经口联合颌下腔镜甲状腺手术并发症与手术时长的影响因素分析

Key factors affecting complications and operative time in endoscopic thyroidectomy via oral vestibule and submandibular approach

摘要:

背景与目的 为克服传统经口腔前庭入路甲状腺手术操作空间狭小、并发症发生的风险高等问题，笔者团队提出一种改良术式——经口联合颌下腔镜甲状腺手术（ETOSA），其安全性与可行性已在初步研究中得到证实。本研究旨在系统评估ETOSA术式中影响术后并发症和手术时长的关键因素，探讨关键因素交互作用，并建立学习曲线模型，以期为术式推广提供依据。方法 回顾性分析2022年3月—2023年3月在中南大学湘雅医院接受ETOSA的125例甲状腺乳头状癌患者的临床资料。提取临床特征、手术相关参数及术后并发症数据，采用随机森林模型识别与并发症和手术时长相关的主要影响因子及其交互效应，并利用病例序号的偏依赖图构建学习曲线。结果 125例患者均顺利完成ETOSA手术，无中转开放病例。中位手术时长95.0 min，中位出血量15.0 mL。术后总并发症发生率为16.0%，无永久性甲状旁腺功能减退或低钙血症发生。平均颈部外观评分为1.05，患者满意度高。随机森林模型分析显示，病例序号、手术范围、中央区淋巴结检出数（LNY）、桥本氏甲状腺炎（HT）及体质量指数（BMI）为影响并发症的关键因素，而手术范围、病例序号、LNY、HT及术中出血量则为影响手术时长的关键因素。病例序号与手术范围及HT之间存在明显正向交互作用，尤其在前20例中更为显著。学习曲线显示手术技术在第20例后趋于成熟，熟练阶段的手术时长及并发症发生率明显低于学习阶段（90.0 min vs. 102.5 min；11.4% vs. 40.0%，均P<0.05）。结论 ETOSA术式安全、可行，具有创伤小、美容效果佳、学习曲线短等优势，病例序号、手术范围、LNY、HT、BMI及术中出血量可以明显影响ETOSA的并发症和手术时长。

Abstract:

Background and Aims To overcome the limitations of the transoral endoscopic thyroidectomy vestibular approach, such as restricted operative space and high complication risks, our team proposed a modified technique—endoscopic thyroidectomy via oral vestibule and submandibular approach (ETOSA). Preliminary studies have confirmed its safety and feasibility. This study aims to systematically evaluate the key factors affecting postoperative complications and operative time in ETOSA, explore the interactions among these variables, and construct a learning curve model to support its broader clinical adoption.Methods A retrospective analysis was conducted on 125 patients with papillary thyroid carcinoma who underwent ETOSA at Xiangya Hospital, Central South University, between March 2022 and March 2023. Clinical characteristics, surgical parameters, and postoperative complications were extracted. A random forest model was employed to identify the major influencing factors for complications and operative time, as well as their interaction effects. Partial dependence plots based on case sequence were used to generate the learning curve.Results All 125 patients successfully underwent ETOSA with no conversion to open surgery. The median operative time was 95.0 min, and the median intraoperative blood loss was 15.0 mL. The overall postoperative complication rate was 16.0%, with no cases of permanent hypoparathyroidism or hypocalcemia. The average neck appearance score was 1.05, indicating high patient satisfaction. The random forest analysis identified case number, surgical extent, lymph node yield (LNY), Hashimoto's thyroiditis (HT), and body mass index (BMI) as the key predictors of postoperative complications, while surgical extent, case number, LNY, HT, and blood loss were the key factors affecting operative time. A significant positive interaction was observed between case number and both surgical extent and HT, particularly in the first 20 cases, suggesting a higher risk during the early learning phase. The learning curve analysis indicated that surgical proficiency stabilized after 20 cases. Operative time and complication rate in the proficient phase were significantly lower than those in the learning phase (90.0 min vs. 102.5 min; 11.4% vs. 40.0%, both P<0.05).Conclusion ETOSA is a safe and feasible technique characterized by minimal invasiveness, favorable cosmetic outcomes, and a relatively short learning curve. case number, surgical extent, LNY, HT, BMI, and blood loss are key factors affecting complications and operation time.