经口腔前庭入路内镜甲状腺切除术中细菌迁移的研究及综合口腔管理流程的建立

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中文摘要

背景： 经口腔前庭入路内镜甲状腺切除术（TOETVA）采用口内切口，引发了对源自口腔的手术部位感染（SSI）的担忧。可能导致TOETVA感染的细菌种类和来源尚不明确，最佳抗生素预防方案仍不清楚，缺乏针对性的围手术期管理。
材料与方法： 在这项前瞻性、非随机对照实验研究中，采用16S rDNA测序和临床回顾分析了52例TOETVA和15例开放手术患者（2025年3月至12月）的引流液。TOETVA患者被分配至三种围手术期抗生素方案：术前头孢呋辛（A组，n=18）、术后头孢呋辛（B组，n=16）或术后甲硝唑（C组，n=18）。纳入标准为T1N0M0甲状腺乳头状癌初次手术、无既往颈部放疗史、患者偏好无瘢痕颈部。主要结局为术后SSI发生率。次要结局包括引流液细菌丰度变化、脓液培养结果、不同口腔清洁方案的效果，以及引流液与消毒颈部皮肤或口腔前庭之间的微生物相关性。统计分析采用卡方检验、Kruskal-Wallis检验和Spearman相关性分析。
结果： 头孢呋辛组未发生SSI，而甲硝唑组记录到两例感染。对前30种差异丰度细菌种类的分析显示，头孢呋辛在48小时内降低了15/30（50%）的丰度，而甲硝唑仅降低4/30（13.3%）（OR：6.50，95% CI：1.90-22.26，P=0.0023）。引流液中的微生物组成与聚维酮碘消毒的下巴皮肤强相关（ρ=0.8195，95% CI：0.6865-0.8994，P<0.001）。然而，感染病例的脓液培养生长出口腔链球菌，而非皮肤菌群。在四种口腔清洁方案中，聚维酮碘最有效地降低了链球菌负荷，而替硝唑更好地保持了整体微生物群平衡。
结论： 尽管TOETVA术后引流液主要反映皮肤微生物群，但临床手术部位感染主要归因于口腔链球菌。与甲硝唑相比，头孢呋辛提供更优越的围手术期抗菌覆盖。基于临床实践考虑，综合口腔管理流程可能有助于TOETVA的治疗。
试验注册： 于2026年4月8日在中国临床试验注册中心回顾性注册（注册号：ChiCTR2600122005）。

英文摘要

BACKGROUND: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) utilizes an intraoral incision, raising concerns about surgical-site infections (SSI) originating from the oral cavity. The types and sources of bacteria that may cause TOETVA infection are not clear, and the optimal antibiotic prevention plan is still unclear, lacking targeted perioperative management.
MATERIALS AND METHODS: In this prospective, non-randomized controlled experimental study, drainage-fluid from 52 TOETVA and 15 open surgery patients (March - December 2025) was analyzed using 16S rDNA sequencing and clinical review. TOETVA patients were allocated to three perioperative antibiotic regimens: preoperative cefuroxime (Group A, n = 18), postoperative cefuroxime (Group B, n = 16), or postoperative metronidazole (Group C, n = 18). Inclusion criteria were initial surgery for T1N0M0 papillary thyroid carcinoma, no prior neck radiation, and patient preference for a scar-free neck. The primary outcome was postoperative SSI rate. Secondary outcomes included changes in drainage-fluid bacterial abundance, pus culture results, effects of different oral cleaning protocols, and microbial correlation between drainage-fluid and disinfected neck skin or oral vestibule. Statistical analyses employed the Chi-Square test, Kruskal-Wallis test, and Spearman Correlation.
RESULTS: No SSI occurred in cefuroxime group, while two infections were recorded in the metronidazole group. Analysis of the top 30 differentially abundant bacterial species showed that cefuroxime reduced the abundance of 15/30 (50%) within 48 h, compared to only 4/30 (13.3%) with metronidazole (OR: 6.50, 95% CI: 1.90-22.26, P = 0.0023). Microbial composition in drainage-fluid strongly correlated with povidone-iodine-disinfected chin skin (ρ = 0.8195, 95% CI: 0.6865-0.8994, P < 0.001). However, pus cultures from infected cases grew oral streptococci, not skin flora. Among four oral cleaning regimens, povidone-iodine most effectively reduced streptococcal load, whereas tinidazole better preserved the overall microbiota balance.
CONCLUSIONS: Although the drainage-fluid following TOETVA primarily reflects skin microbiota, clinical surgical-site infections are mainly attributed to oral streptococci. Cefuroxime provides superior perioperative antibacterial coverage compared to metronidazole. Based on clinical practice considerations, a comprehensive oral management process can be helpful for the treatment of TOETVA.
TRIAL REGISTRATION: Retrospectively registered in Chinese Clinical Trial Registry on April 8, 2026 (Registration number: ChiCTR2600122005).