{"id":2596,"date":"2013-05-21T09:52:56","date_gmt":"2013-05-21T09:52:56","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2596"},"modified":"2013-06-08T07:02:38","modified_gmt":"2013-06-08T07:02:38","slug":"5-diagnostika-a-lecba-onemocneni-stitne-zlazy","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=2596","title":{"rendered":"5 Diagnostika a l\u00e9\u010dba onemocn\u011bn\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy"},"content":{"rendered":"<h4>5.1 \u00davod<\/h4>\n<p style=\"text-align: justify;\">Onemocn\u011bn\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy je nej\u010dast\u011bj\u0161\u00edm endokrinn\u00edm posti\u017een\u00edm v na\u0161\u00ed i sv\u011btov\u00e9 populaci. I v dne\u0161n\u00ed dob\u011b existuje cel\u00e1 \u0159ada rozporupln\u00fdch n\u00e1zor\u016f na indikaci k operaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy, na techniku i taktiku opera\u010dn\u00edho v\u00fdkonu. Interdisciplin\u00e1rn\u00ed spolupr\u00e1ce, zejm\u00e9na mezi endokrinology a chirurgy, sm\u011b\u0159uje v posledn\u00edch patn\u00e1cti letech ke zv\u00fd\u0161en\u00e9 radikalit\u011b opera\u010dn\u00edch v\u00fdkon\u016f. Stoupaj\u00edc\u00ed radikalita v chirurgii \u0161t\u00edtn\u00e9 \u017el\u00e1zy tak vedla mnoh\u00e9 autory k rozpracov\u00e1n\u00ed \u0159ady metod a postup\u016f, v\u010detn\u011b kr\u010dn\u00ed a mediastin\u00e1ln\u00ed lymfadenektomie. Spr\u00e1vn\u011b zvolen\u00e9 opera\u010dn\u00ed postupy jsou prevenc\u00ed vzniku recidiv s men\u0161\u00edm v\u00fdskytem zejm\u00e9na pozdn\u00edch reoperac\u00ed, a t\u00edm i men\u0161\u00edm v\u00fdskytem mo\u017en\u00fdch komplikac\u00ed. St\u00e1le diskutovanou ot\u00e1zkou z\u016fst\u00e1v\u00e1 ochrana nervus laryngeus recurrens, jeho\u017e poran\u011bn\u00ed je v\u00e1\u017enou komplikac\u00ed, v\u00fdrazn\u011b zhor\u0161uj\u00edc\u00ed kvalitu \u017eivota. V\u00fdvoj postup\u016f vedouc\u00edch k ochran\u011b tohoto nervu sm\u011b\u0159oval od po\u010d\u00e1te\u010dn\u00ed p\u0159\u00edsn\u00e9 preparace p\u0159i pouzdru \u017el\u00e1zy k jeho identifikaci, vizualizaci a preparaci. Doposud nen\u00ed stanovena jednotn\u00e1 v\u0161eobecn\u011b akceptovan\u00e1 doktr\u00edna, jak minimalizovat riziko peropera\u010dn\u00ed l\u00e9ze vratn\u00e9ho nervu. P\u0159esto v\u0161ak pokl\u00e1d\u00e1me identifikaci tohoto nervu, a t\u00edm i jeho ochranu za podstatnou.Novodobou metodou v prevenci poran\u011bn\u00ed tohoto nervu je metoda neurostimulace nervus laryngeus recurrens. V \u010cesk\u00e9 republice byla zavedena do praxe na II. chirurgick\u00e9 klinice FN v Olomouci v roce 2005. Na tomto pracovi\u0161ti se stala standardn\u00edm postupem v pr\u016fb\u011bhu tot\u00e1ln\u00ed lobektomie \u010di tot\u00e1ln\u00ed tyreoidektomie, minimalizuj\u00edc\u00ed riziko peropera\u010dn\u00edho poran\u011bn\u00ed vratn\u00e9ho nervu.<\/p>\n<h4>5.2 Anatomie a fyziologie \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h4>\n<p style=\"text-align: justify;\">\u0160t\u00edtn\u00e1 \u017el\u00e1za je endokrinn\u00edm org\u00e1nem, kter\u00fd m\u00e1 \u00fazk\u00fd vztah k laryngu a chrupavce \u0161t\u00edtn\u00e9. Je ulo\u017eena v \u00farovni obrat\u016f C5\u2013Th1. Pr\u016fm\u011brn\u00e1 velikost laloku ve t\u0159ech rovin\u00e1ch je 5 \u00d7 3 \u00d7 2 cm. V\u00e1ha \u017el\u00e1zy se pohybuje mezi 20\u201330g. \u0160t\u00edtn\u00e1 \u017el\u00e1za sest\u00e1v\u00e1 z prav\u00e9ho a lev\u00e9ho laloku, kter\u00e9 jsou propojen\u00e9 r\u016fzn\u011b \u0161irok\u00fdm m\u016fstkem, istmem. Laloky jsou k\u00f3nick\u00e9ho tvaru s r\u016fzn\u011b vyvinut\u00fdm dorzolater\u00e1ln\u00edm v\u00fdb\u011b\u017ekem, tuberculum Zuckerkandli, kter\u00fd m\u016f\u017ee p\u0159ekr\u00fdvat nervus laryngeus recurrens. Istmus \u0161t\u00edtn\u00e9 \u017el\u00e1zy je nej\u010dast\u011bji lokalizov\u00e1n mezi druh\u00fdm a \u010dtvrt\u00fdm prstencem pr\u016fdu\u0161nice, v\u011bt\u0161inou t\u011bsn\u011b pod chrupavkou prstencovou. A\u017e v 80 % v\u00edce vlevo z n\u011bho vyb\u00edh\u00e1 tzv. t\u0159et\u00ed lalok \u0161t\u00edtn\u00e9 \u017el\u00e1zy, lobus pyramidalis, kter\u00fd m\u016f\u017ee zasahovat k t\u011blu jazylky. V\u00fdznamnou strukturou je ligamenum Berry, kter\u00e9 dorzomedi\u00e1ln\u011b \u017el\u00e1zu fixuje k prstencov\u00e9 chrupavce a k horn\u00edm prstenc\u016fm pr\u016fdu\u0161nice. M\u00e1 \u00fazk\u00fd vztah k c\u00e9vn\u00edmu a nervov\u00e9mu z\u00e1soben\u00ed, p\u0159edev\u0161\u00edm k nervus laryngeus recurrens.<\/p>\n<h6>C\u00e9vn\u00ed z\u00e1soben\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h6>\n<p style=\"text-align: justify;\">\u0160t\u00edtn\u00e1 \u017el\u00e1za je velmi dob\u0159e z\u00e1sobena krv\u00ed. Je uv\u00e1d\u011bn pr\u016ftok 4\u20136 ml kr ve\/minutu\/1g tk\u00e1n\u011b. Toto c\u00e9vn\u00ed z\u00e1soben\u00ed zaji\u0161\u0165uje arteria thyroidea superior, jdouc\u00ed k horn\u00edmu p\u00f3lu laloku, a arteria thyroidea inferior, sm\u011b\u0159uj\u00edc\u00ed k doln\u00edmu p\u00f3lu laloku. Arteria thyroidea superior p\u0159ev\u00e1\u017en\u011b vych\u00e1z\u00ed z arteria carotis externa, ve 45 % z arteria carotis communis. Jej\u00ed pr\u016fb\u011bh je p\u0159ev\u00e1\u017en\u011b konstantn\u00ed. Po odstupu prob\u00edh\u00e1 nahoru a dop\u0159edu v karotick\u00e9m troj\u00faheln\u00edku se st\u00e1\u010d\u00ed dol\u016f k apexu \u0161t\u00edtn\u00e9 \u017el\u00e1zy. V pr\u016fb\u011bhu se odstupuj\u00edc\u00ed v\u011btve pod\u00edlej\u00ed na z\u00e1soben\u00ed sliznice a svaloviny horn\u00ed \u010d\u00e1st\u00ed hrtanu i zadn\u00ed st\u011bny hltanu. P\u0159ed vstupem do horn\u00edho p\u00f3lu \u0161t\u00edtn\u00e9 \u017el\u00e1zy se arteria thyroidea superior d\u011bl\u00ed na p\u0159edn\u00ed, zadn\u00ed a later\u00e1ln\u00ed v\u011btve. Arteria thyroidea inferior odstupuje z truncus thyrocervicalis, kter\u00fd vystupu\u00a0je z arteria subclavia. Z tepny v pr\u016fb\u011bhu vystupuj\u00ed v\u011btve rami musculares ke svalov\u00fdm skupin\u00e1m, rami oesophageales, tracheales a arteria laryngica inferior. Arteria thyroidea inferior m\u00e1 \u00fazk\u00fd vztah k nervus laryngeus recurrens. P\u0159ed dosa\u017een\u00edm doln\u00edho p\u00f3lu se d\u011bl\u00ed na horn\u00ed v\u011btev jdouc\u00ed ke st\u0159edn\u00ed t\u0159etin\u011b a doln\u00ed v\u011btev k doln\u00edmu p\u00f3lu. \u017diln\u00ed krev je odv\u00e1d\u011bna do t\u0159\u00ed \u017eiln\u00edch kmen\u016f. Vena thyroidea superior zaji\u0161\u0165uje odtok z horn\u00edho p\u00f3lu \u0161t\u00edtn\u00e9 \u017el\u00e1zy a \u00fast\u00ed do vena facialis. Vena thyroidea media vych\u00e1z\u00ed ze st\u0159edn\u00ed t\u0159etiny laloku \u0161t\u00edtn\u00e9 \u017el\u00e1zy a \u00fast\u00ed do vena jugularis interna. Vena thyroidea inferior sestupuje z doln\u00edho p\u00f3lu a \u00fast\u00ed do vena brachiocephalica.