Pradeep P V, Agarwal Amit, Baxi Mukta, Agarwal Gaurav, Gupta Sushil Kumar, Mishra S K
Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae-Bareillei Road, Lucknow, Uttar Pradesh, 226014, India.
World J Surg. 2007 Feb;31(2):306-12; discussion 313. doi: 10.1007/s00268-006-0572-9.
Ideal management of toxic goiter still remains elusive. Though surgical management of toxic multinodular goiter (MNG) is well accepted, surgical treatment of Graves' disease (GD) is still controversial in view of the presumed increased incidence of complications. In this paper, we discuss the experience of the surgical management of hyperthyroidism at a specialized tertiary care endocrine center in a developing country, highlighting the minimal morbidity and satisfactory outcome in experienced hands.
We retrospectively reviewed 325 consecutive patients with hyperthyroidism managed surgically from 1990 to 2005. The etiologic diagnoses were Graves' disease (185), toxic MNG (105), and autonomously functioning thyroid nodules (AFTN) (n = 35). The indications for surgery in Graves' patients were large goiter, relapse after antithyroid drug therapy (ATD), Graves' ophthalmopathy, and presence of nodule. The indications for surgery in toxic MNG were retrosternal extension (n = 15), compressive symptoms (n = 20), and large size (grade II). Among the AFTN nodule size, those greater than 4 cm (85%) formed the major indication for surgery. Subjects with GD and toxic MNG were subjected to subtotal thyroidectomy (n = 93 prior to 1995) or total thyroidectomy (n = 205 post-1995). Hemithyroidectomy was the procedure of choice in patients with AFTN.
Patients with Graves' disease were younger in age, with shorter mean duration of goiter when compared with the other 2 groups. Eight percent of patients with Graves' disease without a clinically palpable nodule and 25% of those with nodules had associated differentiated carcinoma, including papillary, follicular, and medullary thyroid cancer. Four percent of patients with toxic MNG had malignancy. Complications included temporary hypocalcemia (24%), permanent hypocalcemia (3%), and permanent vocal-cord palsy (1%).
Surgery for hyperthyroidism has negligible mortality and acceptable morbidity in experienced hands. It is a definite option in selected cases. Immediate and permanent cure of hyperthyroidism is achieved, with no recurrences, after total thyroidectomy. The cosmetic outcome is good, with excellent patient satisfaction and acceptance.
毒性甲状腺肿的理想治疗方法仍不明确。虽然毒性多结节性甲状腺肿（MNG）的手术治疗已被广泛接受，但鉴于推测并发症发生率增加，格雷夫斯病（GD）的手术治疗仍存在争议。在本文中，我们讨论了一个发展中国家的专业三级内分泌中心对甲状腺功能亢进症进行手术治疗的经验，强调了在经验丰富的医生手中，发病率极低且预后良好。
我们回顾性分析了1990年至2005年期间连续接受手术治疗的325例甲状腺功能亢进症患者。病因诊断为格雷夫斯病（185例）、毒性MNG（105例）和自主功能性甲状腺结节（AFTN）（35例）。格雷夫斯病患者的手术指征为甲状腺肿大、抗甲状腺药物治疗（ATD）后复发、格雷夫斯眼病和存在结节。毒性MNG的手术指征为胸骨后延伸（15例）、压迫症状（20例）和大尺寸（II级）。在AFTN中，结节大小大于4 cm的患者（85%）构成了主要手术指征。GD和毒性MNG患者接受了次全甲状腺切除术（1995年前93例）或全甲状腺切除术（1995年后205例）。单侧甲状腺切除术是AFTN患者的首选手术方式。
与其他两组相比，格雷夫斯病患者年龄较轻，甲状腺肿大的平均病程较短。8%无临床可触及结节的格雷夫斯病患者和25%有结节的患者伴有分化型癌，包括乳头状、滤泡状和髓样甲状腺癌。4%的毒性MNG患者患有恶性肿瘤。并发症包括暂时性低钙血症（24%）、永久性低钙血症（3%）和永久性声带麻痹（1%）。
在经验丰富的医生手中，甲状腺功能亢进症手术的死亡率可忽略不计，发病率可接受。在某些特定病例中，这是一个明确的选择。全甲状腺切除术后可立即实现甲状腺功能亢进症的永久性治愈，且无复发。美容效果良好，患者满意度和接受度极高。
