Kraimps J L, Marechaud R, Gineste D, Fieuzal S, Metaye T, Carretier M, Barbier J
Department of Surgery, Jean Bernard Hospital, Poitiers University, France.
Surg Gynecol Obstet. 1993 Apr;176(4):319-22.
The current study was done to analyze our experience with recurrent goiter. Prevention must be stressed because reoperations of the thyroid gland present technical difficulties and are associated with an increased risk of hypoparathyroidism and permanent hoarseness. Nodular recurrences occurred in 36 of 1,456 patients (2.5 percent) who underwent thyroidectomy between 1968 and 1983. All patients had the initial operation at Jean Bernard Hospital, Poitiers, France, and had follow-up evaluation from five to 20 years. Multinodular goiter accounted for 70 percent of the recurrences. Sixty percent of the recurrences were in patients with multinodular goiters. Recurrent goiter was usually first detected about eight years after thyroidectomy. Thirty patients with recurrence had reoperations. Two patients had paralysis of the vocal cord and one patient had permanent hypoparathyroidism. Recurrent goiter may occur because of the development of new nodules (true recurrence) or because of the growth of "residual" or persistent macroscopic or microscopic nodules left at the previous thyroid operation. Intraoperative digital palpation of the entire thyroid gland is essential for detecting residual macroscopic thyroid nodules, and all enlarged nodules should be removed. Thyroid-stimulating hormone (TSH) suppressive therapy is recommended by some authorities to prevent "true" recurrences, although its efficacy is debated. Since recurrence is uncommon in the current series, perhaps TSH suppressive therapy should only be used in high-risk patients. In the current experience, only the multinodular character of the nodules in euthyroid patients has a significant correlation with subsequent development of recurrent goiter (p < 0.01), and one must consider patients with multinodular goiter at risk for recurrence. Once TSH treatment is begun, it will logically be continued for life. Total thyroidectomy has been recommended by some endocrine surgeons for treating patients with multinodular goiter. We prefer subtotal thyroidectomy and reserve total thyroidectomy for patients when no normal thyroid tissue can be preserved because only 2.5 percent of the patients in the current study had recurrent goiter. Prevention of residual nodules is probably best assured by systematic palpation during operation of the two thyroid lobes. This considerably lessens the risk of recurrence. Since nodular recurrences occurred in only 2.5 percent of the patients in the current study, although multinodular goiter must be considered at risk for recurrence, we do not recommend systematic total thyroidectomy in multinodular goiter.
本研究旨在分析我们在复发性甲状腺肿方面的经验。必须强调预防，因为甲状腺再次手术存在技术困难，且与甲状旁腺功能减退和永久性声音嘶哑的风险增加相关。在1968年至1983年间接受甲状腺切除术的1456例患者中，有36例（2.5%）出现结节复发。所有患者均在法国普瓦捷的让·伯纳德医院接受了初次手术，并进行了5至20年的随访评估。多结节性甲状腺肿占复发病例的70%。60%的复发患者患有多结节性甲状腺肿。复发性甲状腺肿通常在甲状腺切除术后约八年首次被发现。30例复发患者接受了再次手术。2例患者出现声带麻痹，1例患者出现永久性甲状旁腺功能减退。复发性甲状腺肿可能是由于新结节的形成（真正的复发），或者是由于上次甲状腺手术时遗留的“残余”或持续存在的肉眼或显微镜下可见的结节生长所致。术中对整个甲状腺进行手指触诊对于发现残留的肉眼可见的甲状腺结节至关重要，所有增大的结节均应切除。一些权威机构推荐使用促甲状腺激素（TSH）抑制疗法来预防“真正的”复发，尽管其疗效存在争议。由于在本系列研究中复发并不常见，或许TSH抑制疗法仅应在高危患者中使用。在目前的经验中，仅甲状腺功能正常患者结节的多结节特征与随后复发性甲状腺肿的发生有显著相关性（p<0.01），必须将多结节性甲状腺肿患者视为有复发风险。一旦开始TSH治疗，理论上应终身持续。一些内分泌外科医生推荐对多结节性甲状腺肿患者进行甲状腺全切除术。我们更倾向于次全甲状腺切除术，仅在无法保留正常甲状腺组织时才对患者进行甲状腺全切除术，因为在本研究中只有2.5%的患者出现复发性甲状腺肿。通过在手术中对两个甲状腺叶进行系统触诊，可能最能确保预防残留结节。这可大大降低复发风险。由于在本研究中只有2.5%的患者出现结节复发，尽管必须将多结节性甲状腺肿视为有复发风险，但我们不建议对多结节性甲状腺肿患者常规进行甲状腺全切除术。