<\/p>\n<h6>Lymfatick\u00e1 dren\u00e1\u017e \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h6>\n<p style=\"text-align: justify;\">Lymfatick\u00e1 dren\u00e1\u017e \u0161t\u00edtn\u00e9 \u017el\u00e1zy vytv\u00e1\u0159\u00ed syst\u00e9m, kter\u00fd se d\u011bl\u00ed na vzestupnou a sestupnou \u010d\u00e1st. Vzestupn\u00e1 \u010d\u00e1st sb\u00edr\u00e1 lymfu do pretrache\u00e1ln\u00edch a prelarynge\u00e1ln\u00edch uzlin. Sestupn\u00e9 lymfatick\u00e9 dr\u00e1hy jdou do kr\u010dn\u00edch hlubok\u00fdch uzlin a uzlin horn\u00edho mediastina.<\/p>\n<h6>Nervov\u00e9 z\u00e1soben\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h6>\n<p style=\"text-align: justify;\">Podstatn\u00e1 \u010d\u00e1st nervov\u00fdch vl\u00e1ken vych\u00e1z\u00ed z kr\u010dn\u00edch sympatick\u00fdch gangli\u00ed. Men\u0161\u00ed skupina z nervus vagus, cestou nervus laryngeus recurrens. Ovliv\u0148uj\u00ed vazomotorickou aktivitu, dod\u00e1v\u00e1n\u00ed tyreostimuluj\u00edc\u00edho hormonu a komplexn\u011b p\u016fsob\u00ed na funkci \u017el\u00e1zy.<\/p>\n<h6>Topografick\u00e1 anatomie\u00a0nervus laryngeus recurrens (NLR)<\/h6>\n<p style=\"text-align: justify;\">Identifikace nervu v prevenci poran\u011bn\u00ed a n\u00e1sledn\u00fdch mo\u017en\u00fdch komplikac\u00ed vy\u017eaduje dokonal\u00e9 znalosti topografick\u00e9 anatomie. Jde o p\u00e1rov\u00fd nerv vystupuj\u00edc\u00ed z nervus vagus, prob\u00edhaj\u00edc\u00ed na obou stran\u00e1ch asymetricky. Vpravo se NLR po odstupu z nervus vagus oh\u00fdb\u00e1 okolo arteria subclavia, vlevo okolo arcus aortae. Oba NLR sm\u011b\u0159uj\u00ed nahoru, prob\u00edhaj\u00ed asi v 60 % v tracheoezofage\u00e1ln\u00ed \u0161t\u011brbin\u011b a v dist\u00e1ln\u00ed t\u0159etin\u011b se v\u011btv\u00ed. Dal\u0161\u00ed mo\u017enost\u00ed je posteromedi\u00e1ln\u00ed pr\u016fb\u011bh NLR od zadn\u00edho pouzdra \u0161t\u00edtn\u00e9 \u017el\u00e1zy s t\u011bsn\u00fdm kontaktem na ligamentum Berry a Zuckekandl\u016fv hrbolek. Siln\u011bj\u0161\u00ed v\u011btev, ramus anterolateralis, je motorickou v\u011btv\u00ed, kter\u00e1 se zano\u0159uje do m. constrictor pharyngis inferior a za doln\u00edm okrajem chrupavky \u0161t\u00edtn\u00e9 p\u0159i articulatio cricothyreoidea se d\u011bl\u00ed na zadn\u00ed v\u011btev pro abduktor hlasivky a na v\u011btev p\u0159edn\u00ed pro adduktorov\u00e9 svaly hlasivky. Ten\u010d\u00ed v\u011btev, ramus posteromedialis, je senzorick\u00e1, vstupuje do pretrache\u00e1ln\u00ed tk\u00e1n\u011b a kon\u010d\u00ed ve sliznici pr\u016fdu\u0161nice a hrtanu. V topografick\u00e9m vztahu NLR k arteria thyreoidea inferior je pops\u00e1no 28 mo\u017en\u00fdch typ\u016f. Nerv m\u016f\u017ee prob\u00edhat p\u0159ed arteri\u00ed,dal\u0161\u00ed variantou je ulo\u017een\u00ed za arteri\u00ed nebo mezi jej\u00edmi v\u011btvemi. Podle \u00fadaj\u016f z literatury k\u0159i\u017euje v 27 % arterii thyreoideu interior (ATI) ventr\u00e1ln\u011b, v 36 % dorz\u00e1ln\u011b a ve 32 % proch\u00e1z\u00ed nerv mezi v\u011btvemi arterie. Vedle t\u011bchto mo\u017enost\u00ed existuj\u00ed dal\u0161\u00ed varianty, kdy se nerv i arterie odchyluj\u00ed od norm\u00e1ln\u00edho pr\u016fb\u011bhu. Podle stejn\u00fdch autor\u016f prob\u00edh\u00e1 ATI asi v 75 % p\u0159\u00edpad\u016f tak, \u017ee tvo\u0159\u00ed dvojit\u00fd oblouk v podob\u011b p\u00edsmene S a d\u011bl\u00ed se na v\u011btve krani\u00e1ln\u00ed, kaud\u00e1ln\u00ed a medi\u00e1ln\u00ed, kter\u00e9 jdou ke \u0161t\u00edtn\u00e9 \u017el\u00e1ze. Topografie nervu je rozd\u00edln\u00e1 na obou stran\u00e1ch krku. Je odli\u0161n\u00e1 i ve vztahu ke \u0161t\u00edtn\u00e9 \u017el\u00e1ze a ve vztahu k arteria thyreoidea inferior. Prav\u00fd NLR je krat\u0161\u00ed (7\u20139 cm), pozvoln\u011b vstupuje do oblasti \u0161t\u00edtn\u00e9 \u017el\u00e1zy a hloub\u011bji se ukl\u00e1d\u00e1 do tracheoezofage\u00e1ln\u00ed \u0161t\u011brbiny. Lev\u00fd NLR je del\u0161\u00ed (13\u201314 cm), sm\u011b\u0159uje vertik\u00e1ln\u011bji do tracheoezofage\u00e1ln\u00edho \u017el\u00e1bku s variabiln\u00edm pr\u016fb\u011bhem zejm\u00e9na k arteria thyreoidea inferior. Variabilita pr\u016fb\u011bhu NLR a ve\u0161ker\u00e9 zm\u011bny v p\u0159edpokl\u00e1dan\u00e9 topografii nervu zhor\u0161uj\u00ed mo\u017enost jeho identifikace a jsou zv\u00fd\u0161en\u00fdm rizikem pro \u00fasp\u011b\u0161n\u00fd v\u00fdkon na \u0161t\u00edtn\u00e9 \u017el\u00e1ze.Existuj\u00ed z\u00e1kladn\u00ed orienta\u010dn\u00ed body vztahu NLR k okoln\u00edm struktur\u00e1m, kter\u00e9 pro chirurga jsou nepostradateln\u00e9.Orienta\u010dn\u00ed body \u2013 vztah NLR k okoln\u00edm struktur\u00e1m:<\/p>\n<ul>\n<li>vztah k tracheoezofage\u00e1ln\u00ed \u0161t\u011brbin\u011b,<\/li>\n<li>vztah ke \u0161t\u00edtn\u00e9 \u017el\u00e1ze (dorz\u00e1ln\u00ed, dorzomedi\u00e1ln\u00ed\u00a0pr\u016fb\u011bh od zadn\u00edho pouzdra),<\/li>\n<li>vztah k arteria thyreoidea inferior,<\/li>\n<li>vztah k lig. Berry,<\/li>\n<li>vstup do hrtanu.<\/li>\n<\/ul>\n<h6>Fyziologie \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h6>\n<p style=\"text-align: justify;\">\u0160t\u00edtn\u00e1 \u017el\u00e1za pat\u0159\u00ed mezi \u017el\u00e1zy s vnit\u0159n\u00ed sekrec\u00ed s tvorbou t\u0159\u00ed hormon\u016f:<\/p>\n<ol>\n<li>T3 \u2013 trijodtyronin,<\/li>\n<li>T4 \u2013 tyroxin,<\/li>\n<li>calcitonin.<\/li>\n<\/ol>\n<p style=\"text-align: justify;\">Regula\u010dn\u00edm, nad\u0159azen\u00fdm centrem je podv\u011bsek mozkov\u00fd s tvorbou tyreostimula\u010dn\u00edho hormonu (TSH). Produkce hormon\u016f tyroxinu a trijodtyroninu je ovlivn\u011bna p\u0159\u00edjmem jodu potravou. Je regulov\u00e1na enzymem \u2013 tyreoid\u00e1ln\u00ed peroxid\u00e1zou (TPO), glykoproteinem \u2013 tyreoglobulinem (TGI) a dal\u0161\u00edmi enzymatick\u00fdmi slo\u017ekami. Na vyu\u017eit\u00ed hormon\u016f v bu\u0148k\u00e1ch je nezbytn\u00e1 dostate\u010dn\u00e1 hladina selenu.V\u00fdznam hormon\u016f \u0161t\u00edtn\u00e9 \u017el\u00e1zy:<\/p>\n<ul>\n<li>zvy\u0161uj\u00ed p\u0159em\u011bnu l\u00e1tkovou, spot\u0159ebu kysl\u00edku,<\/li>\n<li>zvy\u0161uj\u00ed tepovou frekvenci,<\/li>\n<li>ovliv\u0148uj\u00ed kontrakce sval\u016f,<\/li>\n<li>ovliv\u0148uj\u00ed imunitn\u00ed syst\u00e9m, krvetvorbu,<\/li>\n<li>ovliv\u0148uj\u00ed slo\u017een\u00ed kostn\u00ed tk\u00e1n\u011b.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Calcitonin ovliv\u0148uje metabolismus v\u00e1pn\u00edku a fosforu. M\u00e1 diagnostick\u00fd v\u00fdznam u medul\u00e1rn\u00edho karcinomu \u0161t\u00edtn\u00e9 \u017el\u00e1zy.<\/p>\n<p style=\"text-align: justify;\">Fyziologick\u00fd stav, kdy tvorba i v\u00fddej hormon\u016f \u0161t\u00edtn\u00e9 \u017el\u00e1zy je v rovnov\u00e1ze, naz\u00fdv\u00e1me eufunkc\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy.<\/p>\n<p style=\"text-align: justify;\">Zv\u00fd\u0161en\u00ed funkce je prov\u00e1zeno zv\u00fd\u0161en\u00fdm v\u00fddejem hormon\u016f T3 a T4 nebo jen T3 do cirkuluj\u00edc\u00ed krve.