분화성 갑상선암의 완결 갑상선 절제술

김명관(Myung Kwan Kim),진정수(Chung Soo Chun),진형민(Hyung Min Chin),이윤복(Yun Bok Lee),김준기(Jun Gi Kim),박우배(Woo Bae Park),서영진(Young Jin Suh) 대한두경부종양학회 1997 대한두경부 종양학회지 Vol.13 No.1

Background: Completion thyroidectomy is defined as the surgical removal of the remnant thyroid tissue following procedures less than total or near-total thyroidectomy. Although some authors advocate subtotal thyroidectomy with lower complication rates, total or completion thyroidectomy have been defended by others because of the improved survival and lower morbidity that is comparable with subtotal thyroidectomy. Objectives: The purpose of this paper is to review the necessity and safety of completion thyroidectomy for differentiated thyroid carcinoma(DTC). Materials & Methods: During the past 10 years(1986 to 1996), authors have performed 211 total thyroidectomy. Ten of these patients were treated by completion thyroidectomy for DTC. Initial operation of 7 patients had been performed at St. Vincents Hospital and 3 patients at other hospital. The medical records of patients undergoing completion thyroidectomy were retrospectively reviewed. Results: The completion thyroidectomy specimen contained residual tumor cells in 8 of the 8 patients with papillary carcinoma and none of the two patients with follicular carcinoma. Complications of completion thyroidectomy were transient hypoparathyroidism in two patients and transient unilateral recurrent laryngeal nerve palsy in one patient. But permanent complications were not noticed. Conclusion: We recommend completion thyroidectomy as an efficient and safe method of surgical treatment with a low complication rate for DTC.

편측 갑상선 절제술을 시행받은 분화 갑상선암 환장에서 Completion Thyroidectomy의 소견

김은숙,고정민,김원배,홍석준,송영기 대한내분비학회 2002 Endocrinology and metabolism Vol.17 No.5

연구배경: 수술 전 갑상선암의 세포진단이 없거나 세포검사상 악성이 분명하지 않은 환자들 중 수술 후 갑상선암이 발견되는 경우가 있는데, 이런 갑상선암 환자에서 completion thyroidectomy 조직에서 종양의 존재에 대한 예측인자를 알아보고자 하였다. 방법: 1995년 5월부터 2001년 12월까지 서울아산병원에서 세포검사상 갑상선암이 확진되지 않은 상태에서 갑상선엽 절제술 및 협부절제술을 시행받은 환자중, 조직검사상 분화된 갑상선암이 발견되어 completion thyroidectomy를 시행받은 환자 65명을 대상으로 하였다. 연령분포는 14세에서 71세(평균 39.8±12.4세)였으며, 남자 12예, 여자 53예였다. 환자들의 임상상 및 1차 수술 시의 조직 병리 소견을 기준으로 2차 수술 시 반대쪽 갑상선엽에 종양이 존재할 위험 인자를 분석하였다. 결과: 대상환자 65명의 첫 수술시 조직유형은 여포선암 45예, 유두선암 18예, 수질암 1예, insular carcinoma 1예였다. 종양의 평균 크기는 4.0±1.8㎝(범위, 0.3∼8.5㎝)이었으며, 결절의 수는 단일결절 38예, 다결절 27예였다. 국소 림프절 전이는 1예, 갑상선피막 침범소견은 4예에서 보였다. 또 전체 65예 중 27예에서 다발성으로 종양이 관찰되었다. Completion thyroidectomy 조직에서는 65예 중 22예(33.8%)에서 종양이 관찰되었다. 조직유형으로는 첫 수술에서 여포선암으로 진단된 45예 중 14예에서, 유두선암으로 진단된 18예 중 8예 종양이 발견되었다. 반대편 갑상선엽에 종양이 발견되었던 군과 그렇지 않은 군 사이에 성별, 나이, 첫 수술시의 종양의 최대크기, 종양의 세포형 등은 차이가 없었으나 첫 수술에서 종양의 다발성 유무와는 유의한 상관관계가 있었다. 결론: 편측 갑상선 절제술을 시행 받은 환자에서 갑상선암으로 진단되는 경우 종양의 다발성 유무가 completion thyroidectomy시 반대편 갑상선엽의 종양 여부를 예측할 수 있는 유일한 인자이며, 이런 경우 completion thyroidectomy의 시행이 필수적으로 생각된다. Background: In some instance, thyroid cancer may be diagnosed only after resection of a putative or suspected benign nodule. In theses cases a complete thyroidectomy is usually recommended to prevent recurrence. We analyzed the frequency of malignancy in the contralateral lobe after a complete thyroidectomy, and assessed the factors that may predict the presences of a malignancy, which might necessitate a complete thyroidectomy. Methods: Between 1995 and 2001, 65 patients, who initially underwent a lobectomy and isthrnectomy, but were finally diagnose with differentiated thyroid carcinoma, underwent complete thyroidectomies. Their mean age was 39.8±12.4 years, ranging, 14 to 71 years. After initial surgery, 45 proved to have follicular carcinomas, 18 papillary carcinomas, 1 medullary and 1 insular carcinoma. The mean tumor size was 4.0±1.8㎝, ranging from 0.3 to 8.5㎝. After a complete thyroidectomy, the presence of a tumor the at contralateral lobe was assessed according to clinical parameters and the pathological findings in the ipsilateral lobe. Results: The first surgeries revealed tumor multifocality in 27 cases, perithyroidal tumor extension in 4 and lymph node metastasis in 1. On completion of the thyroidectomy, 22 of the 65 patients had a malignancy in the contralateral lobe. Age, sex, size or the pathological primary tumor type, were not associated with the presence of additional tumors at the contralateral lobe. Tumor multifocality at the first surgery was the only significant variable to predict the presence of a tumor in the contralaeral lobe. Conclusion: When thyroid cancer is diagnosed after ipsilateral surgery, the only predictive factor for the presence of a contralateral tumor was multifocality. We believe that a complete thyroidectomy is mandatory in these cases (J Kor Soc Endocrinol 17:657∼663, 2002).

