Rosato Lodovico, Avenia Nicola, De Palma Maurizio, Gulino Giuseppe, Nasi Pier Giorgio, Pezzullo Luciano
S.C. di Chirurgia, Modulo di Endocrinochirurgia, Ospedale di Ivrea.
Chir Ital. 2002 Sep-Oct;54(5):635-42.
The range of indications for total thyroidectomy in the treatment of thyroid disease is steadily increasing, but any attempt to assess its real efficacy necessarily calls for a knowledge of the incidence of complications, amongst other things in order to provide the patient with complete information regarding the operation before obtaining his or her consent. Retrospective and observational analysis of 14,934 thyroidectomies performed in 42 Endocrine Surgery Units in Italy has made it possible to compare total thyroidectomy (TT) versus subtotal thyroidectomy with a bilateral remnant (ST-BR), subtotal thyroidectomy with a unilateral remnant (ST-UR) and total lobectomy-isthmectomy (TLI). The correlation between the number of total thyroidectomies and each of the other surgical procedures and the number of complications occurring with each of them was also assessed in order to quantify the effective risk of complications by determining the Odds Ratios on the basis of univariate analysis of the variables considered. The cases reviewed consisted of 9,599 TT (64%), 3,130 TLI (21%), 1,448 ST-UR (22%) and 757 ST-BR (5%); 13,023 (87%) cases were suffering from benign disease and 1,911 (13%) from malignancies. Recurrent laryngeal nerve injuries were present in 4.3% of the TT cases with 2.4% transient and 1.3% definitive (as against 3% in ST-BR and 2% in ST-UR with 1.4% and 1.1% transient, and 1% and 0.6% definitive, respectively; and 1.4% transient and 0.6% definitive in TLI). Hypocalcaemia after TT was transient in 14% and definitive in 2.2% (as against transient rates of 5% in ST-BR and ST-UR and 0.4 in TLI; and definitive hypocalcaemia in 0.6%, 0.8% and 0.07%, respectively). Haemorrhage occurred in 1.6% of TT cases (as against 2.1%, 0.5% and 0.4% in ST-BR, ST-UR and TLI, respectively). The Odds Ratios showed that TT presented a 16% higher complication rate than ST-UR which was assigned a value of 1, a 3% higher rate than ST-BR and a 5% lower rate than TLI. This greater incidence of complications with TT is attributable mainly to the greater incidence of transient hypoglycaemia and to a lesser extent to the slightly higher incidence of definitive hypoglycaemia, whereas the incidences of recurrent laryngeal nerve injuries were very similar in TT and ST-BR. Haemorrhagic complications were more frequent in ST-BR than in TT. Bearing in mind that TT is the absolute indication in the more demanding thyroid diseases (tumours, retrosternal goitre, Basedow's disease, recurrences) and in view of its fairly low complication rate, we believe that TT is a safe, reliable procedure, provided it is performed in a technically scrupulous manner. ST-BR is a technique which should be abandoned owing to the fact that its complication rate is comparable to that of TT and to the recurrences it may give rise to. ST-UR may be indicated if the surgeon is not sure of safeguarding the anatomical integrity of the recurrent nerve on one side.
在甲状腺疾病治疗中，全甲状腺切除术的适应症范围正在稳步扩大，但要评估其实际疗效，就必须了解并发症的发生率等情况，以便在获得患者同意前为其提供有关手术的完整信息。对意大利42个内分泌外科单位进行的14934例甲状腺切除术进行回顾性和观察性分析，得以比较全甲状腺切除术（TT）与双侧残余甲状腺次全切除术（ST - BR）、单侧残余甲状腺次全切除术（ST - UR）以及全叶切除 - 峡部切除术（TLI）。还评估了全甲状腺切除术的数量与其他每种手术方法之间的相关性，以及每种手术方法发生并发症的数量，以便通过基于所考虑变量的单因素分析确定优势比来量化并发症的实际风险。所审查的病例包括9599例TT（64%）、3130例TLI（21%）、1448例ST - UR（22%）和757例ST - BR（5%）；13023例（87%）为良性疾病，1911例（13%）为恶性肿瘤。TT病例中喉返神经损伤发生率为4.3%，其中2.4%为暂时性损伤，1.3%为永久性损伤（相比之下，ST - BR中分别为3%，其中1.4%为暂时性损伤，1%为永久性损伤；ST - UR中分别为2%，其中1.1%为暂时性损伤，0.6%为永久性损伤；TLI中分别为1.4%和0.6%）。TT术后低钙血症暂时性发生率为14%，永久性发生率为2.2%（相比之下，ST - BR和ST - UR的暂时性发生率为5%，TLI为0.4%；永久性低钙血症发生率分别为0.6%、0.8%和0.07%）。TT病例中出血发生率为1.6%（相比之下，ST - BR、ST - UR和TLI中分别为2.1%、0.5%和0.4%）。优势比显示，TT的并发症发生率比赋值为1的ST - UR高16%，比ST - BR高3%，比TLI低5%。TT并发症发生率较高主要归因于暂时性低钙血症发生率较高，在较小程度上归因于永久性低钙血症发生率略高，而TT和ST - BR中喉返神经损伤发生率非常相似。ST - BR的出血性并发症比TT更常见。鉴于TT在更具挑战性的甲状腺疾病（肿瘤、胸骨后甲状腺肿、格雷夫斯病、复发）中是绝对适应症，且其并发症发生率相当低，我们认为只要以严格的技术方式进行，TT是一种安全、可靠的手术方法。ST - BR这种技术应被摒弃，因为其并发症发生率与TT相当，且可能导致复发。如果外科医生不确定能否保护一侧喉返神经的解剖完整性，可考虑ST - UR。