<\/p>\n<p style=\"text-align: justify;\">Hyperfunkce, Gravesova-Basedowova nemoc, je prov\u00e1zena vystup\u0148ov\u00e1n\u00edm fyziologick\u00fdch \u010dinnost\u00ed, regulovan\u00fdch \u0161t\u00edtnou \u017el\u00e1zou. Nach\u00e1z\u00edme vysok\u00e9 hodnoty T3, T4, FT4 (voln\u00fd hormon T4) a n\u00edzk\u00e9 hladiny TSH.<\/p>\n<p style=\"text-align: justify;\">Zvl\u00e1\u0161tn\u00edm p\u0159\u00edpadem je onemocn\u011bn\u00ed, kde \u010d\u00e1st \u0161t\u00edtn\u00e9 \u017el\u00e1zy pracuje autonomn\u011b bez \u0159\u00edzen\u00ed TSH. Jde o autonomn\u00ed nebo toxick\u00fd adenom \u0161t\u00edtn\u00e9 \u017el\u00e1zy. Projevy jsou prakticky shodn\u00e9 jako p\u0159i klasick\u00e9 hypertyre\u00f3ze, pouze laboratorn\u011b se prokazuje v\u011bt\u0161\u00ed nav\u00fd\u0161en\u00ed hladiny T3 ne\u017e T4.<\/p>\n<p style=\"text-align: justify;\">Sn\u00ed\u017een\u00e1 produkce hormon\u016f T3, T4 ve \u0161t\u00edtn\u00e9 \u017el\u00e1ze se naz\u00fdv\u00e1 prim\u00e1rn\u00ed hypotyre\u00f3za. Pokud je sn\u00ed\u017een\u00e1 tvorba T3 a T4 zp\u016fsobena nedostatkem hormonu TSH, pak jde o sekund\u00e1rn\u00ed hypotyre\u00f3zu. Sn\u00ed\u017een\u00e1 funkce, pokud je zp\u016fsobena v obdob\u00ed prenat\u00e1ln\u00edm nebo perinat\u00e1ln\u00edm, se projev\u00ed kretenismem s poruchou funkce centr\u00e1ln\u00ed nervov\u00e9 soustavy.<\/p>\n<h4>5.3 Z\u00e1kladn\u00ed klasifikace\u00a0a diagnostika onemocn\u011bn\u00ed\u00a0\u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h4>\n<p>Onemocn\u011bn\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy pat\u0159\u00ed mezi nej\u010dast\u011bj\u0161\u00ed endokrinn\u00ed poruchy v na\u0161\u00ed populaci. Diagnostika tyreopati\u00ed hodnot\u00ed zm\u011bny morfologick\u00e9 i zm\u011bny funk\u010dn\u00ed:<\/p>\n<h6>Morfologick\u00e9 zm\u011bny<\/h6>\n<p>Ka\u017ed\u00e9 zv\u011bt\u0161en\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy \u2013 <b>struma<\/b><\/p>\n<ul>\n<li>struma nodosa (adenomat\u00f3za):\n<ul>\n<li>\u015c solit\u00e1rn\u00ed uzel<\/li>\n<li>\u015c v\u00edce uzl\u016f<\/li>\n<\/ul>\n<\/li>\n<li>struma difussa (parenchymat\u00f3za)<\/li>\n<\/ul>\n<h6>Funk\u010dn\u00ed zm\u011bny<\/h6>\n<ul>\n<li><strong>eufunkce \u0161t\u00edtn\u00e9 \u017el\u00e1zy (eutyre\u00f3za)<\/strong>\n<ul>\n<li>\u015c tvorba a v\u00fddej hormon\u016f je v rovnov\u00e1ze<\/li>\n<\/ul>\n<\/li>\n<li><strong>hyperfunkce (toxick\u00e1 struma)<\/strong>\n<ul>\n<li>zv\u00fd\u0161en\u00fd v\u00fddej trijodtyroninu (T3)<\/li>\n<li>zv\u00fd\u0161en\u00fd v\u00fddej tetrajodtyroninu (T4)<\/li>\n<\/ul>\n<\/li>\n<li><strong>Hypofunkce (hypotyre\u00f3za)<\/strong>\n<ul>\n<li>sn\u00ed\u017een\u00e1 produkce T3, T4 ve \u0161t\u00edtn\u00e9 \u017el\u00e1ze \u2013 prim\u00e1rn\u00ed hypofunkce<\/li>\n<li>n\u00edzk\u00e1 hladina T3 a T4 p\u0159i nedostatku hormonu\u00a0TSH (tyreostimula\u010dn\u00ed hormon z adenohypof\u00fdzy) \u2013 sekund\u00e1rn\u00ed hypotyre\u00f3za<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h5>5.3.1 Anamn\u00e9za a klinick\u00e9 vy\u0161et\u0159en\u00ed<\/h5>\n<p>K diagnostice onemocn\u011bn\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy vyu\u017e\u00edv\u00e1me vedle anamn\u00e9zy a z\u00e1kladn\u00edho klinick\u00e9ho vy\u0161et\u0159en\u00ed celou \u0159adu speci\u00e1ln\u00edch diagnostick\u00fdch metod, jak to uv\u00e1d\u00ed v p\u0159ehledu tab. 1, obr. 1.<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\"><span style=\"color: #ffffff;\">Tab. 1 <\/span> <span style=\"color: #ffffff;\">P\u0159ehled diagnostiky onemocn\u011bn\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/span><\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>anamn\u00e9za<\/li>\n<li>klinick\u00e9 vy\u0161et\u0159en\u00ed\n<ul>\n<li>aspexe<\/li>\n<li>palpace<\/li>\n<li>auskultace<\/li>\n<\/ul>\n<\/li>\n<li>in vitro testy \u2013 hladina hormon\u016f v krvi (T3, T4,<\/li>\n<li>TSH) \u2013 radioimunoanal\u00fdza<\/li>\n<li>sonografick\u00e9 vy\u0161et\u0159en\u00ed<\/li>\n<li>scintigrafick\u00e9 vy\u0161et\u0159en\u00ed \u2013 radioizotopy (Tc99M,<\/li>\n<li>131J, 123J, 132J)<\/li>\n<li>CT vy\u0161et\u0159en\u00ed (zejm. u retrostern\u00e1ln\u00edch strum)<\/li>\n<li>RTG vy\u0161et\u0159en\u00ed<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_209.png\"><img decoding=\"async\" title=\"Obr. 1 \u2013 Ohromn\u00e1 mnohauzlov\u00e1 struma\" alt=\"Obr. 1 \u2013 Ohromn\u00e1 mnohauzlov\u00e1 struma\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_209.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 1 \u2013 Ohromn\u00e1 mnohauzlov\u00e1 struma<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_211.png\"><img decoding=\"async\" title=\"Obr. 2 \u2013 Obraz exoftalmu u hyperfunkce a pohledov\u011b nezv\u011bt\u0161en\u00e9 \u0161t\u00edtn\u00e9 \u017el\u00e1ze (Graves-Basedowova choroba)\" alt=\"Obr. 2 \u2013 Obraz exoftalmu u hyperfunkce a pohledov\u011b nezv\u011bt\u0161en\u00e9 \u0161t\u00edtn\u00e9 \u017el\u00e1ze (Graves-Basedowova choroba)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_211.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 2 \u2013 Obraz exoftalmu u hyperfunkce a pohledov\u011b nezv\u011bt\u0161en\u00e9 \u0161t\u00edtn\u00e9 \u017el\u00e1ze (Graves-Basedowova choroba)<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>P\u0159i odb\u011bru anamn\u00e9zy a z\u00e1kladn\u00edm klinick\u00e9m vy\u0161et\u0159en\u00ed hodnot\u00edme klinickou symptomatologii onemocn\u011bn\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy, kterou je mo\u017en\u00e9 rozd\u011blit do dvou z\u00e1kladn\u00edch skupin:<\/p>\n<ul>\n<li style=\"text-align: justify;\">Syndrom funk\u010dn\u00ed, kter\u00fd je d\u016fsledkem zm\u011bn\u011bn\u00e9 funkce \u0161t\u00edtn\u00e9 \u017el\u00e1zy a projevuje se odezvou v c\u00edlo\u00ad v\u00fdch tk\u00e1n\u00edch, org\u00e1nech.\u00a0Hodnot\u00edme celkov\u00e9 zm\u011bny: tepov\u00e1 frekvence, krevn\u00ed tlak, teplota, hmotnost, stav k\u016f\u017ee, kontrakce sval\u016f.<\/li>\n<li style=\"text-align: justify;\">Syndrom lok\u00e1ln\u00ed, kter\u00fd je podm\u00edn\u011bn velikost\u00ed, zv\u011bt\u0161en\u00edm nebo tlakem strumy.\u00a0Hodnot\u00edme m\u00edstn\u00ed zm\u011bny: velikost \u0161t\u00edtn\u00e9 \u017el\u00e1zy \u2013 struma, mechanick\u00e1 komprese s projevy \u00fatlaku okol\u00edch struktur. U retrostern\u00e1ln\u00edch strum \u00fatlak c\u00e9v. Dechov\u00e9 a polykac\u00ed pot\u00ed\u017ee, chrapot, otoky v\u00ed\u010dek, exoftalmus.<\/li>\n<\/ul>\n<h5>5.3.2 Laboratorn\u00ed vy\u0161et\u0159en\u00ed \u2013 <i>in vitro\u00a0<\/i>testy<\/h5>\n<p style=\"text-align: justify;\">Ur\u010dujeme hladinu hormon\u016f \u0161t\u00edtn\u00e9 \u017el\u00e1zy v krvi, T4 (tetrajodtyronin), T3 (trijodtyronin). Dal\u0161\u00edm hormonem je stimuluj\u00edc\u00ed hormon \u0161t\u00edtn\u00e9 \u017el\u00e1zy TSH (tyreostimula\u010dn\u00ed hormon adenohypof\u00fdzy).Ur\u010den\u00ed protil\u00e1tek u chronick\u00fdch z\u00e1n\u011btliv\u00fdch stav\u016f \u0161t\u00edtn\u00e9 \u017el\u00e1zy, TPO (tyreoid\u00e1ln\u00ed peroxid\u00e1za), TGl (tyreoglobulin). Protil\u00e1tky proti TSH (TSH receptor anticorper) u endokrinn\u00ed orbitopatie p\u0159i zv\u00fd\u0161en\u00e9 funkci \u0161t\u00edtn\u00e9 \u017el\u00e1zy na autoimunn\u00edm podklad\u011b.