로봇 갑상선 수술

태경 대한이비인후과학회 2010 대한이비인후과학회지 두경부외과학 Vol.53 No.8

Conventional open thyroidectomy provides direct exposure to perform safe and quick operations with minimal morbidity and almost no mortality. However, the procedure leaves a scar on the anterior neck. Thyroid nodules are common in young women, who are interested not only in treatment of the disease but also in aesthetic results. As a result, a variety of minimally invasive techniques to minimize neck scars and surgical morbidity have been developed. The minimally invasive thyroidectomy technique includes mini open incision thyroidectomy, video assisted minimally invasive thyroidectomy, and pure endoscopic thyroidectomy. However, there are some limitations to endoscopic thyroidectomy in obtaining adequate surgical viewing angles,precisely manipulating endoscopic instruments and meticulously dissecting tissues. These limitations result from the narrow working space, two-dimensional operative views and the use of inadequate endoscopic instruments. Recently, robotic technology using the da Vinci surgical system robot has been applied to minimally invasive thyroid surgery to overcome the limitations of endoscopic thyroidectomy. The da Vinci surgical system robot provides a three-dimensional 10-12 x magnified view of the surgical area. It also provides hand-tremor filtration,fine motion scaling, and precise and multi-articulated hand-like motions. Robotic thyroidectomy by a gasless unilateral axillo-breast or axillary approach using da Vinci surgical system robot is safe, feasible and cosmetically excellent procedure in properly selected patients. It might have an advantage in the preservation of recurrent laryngeal nerve and parathyroid gland with magnified view. However, it is more invasive than open thyroidectomy. The postoperative pain or discomfort is comparable with open thyroidectomy. The oncologic safety of robotic thyroidectomy should be verified with long-term follow-up data. Korean J Otorhinolaryngol-Head Neck Surg 2010;53:463-9

그레이브스병의 수술적 치료방법

성태연(Tae-Yon Sung),김연선(Yon Seon Kim),이숙현(Sook Hyun Lee),윤종호(Jong Ho Yoon),홍석준(Suk-Joon Hong) 대한외과학회 2009 Annals of Surgical Treatment and Research(ASRT) Vol.77 No.2

