改良锁骨上入路用于单侧甲状腺微小乳头状癌的甲状腺半切除联合中央区颈淋巴结清扫：一项以可行性为重点的回顾性队列研究

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中文摘要

背景： 传统开放甲状腺切除术可为甲状腺半切除联合中央区颈淋巴结清扫提供可靠显露，但会留下可见的颈前瘢痕。远程入路可能改善美容效果，但通常需要专用设备、更长的手术时间和更高的技术复杂性。本研究评估了改良锁骨上入路在经选择的单侧甲状腺微小乳头状癌（PTMC）患者中的可行性和围手术期结局。
方法： 这项单中心回顾性队列研究纳入130例单侧PTMC患者，这些患者在2023年6月至2026年1月期间接受了甲状腺半切除联合峡部切除及中央区颈淋巴结清扫。患者被分为三个手术组：改良锁骨上入路、锁骨下内镜入路和传统正中开放入路。评估了围手术期结局、中央区淋巴结检出数、术后第1天甲状旁腺激素水平、住院费用、并发症、切口相关结局和学习曲线。为解决基线不平衡，改良锁骨上入路与传统正中开放入路之间的主要比较采用基于年龄、性别、体质指数（BMI）、合并症状态、桥本甲状腺炎、肿瘤大小、肿瘤侧别和肿瘤位置的倾向评分重叠加权进行分析。
结果： 在纳入的130例患者中，29例接受改良锁骨上入路，65例接受传统正中开放甲状腺切除术，36例接受锁骨下内镜入路，后者作为机构背景队列保留。在与正中开放组的主要比较中，对相关协变量进行调整后，未检测到手术时间或中央区淋巴结检出数存在统计学显著差异。改良锁骨上入路组未发生术中中转。未记录到需要再次手术的术后血肿、临床怀疑的永久性喉返神经功能障碍或永久性甲状旁腺功能减退。改良锁骨上入路组的术后疼痛评分较低，颈部不适较少见，尽管这些主观结局应谨慎解读，因为评估是回顾性且非盲法的。未使用经过验证的瘢痕量表评估其相对于传统开放或远程入路甲状腺切除术的美容优越性。累积和（CUSUM）分析发现手术表现在第14例附近出现大致转折。
结论： 在经选择的单侧PTMC患者中，对于已经计划行甲状腺半切除联合同侧中央区颈淋巴结清扫者，改良锁骨上入路作为一种替代性颈部入路在技术上似乎是可行的。在与传统正中开放甲状腺切除术的主要校正比较中，未检测到手术时间或中央区淋巴结检出数存在统计学显著差异，且未发生术中中转。这些发现应被视为探索性，不能确立等效性、非劣效性、美容优越性或长期肿瘤学有效性。

英文摘要

BACKGROUND: Conventional open thyroidectomy provides reliable exposure for hemithyroidectomy and central neck dissection but leaves a visible anterior cervical scar. Remote-access approaches may improve cosmetic outcomes but often require specialized equipment, longer operative time, and greater technical complexity. This study evaluated the feasibility and perioperative outcomes of a modified supraclavicular approach in selected patients with unilateral papillary thyroid microcarcinoma (PTMC).
METHODS: This single-center retrospective cohort study included 130 patients with unilateral PTMC who underwent hemithyroidectomy with isthmusectomy and central neck dissection between June 2023 and January 2026. Patients were categorized into three surgical groups: modified supraclavicular approach, infraclavicular endoscopic approach, and conventional midline open approach. Perioperative outcomes, central lymph node yield, postoperative day 1 parathyroid hormone levels, hospitalization costs, complications, incision-related outcomes, and the learning curve were assessed. To address baseline imbalance, the primary comparison between the modified supraclavicular and conventional midline open approaches was analyzed using propensity score overlap weighting based on age, sex, body mass index (BMI), comorbidity status, Hashimoto's thyroiditis, tumor size, tumor side, and tumor location.
RESULTS: Among the 130 patients included, 29 underwent the modified supraclavicular approach, 65 underwent conventional midline open thyroidectomy, and 36 underwent the infraclavicular endoscopic approach, which was retained as an institutional contextual cohort. In the primary comparison with the midline open group, no statistically significant difference was detected in operative time or central lymph node yield after adjustment for relevant covariates. No intraoperative conversion occurred in the modified supraclavicular group. No postoperative hematoma requiring reoperation, clinically suspected permanent recurrent laryngeal nerve dysfunction, or permanent hypoparathyroidism was documented. The modified supraclavicular group had lower postoperative pain scores and less frequent neck discomfort, although these subjective outcomes should be interpreted cautiously because assessment was retrospective and unblinded. Cosmetic superiority over conventional open or remote-access thyroidectomy was not assessed using a validated scar scale. Cumulative sum (CUSUM) analysis identified an approximate transition in operative performance at case 14.
CONCLUSIONS: In selected patients with unilateral PTMC for whom hemithyroidectomy with ipsilateral central neck dissection had already been planned, the modified supraclavicular approach appeared technically feasible as an alternative cervical access route. In the primary adjusted comparison with conventional midline open thyroidectomy, no statistically significant differences were detected in operative time or central lymph node yield, and no intraoperative conversion occurred. These findings should be considered exploratory and do not establish equivalence, non-inferiority, cosmetic superiority, or long-term oncological effectiveness.