<\/p>\n<h5>5.3.3 Vy\u0161et\u0159en\u00ed zobrazovac\u00edmi metodami, cytologie a ORL<\/h5>\n<h6>Ultrazvukov\u00e9 vy\u0161et\u0159en\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h6>\n<p style=\"text-align: justify;\">\u010cast\u011bji u\u017e\u00edvan\u00fd term\u00edn sonografie (sonos = zvuk) \u0161t\u00edtn\u00e9 \u017el\u00e1zy je metodou zalo\u017eenou na schopnostech proch\u00e1zet a odr\u00e1\u017eet se na hranic\u00edch org\u00e1n\u016f a patologick\u00fdch n\u00e1lez\u016f. Takto z\u00edskan\u00e1 echa se hodnot\u00ed a dokumentuj\u00ed. Je metodou neinvazivn\u00ed, kter\u00e1 nem\u00e1 kontraindikace ani rizika, vylu\u010duje radia\u010dn\u00ed z\u00e1t\u011b\u017e a aplikace kontrastn\u00edch l\u00e1tek. V diagnostick\u00e9m algoritmu je metodou prvn\u00ed volby a n\u00e1sleduje ihned za klinick\u00fdm vy\u0161et\u0159en\u00edm nemocn\u00e9ho.Podle z\u00edskan\u00fdch poznatk\u016f hodnot\u00edme:<\/p>\n<ul>\n<li style=\"text-align: justify;\">velikost, ulo\u017een\u00ed, strukturu tk\u00e1n\u011b, lo\u017eiskov\u00e9 zm\u011bny,\u00a0vztah k okoln\u00edm struktur\u00e1m \u2013 j\u00edcen, pr\u016fdu\u0161nice,m\u00edzn\u00ed uzliny,<\/li>\n<li style=\"text-align: justify;\">ur\u010d\u00edme objem \u0161t\u00edtn\u00e9 \u017el\u00e1zy, kter\u00fd je u \u017een do 18 ml,\u00a0mu\u017e\u016f do 22 ml,<\/li>\n<li style=\"text-align: justify;\">pod ultrazvukovou kontrolou lze prov\u00e9st evakua\u010dn\u00ed\u00a0punkci \u2013 cysta,<\/li>\n<li style=\"text-align: justify;\">pod ultrazvukovou kontrolou lze prov\u00e9st punk\u010dn\u00ed\u00a0aspira\u010dn\u00ed cytologii \u0161t\u00edtn\u00e9 \u017el\u00e1zy.<\/li>\n<\/ul>\n<h6>Scintigrafie \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h6>\n<p style=\"text-align: justify;\">Scintigrafie byla d\u0159\u00edve z\u00e1kladn\u00edm vy\u0161et\u0159en\u00edm u ka\u017ed\u00e9 tyreopatie. Prov\u00e1d\u00ed se na odd\u011blen\u00edch nukle\u00e1rn\u00ed medic\u00edny. Jde o radioizotopov\u00e9 vy\u0161et\u0159en\u00ed, kde ve vy\u0161et\u0159ovan\u00e9m org\u00e1nu hodnot\u00edme rozlo\u017een\u00ed podan\u00e9ho radiofarmaka. U\u017e\u00edv\u00e1 se radioaktivn\u00ed jo d nebo technecium.<\/p>\n<p>Hlavn\u00ed v\u00fdznam scintigrafie je dnes u t\u011bchto stav\u016f:<\/p>\n<ul>\n<li>jednouzlov\u00fdch strum, kde uzel je hyperaktivn\u00ed \u2013\u00a0toxick\u00fd adenom,<\/li>\n<li>studen\u00fd uzel (neaktivn\u00ed) \u2013 podez\u0159en\u00ed na karcinom,<\/li>\n<li>anom\u00e1ln\u00ed ulo\u017een\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy,<\/li>\n<li>vy\u0161et\u0159en\u00ed rezidua nebo recidivy po p\u0159edchoz\u00ed operaci, zvl\u00e1\u0161t\u011b tam, kde je pl\u00e1nov\u00e1na reoperace,<\/li>\n<li>vylou\u010den\u00ed metastatick\u00e9ho posti\u017een\u00ed \u2013 celot\u011blov\u00e1\u00a0scintigrafie,<\/li>\n<li>v diagnostice onemocn\u011bn\u00ed p\u0159\u00ed\u0161t\u00edtn\u00fdch t\u011bl\u00edsek.<\/li>\n<\/ul>\n<h6>Radiologick\u00e9 vy\u0161et\u0159en\u00ed<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_213.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 3 \u2013 Roz\u0161\u00ed\u0159en\u00ed horn\u00edho mediastina a vych\u00fdlen\u00ed vzduchov\u00e9ho sloupce pr\u016fdu\u0161nice p\u0159i intratorak\u00e1ln\u00ed strum\u011b na prost\u00e9m rtg sn\u00edmku plic a horn\u00ed hrudn\u00ed apertury\" alt=\"Obr. 3 \u2013 Roz\u0161\u00ed\u0159en\u00ed horn\u00edho mediastina a vych\u00fdlen\u00ed vzduchov\u00e9ho sloupce pr\u016fdu\u0161nice p\u0159i intratorak\u00e1ln\u00ed strum\u011b na prost\u00e9m rtg sn\u00edmku plic a horn\u00ed hrudn\u00ed apertury\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_213.png\" width=\"200\" height=\"156\" \/><\/a><p class=\"wp-caption-text\">Obr. 3 \u2013 Roz\u0161\u00ed\u0159en\u00ed horn\u00edho mediastina a vych\u00fdlen\u00ed vzduchov\u00e9ho sloupce pr\u016fdu\u0161nice p\u0159i intratorak\u00e1ln\u00ed strum\u011b na prost\u00e9m rtg sn\u00edmku plic a horn\u00ed hrudn\u00ed apertury<\/p><\/div>\n<p style=\"text-align: justify;\">Prost\u00fd sn\u00edmek horn\u00ed hrudn\u00ed apertury a rentgen polykac\u00edho aktu indikujeme ojedin\u011ble v p\u0159\u00edpad\u011b du\u0161nosti a polykac\u00edch obt\u00ed\u017e\u00ed. Rentgenologick\u00e9 posouzen\u00ed vzduchov\u00e9ho sloupce pr\u016fdu\u0161nice a deviace j\u00edcnu je dal\u0161\u00edm mo\u017en\u00fdm krit\u00e9riem k opera\u010dn\u00edmu v\u00fdkonu. Dnes se\u00a0tato vy\u0161et\u0159en\u00ed nahrazuj\u00ed v\u00fdpo\u010detn\u00ed tomografi\u00ed nebo magnetickou rezonanc\u00ed (obr. 3).<\/p>\n<h6>V\u00fdpo\u010detn\u00ed tomografie<\/h6>\n<p style=\"text-align: justify;\">Jde o rentgenologick\u00e9 vy\u0161et\u0159en\u00ed s mo\u017enost\u00ed vy\u0161et\u0159ov\u00e1n\u00ed ur\u010dit\u00e9ho org\u00e1nu ve vrstv\u00e1ch. Tato metoda je indikov\u00e1na p\u0159i velk\u00fdch strum\u00e1ch s retrostern\u00e1ln\u00ed propagac\u00ed. L\u00e9pe hodnot\u00ed i p\u0159\u00edpadn\u00e9 posti\u017een\u00ed lymfatick\u00fdch kr\u010dn\u00edch uzlin.<\/p>\n<h6>Magnetick\u00e1 rezonance<\/h6>\n<p style=\"text-align: justify;\">M\u00e1 prakticky stejn\u00e9 indikace jako v\u00fdpo\u010detn\u00ed tomografie. Jde o zn\u00e1zorn\u011bn\u00ed anatomick\u00fdch vrstev t\u011bla v libovoln\u011b zvolen\u00fdch rovin\u00e1ch bez rentgenov\u00e9 z\u00e1t\u011b\u017ee.<\/p>\n<h6>Punk\u010dn\u00ed aspira\u010dn\u00ed cytologie<\/h6>\n<p style=\"text-align: justify;\">Prov\u00e1d\u00ed se nej\u010dast\u011bji v kombinaci s ultrazvukov\u00fdm vy\u0161et\u0159en\u00edm p\u0159i patologick\u00e9m n\u00e1lezu \u0161t\u00edtn\u00e9 \u017el\u00e1zy. Je dostate\u010dn\u011b spolehlivou metodou v diferenci\u00e1ln\u00ed diagnostice tyreoid\u00e1ln\u00edch uzl\u016f. M\u00e1 v\u00fdznam pro v\u010dasnou detekci malign\u00edho posti\u017een\u00ed a jeho n\u00e1sledn\u00fd radik\u00e1ln\u00ed chirurgick\u00fd v\u00fdkon.Spr\u00e1vn\u00e9 ur\u010den\u00ed povahy vlastn\u00edho onemocn\u011bn\u00ed v\u00fdznamn\u011b sni\u017euje po\u010det nutn\u00fdch reoperac\u00ed u nedostate\u010dn\u011b radik\u00e1ln\u00edch opera\u010dn\u00edch v\u00fdkon\u016f, kde operat\u00e9r p\u0159edopera\u010dn\u011b neznal povahu onemocn\u011bn\u00ed.Z\u00edskan\u00fd vzorek se po zaschnut\u00ed na podlo\u017en\u00edm skl\u00ed\u010dku barv\u00ed r\u016fzn\u00fdmi technikami. K za\u0159azen\u00ed n\u00e1lez\u016f se pou\u017e\u00edvaj\u00ed krit\u00e9ria uveden\u00e1 v mezin\u00e1rodn\u00ed cytologick\u00e9 klasifikaci, respektuj\u00edc\u00ed kategorie mezin\u00e1rodn\u00ed histologick\u00e9 klasifikace.V na\u0161ich podm\u00ednk\u00e1ch jsou cytologick\u00e9 n\u00e1lezy d\u011bleny do p\u011bti skupin.1. standardn\u00ed cytologick\u00fd obraz \u2013 norm\u00e1ln\u00ed bu\u0148ky \u0161t\u00edtn\u00e9 \u017el\u00e1zy,2. tyreoiditidy \u2013 degenerativn\u00ed zm\u011bny, cysty,3. atypick\u00e9 bu\u0148ky,4. suspektn\u00ed n\u00e1lez z malignity,5. pozitivn\u00ed malignita.