Purpose: Subtotal thyroidectomy has been the standard operation for Graves’ disease in achieving a favorable outcome in recovery of euthyroid state. However, the postoperative outcomes following subtotal thyroidectomy differ by surgeon and postoperative thyroid dysfunctions develop as time passes. Here, we have studied the validity of total thyroidectomy for Graves’ disease patients, with a comparison to subtotal thyroidectomy. Methods: A total of 299 patients with Graves’ disease underwent thyroid operation consecutively in Asan Medical Center, Seoul, Korea from December 1995 to December 2005. Among them, 241 cases had subtotal thyroidectomy and 43 had total thyroidectomy. The subtotal thyroidectomy cases were divided into 3 groups according to estimated remnant thyroid; <4 g, 4≤∼<6 g and ≥6 g. Also, according to postoperative thyroid function, the patients were divided into euthyroid, hypothyroidism and hyperthyroidism groups. The postoperative changes of thyroid function, postoperative complications and hospital days were analyzed. Results: In subtotal thyroidectomy, postoperative thyroid function showed euthyroid in 25 (10.4%), hypothyroidism 206 (85.5%) and hyperthyroidism 10 (4.1%). However, total thyroidectomy showed no persistent hyperthyroidism or recurrence. The postoperative thyroid function state changed in 24 patients out of 148 who had more than 2 years postoperative follow-up. Hyper-functional changes developed with higher rates (Hypo-6 vs. hyper-18). The postoperative complication rate was higher in subtotal thyroidectomy including bleeding, hoarseness and hypocalcemia. Conclusion: In our study, the patients showing normal thyroid function after subtotal thyroidectomy were very limited and thyroid dysfunction developed continuously with time lapse, especially towards hyperthyroid state. Therefore, we suggest that total thyroidectomy should be considered as a treatment option in Graves’ disease.

경부-액와접근법을 이용한 내시경 갑상선절제술과 로봇하 갑상선절제술의 비교 및 고찰

박영민,임우성,문병인 대한갑상선-내분비외과학회 2012 The Koreran journal of Endocrine Surgery Vol.12 No.4

Purpose: Endoscopic and robot-assisted thyroidectomy has shown rapid development worldwide. In addition, there is no treatment of choice for thyroidectomy as usual. We propose an endoscopic thyroidectomy using a cervico-transaxillary approach, comparing its results with those of robot-assisted thyroidectomy. We present this study in order to provide advantages and disadvantages. Methods: Between January 2010 and March 2012, 132 patients were recruited with clinicopathological data for this study. We divided patients into two groups, the endoscopic and the robot groups, with respect to their clinical characteristics, surgical outcomes. The outcomes were evaluated in terms of operation time, estimated blood loss, hemovac amount, hospital stay, and number of lymph nodes harvested. Results: A total of 132 patients (male 6 and female 126) were recruited with clinicopathological data for this study. Of these, 78 patients underwent endoscopic thyroidectomy (the endo group) and 54 underwent robot-assisted thyroidectomy (the robot group) using a cervico-transaxillary approach. The two groups did not differ significantly in terms of age, estimated blood loss, and complications. None of the patients experienced severe complications. Conclusion: Results of the preliminary comparison in this study show that both approaches are safe and feasible, with similar results. However, a smaller hemovac amount was observed with endoscopic thyroidectomy, compared to robot-assisted thyroidectomy. In order to cut costs, part of robot-assisted thyroidectomy could be replaced by endoscopic thyroidectomy.

갑상선암의 내시경 갑상선 절제술에서 근전절제술 및 전절제술의 임상적 비교

유한모,김태원,배자성<SUP>1<,SUP>,조항주,김기환,안창혁,박우찬<SUP>2<,SUP>,이동호<SUP>3<,SUP>,김정수,Han Mo Yoo,M,D,Tae Won Kim,M,D,Ja Sung Bae,M,D,<SUP>1<,SUP>,Hang Joo Cho,M,D,Kee Hwan Kim,M,D,Chang Hyuk An,M,D,Woo Chan Park,M 대한갑상선-내분비외과학회 2009 The Koreran journal of Endocrine Surgery Vol.9 No.4

