tracheales and hypopharyng-oesophagus muscular layer, were shaved off the invading part with electricity sword. TypeⅡ: To invading the cartilagines tracheales, trachea ring space tissue, or endomembrane lamina propria, the area is no more than 1.5cm2.The fenestration of trachea was used (1 case). The area of thyroid carcinoma invading hypopharyng or oesophagus mucosa was small, the defect parts were sutured directly (3 cases). TypeⅢ: If the full-thickness of larynx, hypopharynx, trachea and cervical esophagus were invaded, the invading parts of the organ were resected. These defects were repaired by end to end anastomosis of the trachea (8 cases), the folded pectoralis major myocutaneous flap (1 case), Sternocleidomastoideus flap with clavicular periosteum flap or clavicle skinnes flap (3 cases), band muscle and so on, and reconstructed the aerodigestive. If the larynx was`invaded and it ’s impossible to be preserved, the total larynx was resected. Results: The 22 patients were followed 1.5-5.0 years. Three died, the others are survival. Two ever appeared pharyngeal fistula after operation, the wound was healed by dressing change. Two patients came forth temporarily error swallow, Three cases who bilateral laryngeal recurrence nerve were resected in operation, two patients could speak with tracheal cannula, one patient can speak without tracheal cannula. The heart functions of three patients in these four congestive heart failure patients had obviously were improved after operation. Conclusions: Overall neoplasms were resected according to neoplasm surgery principle and preserve and reconstruct organ’s function to the best of our abilities to improve the patient survival rate and life quality.
Keywords: Thyroid Carcinoma  Surgery treatment  Staging