<\/p>\n<p style=\"text-align: justify;\">Cytologick\u00e1 diagnostika je cennou metodou p\u0159i odhalov\u00e1n\u00ed malignit, nen\u00ed v\u0161ak metodou absolutn\u00ed. Pozitivn\u00ed cytologick\u00fd n\u00e1lez je sice dokladem malignity, av\u0161ak m\u016f\u017ee b\u00fdt n\u011bkdy v porovn\u00e1n\u00ed s poopera\u010dn\u00ed histologi\u00ed fale\u0161n\u011b pozitivn\u00ed. Rovn\u011b\u017e negativn\u00ed cytologick\u00fd n\u00e1lez malignitu nevylu\u010duje.Hlavn\u00ed podm\u00ednkou \u00fasp\u011b\u0161nosti cytologick\u00e9ho vy\u0161et\u0159en\u00ed je z\u00edsk\u00e1n\u00ed dostate\u010dn\u011b reprezentativn\u00edho materi\u00e1lu tenkou jehlou.<\/p>\n<h6>ORL (otorinolaryngologick\u00e9) vy\u0161et\u0159en\u00ed<\/h6>\n<p>Hodnot\u00ed stav hlasivek p\u0159ed operac\u00ed a po v\u00fdkonu.<\/p>\n<h4>5.4 Onemocn\u011bn\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h4>\n<p>Z\u00e1kladn\u00ed rozd\u011blen\u00ed<\/p>\n<ul>\n<li>eufunk\u010dn\u00ed struma<\/li>\n<li>porucha funkce\n<ul>\n<li>zv\u00fd\u0161en\u00e1<\/li>\n<li>sn\u00ed\u017een\u00e1<\/li>\n<\/ul>\n<\/li>\n<li>z\u00e1n\u011bty<\/li>\n<li>n\u00e1dory<\/li>\n<\/ul>\n<p>P\u0159\u00ed\u010diny vzniku: jsou rozmanit\u00e9, z\u00e1visl\u00e9 na vlivech zevn\u00edho i vnit\u0159n\u00edho prost\u0159ed\u00ed. Faktory zevn\u00ed:<\/p>\n<ol>\n<li>nedostatek jodu, nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dina onemocn\u011bn\u00ed;<\/li>\n<li>strumigeny, l\u00e1tky p\u016fsob\u00edc\u00ed na formov\u00e1n\u00ed hormon\u016f. Mohou b\u00fdt sou\u010d\u00e1st\u00ed potravy i sou\u010d\u00e1st\u00ed n\u011bkter\u00fdch l\u00e9k\u016f, nap\u0159. n\u011bkter\u00e1 psychofarmaka;<\/li>\n<li>mikrobi\u00e1ln\u00ed p\u016fvod, zp\u016fsobuj\u00edc\u00ed z\u00e1n\u011btliv\u00e9 posti\u017een\u00ed;<\/li>\n<li>zevn\u00ed oz\u00e1\u0159en\u00ed \u2013 nej\u010dast\u011bji v souvislosti s jinou chorobou;<\/li>\n<li>toxick\u00e9 l\u00e1tky, kou\u0159en\u00ed.<\/li>\n<\/ol>\n<p>Faktory vnit\u0159n\u00ed:<\/p>\n<ol>\n<li>autoimunitn\u00ed onemocn\u011bn\u00ed, kde porucha imunity je \u010dastou p\u0159\u00ed\u010dinou onemocn\u011bn\u00ed,<\/li>\n<li>genetick\u00e1 dispozice.<\/li>\n<\/ol>\n<h5>5.4.1 Eufunk\u010dn\u00ed struma<\/h5>\n<p>Jde o zv\u011bt\u0161en\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy, hodnoceno na z\u00e1klad\u011b klasifikace WHO (aspekce, palpace). Z\u00e1kladn\u00ed \u00fadaje jsou uvedeny v tab. 2. M\u016f\u017ee j\u00edt o difuzn\u00ed posti\u017een\u00ed nebo uzlovou p\u0159estavbu v d\u011btsk\u00e9m i dosp\u011bl\u00e9m v\u011bku, kde neprokazujeme poruchu funkce ani jin\u00e9 onemocn\u011bn\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy. Vzhledem ke sv\u00e9mu ulo\u017een\u00ed nemus\u00ed b\u00fdt ani patrn\u00e1, ani hmatn\u00e1 a nemus\u00ed \u010dinit \u017e\u00e1dn\u00e9 pot\u00ed\u017ee.<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\"><span style=\"color: #ffffff;\">Tabulka 2<\/span> <span style=\"color: #ffffff;\"> Eufunk\u010dn\u00ed prost\u00e1 struma \u2013 struma simplex<\/span><\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>morfologick\u00e1 forma\n<ul>\n<li>difuzn\u00ed<\/li>\n<li>nod\u00f3zn\u00ed<\/li>\n<\/ul>\n<\/li>\n<li>etiologie \u2013 nedostatek jodu v potrav\u011b v obdob\u00ed\u00a0zv\u00fd\u0161en\u00fdch n\u00e1rok\u016f na organizmus (jodizace soli)<\/li>\n<li>symptomatologie \u2013 p\u0159\u00edznaky z \u00fatlak\u016f okol\u00ed p\u0159i\u00a0v\u011bt\u0161\u00edch rozm\u011brech strumy (poruchy d\u00fdch\u00e1n\u00ed,\u00a0polyk\u00e1n\u00ed), kosmetick\u00e9 hledisko<\/li>\n<li>l\u00e9\u010dba \u2013 tot\u00e1ln\u00ed lobektomie, tot\u00e1ln\u00ed nebo neartot\u00e1ln\u00ed thyreoidektomie<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Zpo\u010d\u00e1tku jde o difuzn\u00ed zv\u011bt\u0161en\u00ed \u2013 struma diffusa, parenchymat\u00f3za. V pr\u016fb\u011bhu doch\u00e1z\u00ed k uzlov\u00e9 p\u0159estavb\u011b\u2013 struma nod\u00f3zn\u00ed (jeden uzel), struma polynod\u00f3zn\u00ed (n\u011bkolik uzl\u016f). Zv\u011bt\u0161en\u00ed m\u016f\u017ee b\u00fdt tak\u00e9 zp\u016fsobeno cystou \u010di cystami, kde dutina je vypln\u011bna tekutinou.\u010castou p\u0159\u00ed\u010dinou endemick\u00e9 strumy je deficit jodu. Endemick\u00e1 struma znamen\u00e1 v\u00fdskyt zv\u011bt\u0161en\u00e9 \u0161t\u00edtn\u00e9 \u017el\u00e1zy v dan\u00e9m regionu u dosp\u011bl\u00fdch 10 % a d\u011bt\u00ed 5 %. Doporu\u010den\u00fd p\u0159\u00edjem jodu je 150 mg za den.V po\u010d\u00e1tku struma nevyvol\u00e1v\u00e1 \u017e\u00e1dn\u00e9 pot\u00ed\u017ee. Dal\u0161\u00ed zv\u011bt\u0161ov\u00e1n\u00ed zp\u016fsobuje mechanick\u00e9 p\u0159\u00edznaky s kompres\u00ed okoln\u00edch org\u00e1n\u016f (pr\u016fdu\u0161nice, j\u00edcen, nerv). \u00datlak c\u00e9vn\u00edho svazku m\u016f\u017ee vyvolat syndrom horn\u00ed dut\u00e9 \u017e\u00edly. \u0160t\u00edtn\u00e1 \u017el\u00e1za se m\u016f\u017ee zano\u0159ovat i za hrudn\u00ed kost \u2013 retrostern\u00e1ln\u00ed struma. Prim\u00e1rn\u00ed retrostern\u00e1ln\u00ed struma vznik\u00e1 z aberantn\u00ed tk\u00e1n\u011b \u0161t\u00edtn\u00e9 \u017el\u00e1zy. Sekund\u00e1rn\u00ed retrostern\u00e1ln\u00ed struma se propaguje z krku do r\u016fzn\u00e9 v\u00fd\u0161e mediastina.<\/p>\n<p style=\"text-align: justify;\">Pacient m\u00e1 pocit ciz\u00edho t\u011blesa, obt\u00ed\u017en\u011b d\u00fdch\u00e1, polyk\u00e1, m\u00e1 n\u00e1znak chrapotu. Rovn\u011b\u017e kosmetick\u00e9 hledisko nen\u00ed zanedbateln\u00e9.<\/p>\n<p style=\"text-align: justify;\">\u00datlakov\u00e9 pot\u00ed\u017ee mohou b\u00fdt vystup\u0148ov\u00e1ny u retrostern\u00e1ln\u00ed strumy.<\/p>\n<p><em>Klinick\u00e9 p\u0159\u00edznaky:<\/em> Du\u0161nost, dysfagie, pareza n. laryngeus recurrens. <em>L\u00e9\u010dba:<\/em> P\u0159i ne\u00fasp\u011bchu konzervativn\u00ed l\u00e9\u010dby (Euthyrox, Letrox) chirurgick\u00e1 l\u00e9\u010dba v rozsahu LT (lobectomia totalis) nebo TTE (thyroidectomia totalis). Nej\u010dast\u011bji si vysta\u010d\u00edme z kr\u010dn\u00edho p\u0159\u00edstupu, ojedin\u011ble u v\u011bt\u0161\u00edch retrostern\u00e1ln\u00edch strum je indikov\u00e1na sternotomie. Indikace k chirurgick\u00e9 l\u00e9\u010db\u011b je nejen mechanick\u00fd syndrom, ale i degenerativn\u00ed zm\u011bny s kalcifikac\u00ed uzl\u016f a podez\u0159en\u00edm na malignitu. V p\u0159\u00edpad\u011b cysty jej\u00ed opakovan\u00e9 pln\u011bn\u00ed po punkci.