微创医学

目的通过前瞻性随机对照研究，比较三种不同甲状腺术式的创伤影响。方法150例患者按随机分配原则分为三组，每组50例，COT组采用常规开放甲状腺手术、EAT组采用腔镜辅助手术、TET组采用全腔镜手术。比较三组手术时间、术中出血量、不同时段外周血C反应蛋白（CRP）的水平、术后第1天引流量、术后拔管时间、术后第1天疼痛视觉模拟评分、切口美容满意度、术后3个月吞咽不适感等方面的差异。结果（1）所有手术均完成患侧腺叶切除（106例）或部分切除（44例）。EAT组、COT组中，未出现中转开放手术的病例。三组均无气管、甲状旁腺损伤以及不可控的术中大出血等并发症发生。术中冰冻切片病理结果均为良性。（2）三组手术时间、术中出血量、术后第1天引流量及拔管时间比较，差异均有统计学意义（P＜0.05）。TET组的手术时间最长，COT组最短；TET组、EAT组的术中出血量明显少于 COT组；EAT组的术后第1天引流量最少，TET组最多；EAT组拔管时间明显短于TET组、COT组（均P＜0.05）。（3）三组患者术后6 h、24 h、72 h的CRP水平比较，差异均有统计学意义（P＜0.05）。术后6 h，TET组CRP明显高于EAT组、COT组；术后24 h EAT组最低；术后72 h的CRP以EAT组最低、 TET组最高（均P＜0.05）。（4）三组患者术后第1天疼痛视觉模拟评分、美容满意度、术后3个月吞咽不适感比较，差异均有统计学意义（P＜0.05）。EAT组术后第1天疼痛感明显低于TET组、COT组；TET组美容满意度最高，COT组最低；EAT组术后3个月吞咽不适感最轻，TET组最重（均P＜0.05）。结论三种手术方式均为安全手术方式，就总体创伤性影响而言，腔镜辅助甲状腺手术应该是创伤最小的手术方式。临床实践中应根据患者美容需求和病情决定手术方式。

ObjectiveTo compare the traumatic effects of three different thyroid surgery procedures in a prospective, randomized-controlled trial. MethodsA total of 150 patients were divided into three groups according to the principle of random allocation, with 50 cases in each group. Conventional open thyroidectomy (COT) in the COT group, endoscopic assisted thyroidectomy (EAT) in the EAT group , and totally endoscopic thyroidectomy (TET) was performed in the TET group. The differences in operation duration, intraoperative blood loss, levels of peripheral blood C-reactive protein (CRP) during different periods, drainage volume on the first day after operation, postoperative extubation time, visual analogue scale pain score on the first day after operation, satisfaction with incision cosmetic effect, and swallowing discomfort 3 months after operation were compared among the three groups. Results(1) All operations were accomplished successfully, of which 106 underwent total resection of the affected gland lobe and 44 underwent partial resection. No conversion to open surgery occurred in the EAT and COT groups. There were no complications such as trachea injury, parathyroid gland injury and uncontrollable intraoperative massive hemorrhage among the three groups. The pathological results of intraoperative frozen sections were all benign. (2) There were statistically significant differences in operation duration, intraoperative blood loss, drainage volume on the first day after operation, and extubation time among the three groups (P＜0.05). The longest operation duration was reported in the TET group, and the shortest in the COT group; the TET and EAT groups exhibited a significantly less intraoperative blood loss than the COT group; the minimum drainage volume on day 1 postoperatively was reported in the EAT group, and the maximum in the TET group; the extubation time in the EAT group was significantly shorter than that in the TET and COT groups (all P＜0.05). (3) CRP levels 6, 24 and 72 hours after operation showed statistically significant differences among the three groups (P＜0.05). Six hours after operation, the TET group got significantly higher CRP than the EAT and COT groups; 24 hours after operation, the lowest CRP was observed in the EAT group; 72 hours after operation, the EAT group had the lowest CRP, and the TET group got the highest one(all P＜0.05). (4) There were statistically significant differences in VAS score on the first day after operation, satisfaction with cosmetic effect, and swallowing discomfort 3 months after operation among the three groups (P＜0.05). The EAT group got significantly milder pain on the first day after operation than the TET and COT groups; the TET group had the highest satisfaction with cosmetic effect, and the COT group got the lowest one; the EAT group reported the mildest swallowing discomfort 3 months after operation, and the TET group suffered the condition most severely (all P＜0.05). ConclusionAll of the three surgical procedures are safe. EAT should be the surgical procedure with the minimum trauma in terms of overall effect of trauma. Option of surgical procedure should depend on patients′ cosmetic demands and their conditions in clinical practice.