Purpose: The aim of this study was to evaluate and compare the surgical outcomes of endoscopic total and near-total thyroidectomies in patients with thyroid cancer. Methods: Between February 2000 and January 2009, among 387 patients who underwent endoscopic thyroidectomy in our hospital, we evaluated 50 patients who underwent endoscopic total or near-total thyroidectomy. Thirty- five and 15 patients underwent endoscopic total thyroidectomy and near-total thyroidectomy, respectively. We analyzed the patients' clinicopathologic characteristics and post-operative complications between the two groups. Results: The mean size of tumors was 1.08 cm (range, 0.1∼3.5 cm) and the mean operative time was 192 minutes. Forty-nine tumors were papillary cancers and 1 tumor was a follicular cancer. Two patients in the endoscopic total thyroidectomy group underwent re-operation because of bleeding. In the near-total thyroidectomy group, one patient had transient hypocalcemia and one patient had temporary recurrent laryngeal nerve palsy. In the total thyroidectomy group, nine patients had transient hypocalcemia and one patient had temporary recurrent laryngeal nerve palsy. There was no statistical difference in the post-operative complicationrates between the two groups (P=0.254 for hypocalcemia and P=0.470 for injury to the recurrent laryngeal nerve). Conclusion: Based on our experience, endoscopic total thyroidectomy is a safe and feasible alternative to endoscopic near-total thyroidectomy. (Korean J Endocrine Surg 2009; 9:201-205)

갑상선 악성종양의 내시경하 갑상선 절제술

이승아,배자성,김기환,김지일,안창혁,박우찬,송병주,정상설,김정수,Seung Ah Lee,M.D.,Ja Seong Bae,M.D.,Kee Hwan Kim,M.D.,Ji Il Kim,M.D.,Chang Hyuck An,M.D.,Ph.D.,Woo Chan Park,M.D.,Ph.D.,Byung Joo Song,M.D.,Ph.D.,Sang Seol Jung,M.D 대한갑상선-내분비외과학회 2007 The Koreran journal of Endocrine Surgery Vol.7 No.2

Purpose: Endoscopic surgery to treat thyroid neoplasm was developed to solve the aesthetic problems that resulted from conventional open surgery. Although endoscopic thyroidectomy was initially performed in patients with benign thyroid neoplasm, its use has recently been extended to patients with Graves's disease and early cases of thyroid cancer.The purpose of this study was to determine whether this surgical approach is feasible and safe for the treatment of thyroid cancer. Methods: Between December 1999 and April 2006, 132 thyroid cancer patients at our institution were treated by either conventional thyroidectomy or endoscopic thyroidectomy. Endoscopic thyroidectomy was conducted using a gasless anterior neck skin lifting method. The inclusion criteria for endoscopic thyroidectomy in thyroid cancer patients included a tumor size of less than 2cm, absence of extrathyroidal extension, absence of cervical lymph node metastasis, and well differentiated cancers. Results: We performed endoscopic thyroidectomy in 29 thyroid cancer patients. There were no significant differences in operative time, the amount of drainage and the number of retrieved lymph nodes between conventional thyroidectomy and endoscopic thyroidectomy. In addition, although endoscopic thyroidectomy was associated with more complications, it was also associated with a shorter hospital stay. Conclusion: The completeness of surgical resection conducted via an endoscopic thyroidectomy may be comparable to that of conventional surgery, however, a larger series and longer follow-up evaluation are necessary for definitive conclusions to be drawn about its oncologic validity. (Korean J Endocrine Surg 2007;7:103-106)

Total Thyroidectomy in the Mouse: the Feasibility Study in the Non-thyroidal Tumor Model Expressing Human Sodium/Iodide Symporter Gene

Shim, Hye-Kyung,Kim, Seog-Gyun,Kim, Tae-Sung,Kim, Seok-Ki,Lee, Sang-Jin The Korea Society of Nuclear Medicine 2011 핵의학 분자영상 Vol.45 No.2