<\/p>\n<h5>5.4.2 Poruchy funkce \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h5>\n<p style=\"text-align: justify;\">Hormony \u0161t\u00edtn\u00e9 \u017el\u00e1zy p\u016fsob\u00ed na org\u00e1ny a tk\u00e1n\u011b komplexn\u011b a stimula\u010dn\u011b. Zvy\u0161uj\u00ed baz\u00e1ln\u00ed metabolizmus, spot\u0159ebu kysl\u00edku. Potencuj\u00ed \u00fa\u010dinek katecholamin\u016f a kortikosteroid\u016f. P\u0159i nadbytku jsou projevy hyperfunkce, hypermetabolizmu, zv\u00fd\u0161en\u00e1 termoregulace a zv\u00fd\u0161en\u00e1 aktivita org\u00e1n\u016f vedouc\u00ed a\u017e k vy\u010derpanosti.P\u0159i poklesu hormon\u016f jsou zn\u00e1mky hypofunkce, zpomalen\u00ed metabolismu a org\u00e1nov\u00fdch funkc\u00ed.<\/p>\n<p style=\"text-align: justify;\">D\u011blen\u00ed:1. perifern\u00ed: p\u0159\u00edm\u00e9 posti\u017een\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy,2. centr\u00e1ln\u00ed: posti\u017een\u00ed nad\u0159azen\u00fdch center, hypotalamo-hypofyz\u00e1rn\u00edch, v\u00fdskyt vz\u00e1cn\u00fd.<\/p>\n<p>Zv\u00fd\u0161en\u00e1 funkce (hyperfunkce) \u2013\u00a0tyreotoxik\u00f3za Zv\u00fd\u0161en\u00e1 funkce \u0161t\u00edtn\u00e9 \u017el\u00e1zy m\u016f\u017ee m\u00edt r\u016fzn\u00e9 klinick\u00e9 formy, jejich p\u0159ehled a z\u00e1sady l\u00e9\u010dby jsou uvedeny v tab. 3. P\u0159\u00ed\u010diny perifern\u00ed hyperfunkce:<\/p>\n<ul>\n<li>Gravesova-Basedowova nemoc (obr. 2)<\/li>\n<li>toxick\u00e1 polynod\u00f3zn\u00ed struma, toxick\u00fd adenom,<\/li>\n<li>subakutn\u00ed (de Quervainova) tyreoiditis,<\/li>\n<li>chronick\u00e1 lymfocyt\u00e1rn\u00ed tyreoiditis v hyperfunk\u010dn\u00ed\u00a0f\u00e1zi,<\/li>\n<li>indukovan\u00e1 hypertyre\u00f3za jodem.<\/li>\n<\/ul>\n<p>P\u0159\u00ed\u010diny centr\u00e1ln\u00ed hyperfunkce:<\/p>\n<ul>\n<li>adenom hypof\u00fdzy s hyperprodukc\u00ed TSH.<\/li>\n<\/ul>\n<h6>Graves-Basedowova choroba<\/h6>\n<p style=\"text-align: justify;\">Z nadprodukce hormon\u016f neodpov\u00eddaj\u00edc\u00ed pot\u0159eb\u011b organismu. Autoimunitn\u00ed onemocn\u011bn\u00ed, kdy obrann\u00fd syst\u00e9m pracuje proti vlastn\u00edm tk\u00e1n\u00edm. Vzniku choroby m\u016f\u017ee p\u0159edch\u00e1zet stres, fyzick\u00e9 vyp\u011bt\u00ed, infek\u010dn\u00ed choroby.<\/p>\n<p>Projevy:<\/p>\n<ul>\n<li>p\u0159i zv\u00fd\u0161en\u00e9m p\u0159\u00edjmu potravy v\u00fdrazn\u00e9 hubnut\u00ed,\u00a0pr\u016fjmy,<\/li>\n<li>pocen\u00ed, labilita,<\/li>\n<li>poruchy sp\u00e1nku, neklid,<\/li>\n<li>bu\u0161en\u00ed srdce a dysrytmie,<\/li>\n<li>svalov\u00e1 slabost, \u00fanava,<\/li>\n<li>o\u010dn\u00ed p\u0159\u00edznaky \u2013 endokrinn\u00ed orbitopatie (exoftalmus).<\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><em>L\u00e9\u010dba:<\/em> Za\u010d\u00edn\u00e1 se vysok\u00fdmi d\u00e1vkami tyreostatik (Carbimazol, Thyrozol, Propycil). Postupn\u00e9 sni\u017eov\u00e1n\u00ed se odv\u00edj\u00ed od klinick\u00e9ho a laboratorn\u00edho n\u00e1lezu. P\u0159i kardi\u00e1ln\u00edch projevech (tachykardie) se p\u0159id\u00e1vaj\u00ed betablok\u00e1tory. P\u0159i opakovan\u00fdch relapsech po zhodnocen\u00ed klinick\u00e9ho n\u00e1lezu je indikace opera\u010dn\u00ed l\u00e9\u010dby.K operaci se p\u0159istupuje v klidov\u00e9m funk\u010dn\u00edm stavu. V ojedin\u011bl\u00fdch p\u0159\u00edpadech, zejm\u00e9na u star\u0161\u00edch lid\u00ed, je l\u00e9\u010dba radiojodem \u0161etrn\u011bj\u0161\u00ed.P\u0159i dlouhodob\u00e9 nespr\u00e1vn\u00e9 \u010di nedostate\u010dn\u00e9 l\u00e9\u010db\u011b je vy\u0161\u0161\u00ed riziko fibrilace s\u00edn\u00ed i kardiogenn\u00edho selh\u00e1n\u00ed.<\/p>\n<h6>Toxick\u00fd adenom<\/h6>\n<p>Uzel ve \u0161t\u00edtn\u00e9 \u017el\u00e1ze se zv\u00fd\u0161enou tvorbou hormon\u016f.<\/p>\n<h6>Toxick\u00e1 polynod\u00f3zn\u00ed struma<\/h6>\n<p style=\"text-align: justify;\">Ve vy\u0161\u0161\u00edm v\u011bku v d\u016fsledku nedostatku jodu, p\u0159i dlouhodob\u00e9m trv\u00e1n\u00ed.Rizikem jsou poruchy srde\u010dn\u00edho rytmu, tachykardie, fibrilace s\u00edn\u00ed. L\u00e9\u010dba kardi\u00e1ln\u00ed je sou\u010dasn\u011b vedena s pod\u00e1v\u00e1n\u00edm tyreoistatik. Operace je optim\u00e1ln\u00edm \u0159e\u0161en\u00edm.<\/p>\n<h6>Subakutn\u00ed (de Quervainova) tyreoiditis<\/h6>\n<p style=\"text-align: justify;\">Jde o postinfek\u010dn\u00ed imunopatologick\u00e9 posti\u017een\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy, p\u0159ev\u00e1\u017en\u011b virov\u00e9ho p\u016fvodu. Zn\u00e1mkou je jednostrann\u00e9 bolestiv\u00e9 zdu\u0159en\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy, subfebrilie a celkov\u00e1 \u00fanava. Hyperfunkce odezn\u00edv\u00e1 do 6 t\u00fddn\u016f. V t\u011b\u017e\u0161\u00edch p\u0159\u00edpadech se pod\u00e1vaj\u00ed kortikoidy, v\u00fdjime\u010dn\u011b antibiotika. Symptomatick\u00e1 l\u00e9\u010dba betablok\u00e1tory.<\/p>\n<h6>Chronick\u00e1 lymfocyt\u00e1rn\u00ed tyreoiditis s hyperfunkc\u00ed<\/h6>\n<p>Hyperfunkce je p\u0159echodn\u00fdm, po\u010d\u00e1te\u010dn\u00edm stavem tohoto onemocn\u011bn\u00ed. Projevem jsou ob\u011bhov\u00e9 pot\u00ed\u017ee z hyperfunkce s dobrou odezvou na betablok\u00e1tory, p\u0159i mal\u00fdch d\u00e1vk\u00e1ch tyreostatik. N\u00e1sledn\u00e1 hypofunkce se\u00a0vyv\u00edj\u00ed pozvolna a dlouhodob\u011b. Vy\u017eaduje pravideln\u00e9\u00a0sledov\u00e1n\u00ed.<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\"><span style=\"color: #ffffff;\">Tabulka 3<\/span> <span style=\"color: #ffffff;\"> Hyperfunk\u010dn\u00ed \u2013 toxick\u00e1 struma<\/span><\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>nej\u010dast\u011bji mezi 20. a 40. rokem \u017eivota, v\u00edce \u017eeny<\/li>\n<li>Graves-Basedowa nemoc, p\u0159\u00edznakov\u00e1 trias (exoftalmus, struma, tachykardie)\n<ul>\n<li>p\u0159\u00edznaky: nervozita, emo\u010dn\u00ed labilita, nespavost, pocen\u00ed, palpitace, du\u0161nost, \u017e\u00edze\u0148, zv\u00fd\u0161en\u00e1 chu\u0165 k j\u00eddlu\u00a0a paradoxn\u011b hubnut\u00ed<\/li>\n<\/ul>\n<\/li>\n<li>toxick\u00fd autonomn\u00ed adenom \u2013 scintigraficky prokazujeme hork\u00fd uzel\n<ul>\n<li>p\u0159\u00edznaky: chyb\u00ed exoftalmus, jinak stejn\u00e9<\/li>\n<\/ul>\n<\/li>\n<li>tyreotoxick\u00e1 krize \u2013 vystup\u0148ov\u00e1n\u00ed p\u0159\u00edznak\u016f: tachykardie, hypertermie, hypertenze; m\u016f\u017ee ohrozit nemocn\u00e9ho\u00a0na \u017eivot\u011b<\/li>\n<\/ul>\n<p><strong>L\u00e9\u010dba<\/strong><\/p>\n<ul>\n<li>konzervativn\u00ed\n<ul>\n<li>tyreostatika<\/li>\n<li>betablok\u00e1tory<\/li>\n<\/ul>\n<\/li>\n<li>star\u0161\u00ed nemocn\u00ed, pacienti se zv\u00fd\u0161en\u00fdm rizikem, kardiopati\u00ed \u2013 mo\u017eno l\u00e9\u010dit radioaktivn\u00edm j\u00f3dem (131J)<\/li>\n<li style=\"text-align: justify;\">l\u00e9\u010dba chirurgick\u00e1 (ne\u00fasp\u011bch konzervativn\u00edho postupu, recidivy, vystup\u0148ovan\u00e1 hypertyre\u00f3za, velk\u00e1 struma)\n<ul>\n<li>tot\u00e1ln\u00ed nebo neartot\u00e1ln\u00ed tyreoidektomie, n\u00e1sledn\u011b hormon\u00e1ln\u00ed substituce<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Rizika hyperfunkce \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h6>\n<p style=\"text-align: justify;\"><strong>Tyreotoxick\u00e1 krize <\/strong>Vystup\u0148ovan\u00e1 \u010dinnost \u0161t\u00edtn\u00e9 \u017el\u00e1zy ohro\u017euj\u00edc\u00ed \u017eivot nemocn\u00e9ho. Projevem jsou vysok\u00e9 teploty, tachykardie,srde\u010dn\u00ed selh\u00e1n\u00ed. Psychick\u00e9 p\u0159\u00edznaky zmatenosti, bezv\u011bdom\u00ed a k\u0159e\u010de, svalov\u00e1 slabost. Zn\u00e1mky dehydratace s pr\u016fjmy a zvracen\u00edm.L\u00e9\u010dba spo\u010d\u00edv\u00e1 v pod\u00e1v\u00e1n\u00ed tyreostatik, kter\u00e9 tlum\u00ed tvorbu hormon\u016f, jod, tlum\u00edc\u00ed uvol\u0148ov\u00e1n\u00ed z\u00e1sob hormon\u016f do krve. D\u00e1le se pod\u00e1vaj\u00ed kortikoidy, kardiotonika, betablok\u00e1tory, antipyretika.