避免胸骨切开：混合颈部和机器人辅助胸腔镜切除术与胸骨切开术治疗胸骨后甲状腺肿的围手术期结局比较

文献信息

中文摘要

背景： 胸骨后甲状腺肿偶尔需要胸骨切开以确保安全切除。混合颈部入路联合机器人辅助胸腔镜手术提供了一种创伤更小的替代方案，尽管在美国应用不足。我们报告了美国最大的比较混合入路与胸骨切开术的系列之一。
方法： 我们进行了一项回顾性队列研究，纳入2012年至2023年间在单一三级学术中心进行的7,370例甲状腺切除术。通过术前计算机断层扫描成像识别出甲状腺肿延伸至胸骨切迹以下的患者。当根据术前影像和多学科评估预计需要纵隔松解时，胸外科协助参与。需要胸外科参与的患者被分为3个手术组：混合颈部甲状腺切除术联合机器人辅助胸腔镜手术、胸骨切开术、或颈部甲状腺切除术联合深部纵隔解剖。比较混合组与胸骨切开术组的围手术期结局，包括手术时间、失血量、胸管使用、重症监护室入住、住院时间和术后并发症。并发症包括低钙血症、喉返神经损伤和声音改变。连续变量和分类变量使用适当的参数和非参数统计检验进行比较。
结果： 在34例需要胸外科协助的患者中，16例接受了混合颈部甲状腺切除术联合机器人辅助胸腔镜手术，13例接受了胸骨切开术。两组基线人口统计学相似，包括年龄（62 ± 13 vs 58 ± 10岁）、女性性别（56% vs 46%）和体重指数（33.7 ± 7.4 vs 32.1 ± 8.7）。混合组和胸骨切开术组的种族分布分别为37.5% vs 76.9%黑人和62.5% vs 23.1%白人。两组术前症状相当。手术结局有利于混合入路，包括更短的手术时间（3.2 vs 5.0小时，P < .001）、更低的估计失血量（180 [120-250] vs 344 [200-533]，P < .001）、更短的住院时间（2 vs 4天，P < .001）和更少的胸管使用（25% vs 92%，P < .001）。混合组重症监护室入住率更低（13% vs 29%）。低钙血症（14%）、声音嘶哑（29%）和喉返神经损伤（7%）的发生率在两组间相似。术中并发症和围手术期死亡仅发生在胸骨切开术组（15%）。
结论： 混合颈部甲状腺切除术联合机器人辅助胸腔镜手术松解与胸骨切开术相比，与改善的围手术期结局相关，对于需要胸腔入路的特定胸骨后甲状腺肿患者，可能代表一种安全的微创替代方案。

英文摘要

BACKGROUND: Substernal goiters occasionally require sternotomy for safe resection. Hybrid cervical and robotic-assisted thoracoscopic surgery offers a less invasive alternative, though it is underutilized in the United States. We report one of the largest United States series comparing hybrid and sternotomy approaches.
METHODS: We performed a retrospective cohort study of 7,370 thyroidectomies performed at a single tertiary academic center between 2012 and 2023. Patients with substernal goiters extending below the sternal notch on preoperative computed tomography imaging were identified. Thoracic surgical assistance was involved when mediastinal mobilization was anticipated based on preoperative imaging and multidisciplinary evaluation. Patients requiring thoracic involvement were categorized into 3 operative groups: hybrid cervical thyroidectomy with robotic-assisted thoracoscopic surgery, sternotomy, or cervical thyroidectomy with deep mediastinal dissection. Perioperative outcomes, including operative time, blood loss, chest tube use, intensive care unit admission, length of stay, and postoperative complications, were compared between hybrid and sternotomy groups. Complications included hypocalcemia, recurrent laryngeal nerve injury, and voice changes. Continuous and categorical variables were compared using appropriate parametric and nonparametric statistical tests.
RESULTS: Among 34 patients requiring thoracic surgical assistance, 16 underwent hybrid cervical thyroidectomy with robotic-assisted thoracoscopic surgery, and 13 underwent sternotomy. Baseline demographics were similar between groups, including age (62 ± 13 vs 58 ± 10 years), female sex (56% vs 46%), and body mass index (33.7 ± 7.4 vs 32.1 ± 8.7). Racial distribution within the hybrid and sternotomy groups was 37.5% vs 76.9% Black and 62.5% vs 23.1% White, respectively. Preoperative symptoms were comparable between groups. Operative outcomes favored the hybrid approach, including shorter operative time (3.2 vs 5.0 hours, P < .001), lower estimated blood loss (180 [120-250] vs 344 [200-533], P < .001), shorter hospital stay (2 vs 4 days, P < .001), and fewer chest tubes (25% vs 92%, P < .001). Intensive care unit admission occurred less frequently in the hybrid group (13% vs 29%). Rates of hypocalcemia (14%), hoarseness (29%), and recurrent laryngeal nerve injury (7%) were similar between groups. Intraoperative complications and perioperative mortality occurred only in the sternotomy group (15%).
CONCLUSION: Hybrid cervical thyroidectomy with robotic-assisted thoracoscopic surgery mobilization was associated with improved perioperative outcomes compared with sternotomy and may represent a safe minimally invasive alternative for select patients with substernal goiters requiring thoracic access.