Purpose This study sought to probe the feasibility of performing total thyroidectomy in the mouse using a nonthyroidal hNIS expressing tumor model. Materials and Methods Our thyroidectomy protocol included thorough excision of both lobes and the isthmus. For evaluating the completeness of thyroidectomy, we compared the $^{99m}Tc$-pertechnetate scans taken before and after thyroidectomy. The prostate cancer cell line was subcutaneously inoculated 2 weeks after the thyroidectomy. When the tumor reached 5-10 mm in diameter, Ad5/35-E4PSESE1a-hNIS was injected intratumorally, and $^{131}I$ scans were performed. The radioiodine uptakes of the neck and the tumor were compared with those of the other regions. Results Total thyroidectomy was performed in 13 mice. Although 38.5% died during or just after thyroidectomy, the others survived in good health for 2 months. Thyroid tissue was completely eliminated using our protocol; the residual uptake of $^{99m}Tc$-pertechnetate was minimal in the neck area. The neck/background uptake ratio after thyroidectomy was significantly lower than that before thyroidectomy (p<0.05). Non-thyroidal tumor models were successfully established in all the surviving mice. Radioiodine accumulation in the tumors was visualized on $^{131}I$ scans, and the neck uptakes were minimal. Conclusion Using our total thyroidectomy protocol, we successfully established a hNIS-transfected prostate cancer model with a minimal accumulation of radioiodine in the neck. The relatively high mortality after surgery can be a problem, and this might be reduced by minimizing the surgical stress.

Robotic thyroidectomy: Evolution and Outcomes

송창면,태경 한양대학교 의과대학 2016 Hanyang Medical Reviews Vol.36 No.4

Recently robotic thyroidectomy has gained its popularity for the treatment of differentiated thyroid cancer and benign thyroid tumors. It has been developed to overcome the drawbacks of conventional open trans-cervical thyroidectomy, which is an apparent neck wound that is visible unless concealed with clothes. Robotic thyroidectomy provides surgeons with three-dimensional magnified view and multiarticulated robotic arms that can stabilize hand tremors. It also has advantages over conventional trans-cervical thyroidectomy that include recovery of voice symptoms and acoustic parameters along with superior cosmetic outcomes. Robotic thyroidectomy results in equivalent surgical outcomes including oncologic safety and complications compared with conventional thyroidectomy. Various approaches including transaxillary, postauricular facelift, and breast-axillary approaches have been developed for robotic thyroidectomy. Recently, the indication of robotic surgery has been extended to neck dissection of the lateral compartment. Herein we summarize the indication, procedures, and efficacy of robotic thyroidectomy, and also introduce our experience with robotic thyroidectomy.

단일 기관에서의 기존 갑상선 수술과 무기하 및 가스주입 전흉부접근 내시경 갑상선절제술의 임상적 고찰

김미형(Mi-hyeong Kim),김태원(Tae-won Kim),김기환(Kee-hwan Kim),안창혁(Chang-hyeok An),배자성(Ja-sung Bae),박우찬(Woo-chan Park),김정수(Jeong-soo Kim) 대한외과학회 2010 Annals of Surgical Treatment and Research(ASRT) Vol.79 No.6

Purpose: After the first endoscopic thyroidectomy by Huscher in 1997, several surgeons reported their experiences with endoscopic thyroidectomies. And these papers showed that clinical outcomes of endoscopic thyroidectomy are similar to conventional thyroidectomy. But, there was no randomized prospective trial to determine which approach of endoscopic thyroidectomy achieved better results. We evaluated clinical data of gasless and gas insufflation endoscopic thyroidectomies with conventional thyroidectomy to define its advantages or disadvantages. Methods: Between 1999 and 2009, 1,117 patients underwent thyroidectomies (1,149 cases). 747 cases was performed by conventional open method, 402 cases by endoscopic thyroidectomy. Among them, 317 cases were operated by gasless techniques and 85 cases by carbon dioxide gas insufflation. Results: Between conventional and endoscopic thyroidectomy groups, operation time, hospitalization period, tumor size, and number of retrieved lymph nodes were similar (P-value >0.05). Among 441 thyroid cancer patients, 19 had recurrence, of which 15/301 (4.98%) had conventional thyroidectomy, and 4/140 (2.85%) had endoscopic thyroidectomy. After postoperative radioactive iodine therapy, follow-up Tg levels were checked in 274 patients, the levels were <2.0 ng/㎖ in 87.63% (163/186) of patients after conventional thyroidectomies and in 93.18 % (82/88) following endoscopic thyroidectomies. There were no significant differences (P-value=0.58). Complication incidences (hypocalcemia, hoarseness, bleeding, wound infection) in both groups were not significantly distinctive (P-value=0.58). Conclusion: Minimally invasive techniques are generally applied even for malignancy in selected cases because of its advantages, such as cosmetic results. Through this study, we showed similar clinical outcomes of conventional and gasless or gas insufflations endoscopic thyroidectomy.