<\/p>\n<p style=\"text-align: justify;\"><strong>Tyreoid\u00e1ln\u00ed orbitopate <\/strong>B\u00fdv\u00e1 spojena \u010dasto s imunogenn\u00ed tyreotoxik\u00f3zou, n\u011bkdy se z\u00e1n\u011btem \u0161t\u00edtn\u00e9 \u017el\u00e1zy. V d\u016fsledku protil\u00e1tek doch\u00e1z\u00ed ke zmno\u017een\u00ed vaziv a zes\u00edlen\u00ed okohybn\u00fdch sval\u016f o\u010dnice.<\/p>\n<p style=\"text-align: justify;\">Z projev\u016f je n\u00e1padn\u00fd exoftalmus a protruze, vysunut\u00ed o\u010dn\u00edho bulbu. Porucha pohyblivosti oka a dvojit\u00e9 vid\u011bn\u00ed. Zes\u00edlen\u00e9 nitroo\u010dn\u00ed svaly a zv\u00fd\u0161en\u00fd nitroo\u010dn\u00ed tlak m\u016f\u017ee v\u00e9st a\u017e k slepot\u011b. V l\u00e9\u010db\u011b je indikov\u00e1na tot\u00e1ln\u00ed tyreoidektomie. Dlouhodob\u00e9 pod\u00e1v\u00e1n\u00ed kortikosteroid\u016f. P\u0159i zkr\u00e1cen\u00ed o\u010dn\u00edch v\u00ed\u010dek a poruch\u00e1ch vid\u011bn\u00ed jsou v n\u011bkter\u00fdch p\u0159\u00edpadech indikov\u00e1ny o\u010dn\u00ed operace.<\/p>\n<h6>Sn\u00ed\u017een\u00e1 funkce (hypofunkce) \u2013 hypotyre\u00f3za<\/h6>\n<p style=\"text-align: justify;\">Sn\u00ed\u017een\u00e1 funkce \u0161t\u00edtn\u00e9 \u017el\u00e1zy je zp\u016fsoben\u00e1 nedostate\u010dnou tvorbou hormon\u016f, p\u0159ev\u00e1\u017en\u011b perifern\u00edho typu. Centr\u00e1ln\u00ed typ, vyvolan\u00fd poruchou koordinace \u0161t\u00edtn\u00e9 \u017el\u00e1zy z podv\u011bsku mozkov\u00e9ho, je vz\u00e1cn\u00fd.P\u0159\u00ed\u010diny perifern\u00ed hypofunkce:<\/p>\n<ul>\n<li>chronick\u00e1 lymfocyt\u00e1rn\u00ed tyreoiditis s tvorbou protil\u00e1tek proti vlastn\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1ze,<\/li>\n<li>poopera\u010dn\u00ed stavy \u2013 tyreoidektomie,<\/li>\n<li>l\u00e9\u010dba radiojodem, oz\u00e1\u0159en\u00ed,<\/li>\n<li>porucha v\u00fdvoje, enzymatick\u00e9 poruchy,<\/li>\n<li>nedostatek jodu,<\/li>\n<li>n\u00e1dorov\u00e1 onemocn\u011bn\u00ed,<\/li>\n<li>u\u017e\u00edv\u00e1n\u00ed ur\u010dit\u00fdch l\u00e9k\u016f \u2013 n\u011bkter\u00e1 antidiabetika, psychofarmaka, n\u011bkter\u00e9 l\u00e9ky p\u0159i poruch\u00e1ch srde\u010dn\u00edho rytmu.<\/li>\n<\/ul>\n<p>P\u0159\u00ed\u010diny centr\u00e1ln\u00ed hypofunkce:<\/p>\n<ul>\n<li>n\u00e1dory hypof\u00fdzy,<\/li>\n<li>onemocn\u011bn\u00ed hypotalamu,<\/li>\n<li>stavy po operaci hypof\u00fdzy.<\/li>\n<\/ul>\n<p>Projevy:<\/p>\n<ul>\n<li>poruchy sp\u00e1nku, \u00fanava, poruchy pam\u011bti, deprese,\u00a0zhor\u0161en\u00e1 artikulace, hlub\u0161\u00ed hlas,<\/li>\n<li>retence tekutin s p\u0159\u00edr\u016fstkem v\u00e1hy,<\/li>\n<li>zimom\u0159ivost.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><em>L\u00e9\u010dba hypofunkce:<\/em> ubstitu\u010dn\u00ed l\u00e9\u010dba dle klinick\u00e9ho stavu a laboratorn\u00edch n\u00e1lez\u016f. L\u00e9\u010dba L-tyroxinem (Letrox, Euthyrox).<\/p>\n<p style=\"text-align: justify;\">Nel\u00e9\u010den\u00e1 hypofunkce m\u016f\u017ee v\u00e9st k ohro\u017een\u00ed \u017eivota \u2013 myxed\u00e9mov\u00e9 koma. Sp\u00ed\u0161e vz\u00e1cn\u00fd stav s bezv\u011bdom\u00edm, hypotermi\u00ed, s ob\u011bhov\u00fdm a dechov\u00fdm selh\u00e1n\u00edm.<\/p>\n<h5>5.4.3 Z\u00e1n\u011bty \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h5>\n<h6>Chronick\u00e1 forma z\u00e1n\u011btu:<\/h6>\n<p><strong>Hashimotova struma<\/strong><\/p>\n<ul>\n<li>autoimunn\u00ed posti\u017een\u00ed s tvorbou protil\u00e1tek<\/li>\n<li>lymfocyt\u00e1rn\u00ed infiltrace<\/li>\n<li>tu\u017e\u0161\u00ed, nebolestiv\u00e1 struma, sp\u00ed\u0161e tlak na krku<\/li>\n<li>pozvoln\u00fd v\u00fdvoj<\/li>\n<li>p\u0159\u00edznaky hypofunkce<\/li>\n<li>mo\u017en\u00e1 malignizace<\/li>\n<\/ul>\n<p><strong>L\u00e9\u010dba:<\/strong><\/p>\n<ul>\n<li>\u00a0tyreoid\u00e1ln\u00ed hormony<\/li>\n<li>kortikoidy<\/li>\n<li>tot\u00e1ln\u00ed tyreoidektomie<\/li>\n<\/ul>\n<p><strong>Riedlova struma<\/strong><\/p>\n<ul>\n<li>fibr\u00f3zn\u00ed p\u0159em\u011bna \u017el\u00e1zy<\/li>\n<li>tuh\u00e1 struma fixovan\u00e1 do okol\u00ed, imituj\u00edc\u00ed karcinom<\/li>\n<li>p\u0159\u00edznaky komprese<\/li>\n<\/ul>\n<p><strong>L\u00e9\u010dba:<\/strong><\/p>\n<ul>\n<li>operace z d\u016fvod\u016f nar\u016fstaj\u00edc\u00ed komprese, minim\u00e1ln\u011b\u00a0prot\u011bt\u00ed istmu \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/li>\n<\/ul>\n<h6>Akutn\u00ed forma z\u00e1n\u011btu:<\/h6>\n<ul>\n<li>bakteri\u00e1ln\u00ed infekce<\/li>\n<li>zdu\u0159en\u00ed, bolestiv\u00e1 \u017el\u00e1za<\/li>\n<li>teplota<\/li>\n<\/ul>\n<h6>Subakutn\u00ed forma z\u00e1n\u011btu:<\/h6>\n<p>De Quervainova nemoc:<\/p>\n<ul>\n<li>virov\u00e9ho p\u016fvodu L\u00e9\u010dba:\n<ul>\n<li>vy\u017eaduje klidov\u00fd re\u017eim, protiz\u00e1n\u011btliv\u00e1 medikace, v p\u0159\u00edpad\u011b abscesu opera\u010dn\u00ed v\u00fdkon<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h5>5.4.4 N\u00e1dory \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h5>\n<h6>Benign\u00ed n\u00e1dory<\/h6>\n<p>Nezhoubn\u00e9, ohrani\u010den\u00e9 n\u00e1dory bez tvorby druhotn\u00fdch lo\u017eisek. P\u0159i progresi mohou p\u016fsobit kompresn\u00ed p\u0159\u00edznaky a n\u011bkter\u00e9 mohou malignizovat. \u010cast\u00e9 adenomy jsou zjistiteln\u00e9 sonografi\u00ed a progrese n\u00e1lezu vede k celkov\u00e9mu zv\u011bt\u0161en\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy jako prost\u00e1 struma. N\u011bkter\u00e9 jsou svoj\u00ed zv\u00fd\u0161enou funkc\u00ed diagnostikov\u00e1ny jako toxick\u00e9 adenomy. V r\u00e1mci cytologick\u00e9ho vy\u0161et\u0159en\u00ed jsou n\u011bkter\u00e9 hodnoceny s bun\u011b\u010dnou atypi\u00ed s mo\u017enost\u00ed malign\u00edho zvratu.L\u00e9\u010dba: P\u0159i zv\u011bt\u0161ov\u00e1n\u00ed adenomu a bun\u011b\u010dn\u00e9 atypii je indikace k operaci.<\/p>\n<h6>Zhoubn\u00e9 n\u00e1dory<\/h6>\n<p>P\u0159ev\u00e1\u017en\u011b se jedn\u00e1 o epitelov\u00e9 n\u00e1dory z folikul\u00e1rn\u00edho epitelu \u0161t\u00edtn\u00e9 \u017el\u00e1zy, m\u00e9n\u011b \u010dasto z parafolikul\u00e1rn\u00edch bun\u011bk. Na vzniku se pod\u00edlej\u00ed genetick\u00e9 vlivy, dlouhodob\u011b nel\u00e9\u010den\u00e9 endemick\u00e9 strumy, Hashimotova struma, neadekv\u00e1tn\u00ed hormon\u00e1ln\u00ed l\u00e9\u010dba po d\u0159\u00edv\u011bj\u0161\u00edch m\u00e9n\u011b radik\u00e1ln\u00edch operac\u00edch. P\u0159ehledn\u011b tuto problematiku uv\u00e1d\u00ed tab. 4.<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\"><span style=\"color: #ffffff;\">Tabulka 4<\/span> <span style=\"color: #ffffff;\"> N\u00e1dory \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/span><\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>99 % n\u00e1dor\u016f tvo\u0159\u00ed karcinomy, zbytek benign\u00ed\u00a0folikul\u00e1rn\u00ed adenomy, sarkomy, malign\u00ed lymfomy,\u00a0metastatick\u00e9 n\u00e1dory<\/li>\n<li>diagn\u00f3za\n<ul>\n<li>zobrazovac\u00ed metody (sonografie, CT, scintigrafie)<\/li>\n<li>punk\u010dn\u00ed aspira\u010dn\u00ed cytologie, histologie<\/li>\n<\/ul>\n<\/li>\n<li>metast\u00e1zov\u00e1n\u00ed \u2013 region\u00e1ln\u00ed uzliny, pl\u00edce, kosti<\/li>\n<li>rozhoduj\u00edc\u00ed v\u010dasn\u00e1 diagn\u00f3za<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Klasifikace<\/h6>\n<p>Diferencovan\u00e9 n\u00e1dory \u2013 \u010d\u00e1ste\u010dn\u011b zachovan\u00e1 schopnost vychyt\u00e1vat jod:<\/p>\n<ul>\n<li>karcinomy \u0161t\u00edtn\u00e9 \u017el\u00e1zy,<\/li>\n<li>papil\u00e1rn\u00ed karcinom (60\u201370 %),<\/li>\n<li>folikul\u00e1rn\u00ed karcinom (15\u201330 %),<\/li>\n<li>l\u00e9\u010dba \u2013 tot\u00e1ln\u00ed thyreoidektomie, destrukce zbyl\u00e9\u00a0tk\u00e1n\u011b a p\u0159\u00edpadn\u00fdch metast\u00e1z radioj\u00f3dem 131J\n<ul>\n<li>\u015c supresn\u00ed l\u00e9\u010dba \u2013 dlouhodob\u00e9 pod\u00e1v\u00e1n\u00ed tyroxinu,<\/li>\n<li>\u015c progn\u00f3za p\u0159\u00edzniv\u00e1 \u2013 dlouhodob\u011b p\u0159e\u017e\u00edv\u00e1 90 %\u00a0pacient\u016f.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Medul\u00e1rn\u00ed a anaplastick\u00e9 n\u00e1dory jod neakumuluj\u00ed<\/p>\n<ul>\n<li>medul\u00e1rn\u00ed karcinom (1\u20137 %) (apudom),<\/li>\n<li>anaplastick\u00fd karcinom (10\u201315 %),<\/li>\n<li>jsou agresivn\u00ed, rychle rostou, z\u00e1hy metast\u00e1zuj\u00ed,<\/li>\n<li>l\u00e9\u010dba:\n<ul>\n<li>tot\u00e1ln\u00ed thyreoidektomie s odstran\u011bn\u00edm uzlin\u00a0+ aktinoterapie,<\/li>\n<li>paliativn\u00ed odstran\u011bn\u00ed n\u00e1doru + aktinoterapie\u00a0+ chemoterapie,\u00a0progn\u00f3za \u0161patn\u00e1.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Epitelov\u00e9 n\u00e1dory:<\/p>\n<ul>\n<li>papil\u00e1rn\u00ed karcinom,<\/li>\n<li>folikul\u00e1rn\u00ed karcinom,<\/li>\n<li>medul\u00e1rn\u00ed karcinom,<\/li>\n<li>nediferencovan\u00fd \u2013 anaplastick\u00fd karcinom.<\/li>\n<\/ul>\n<p>Neepitelov\u00e9 n\u00e1dory:<\/p>\n<ul>\n<li>fibrosarkom,<\/li>\n<li>jin\u00e9.<\/li>\n<\/ul>\n<p>Ostatn\u00ed n\u00e1dory:<\/p>\n<ul>\n<li>karcinosarkom,<\/li>\n<li>malign\u00ed lymfom,<\/li>\n<li>teratom,<\/li>\n<li>malign\u00ed hemangioepiteliom.<\/li>\n<\/ul>\n<p>Nej\u010dast\u011bj\u0161\u00ed druhy karcinomu \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/p>\n<ul>\n<li>\u2022 diferencovan\u00e9 karcinomy: \u015c papil\u00e1rn\u00ed karcinom,\n<ul>\n<li>folikul\u00e1rn\u00ed karcinom,<\/li>\n<\/ul>\n<\/li>\n<li>\u2022 nediferencovan\u00e9 karcinomy:\n<ul>\n<li>anaplastick\u00fd karcinom,<\/li>\n<li>medul\u00e1rn\u00ed karcinom.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Papil\u00e1rn\u00ed karcinom je typick\u00fd pro d\u011btsk\u00fd i dosp\u011bl\u00fd v\u011bk. P\u0159ev\u00e1\u017en\u011b jde o neopouzd\u0159en\u00fd n\u00e1dor, tuh\u00e9 konzistence. Metast\u00e1zy v region\u00e1ln\u00edch lymfatick\u00fdch uzlin\u00e1ch se vyskytuj\u00ed ve 20\u201370 %. Karcinom do 1 cm (mikrokarcinom) ulo\u017een\u00fd intratyreoid\u00e1ln\u011b je m\u00e9n\u011b rizikov\u00fd.<\/p>\n<p style=\"text-align: justify;\">Folikul\u00e1rn\u00ed karcinom je \u010dast\u011bj\u0161\u00ed ve v\u011bku 50\u201360 let a je \u010dast\u011bj\u0161\u00ed u \u017een. Objevuje se v\u00edce u endemick\u00fdch strum s deficitem jodu. Tvo\u0159\u00ed solit\u00e1rn\u00ed, opouzd\u0159en\u00e1 lo\u017eiska a jejich agresitiva souvis\u00ed s invaz\u00ed do okol\u00ed pouzdra a c\u00e9v.<\/p>\n<p style=\"text-align: justify;\">Anaplastick\u00fd karcinom je nediferencovan\u00fd n\u00e1dor s velkou agresivitou, rychl\u00fdm r\u016fstem a sklonem k metast\u00e1zov\u00e1n\u00ed. Vyskytuje se p\u0159ev\u00e1\u017en\u011b u star\u0161\u00edch lid\u00ed. Progn\u00f3za je velmi \u0161patn\u00e1.<\/p>\n<p style=\"text-align: justify;\">Medul\u00e1rn\u00ed karcinom vych\u00e1z\u00ed z parafolikul\u00e1rn\u00edch bun\u011bk, tzv. C-bun\u011bk. N\u00e1dor produkuje hormon calcitonin. Jeho p\u016fsoben\u00edm doch\u00e1z\u00ed k resorpci kostn\u00ed\u00a0tk\u00e1n\u011b a poruch\u00e1m metabolismu Ca, P, Mg, Na a K. Progn\u00f3za je v\u00e1\u017en\u00e1.<\/p>\n<h6>Klinick\u00fd obraz karcinomu<\/h6>\n<p>Syndrom lok\u00e1ln\u00edho r\u016fstu n\u00e1doru:<\/p>\n<ul>\n<li>uzel ve \u017el\u00e1ze,<\/li>\n<li>obraz z\u00e1n\u011btu,<\/li>\n<li>p\u0159\u00edznaky retrostern\u00e1ln\u00ed strumy,<\/li>\n<li>obraz rostouc\u00edho n\u00e1doru.<\/li>\n<\/ul>\n<p>Syndrom metast\u00e1z:<\/p>\n<ul>\n<li>metast\u00e1zy v region\u00e1ln\u00edch kr\u010dn\u00edch uzlin\u00e1ch,<\/li>\n<li>metast\u00e1zy plicn\u00ed,<\/li>\n<li>metast\u00e1zy kostn\u00ed,<\/li>\n<li>mnoho\u010detn\u00e9.<\/li>\n<\/ul>\n<p>Syndrom funk\u010dn\u00ed poruchy:<\/p>\n<ul>\n<li>zv\u00fd\u0161en\u00e1, sn\u00ed\u017een\u00e1 funkce \u0161t\u00edtn\u00e9 \u017el\u00e1zy,<\/li>\n<li>zv\u00fd\u0161en\u00e1 sekrece kalcitoninu.<\/li>\n<\/ul>\n<h6>Indikace chirurgick\u00e9 l\u00e9\u010dby<\/h6>\n<ul>\n<li>hmatn\u00fd uzel na krku,<\/li>\n<li>bolest v m\u00edst\u011b tumoru,<\/li>\n<li>chrapot, stridor,<\/li>\n<li>aspirace, hemopt\u00fdza, dysfagie, du\u0161nost,<\/li>\n<li>bolesti kost\u00ed, patologick\u00e9 zlomeniny,<\/li>\n<li>syndrom horn\u00ed dut\u00e9 \u017e\u00edly.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">U v\u011bt\u0161iny zhoubn\u00fdch n\u00e1dor\u016f je indikace k tot\u00e1ln\u00ed tyreoidektomii. V n\u011bkter\u00fdch p\u0159\u00edpadech je dopln\u011bna radik\u00e1ln\u00ed disekc\u00ed uzlin i v\u00fdkony na okoln\u00edch org\u00e1nech. U anaplastick\u00e9ho karcinomu p\u0159eva\u017euje oz\u00e1\u0159en\u00ed a chemoterapie.<\/p>\n<h4>5.5 Sou\u010dasn\u00e9 trendy\u00a0v chirurgii \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h4>\n<p style=\"text-align: justify;\">Chirurgie \u0161t\u00edtn\u00e9 \u017el\u00e1zy v dne\u0161n\u00ed dob\u011b sleduje trend zv\u00fd\u0161en\u00e9 radikality opera\u010dn\u00edho v\u00fdkonu a zv\u00fd\u0161en\u00e9 prevence mo\u017en\u00fdch komplikac\u00ed. Tuto problematiku lze zahrnout do n\u00e1sleduj\u00edc\u00edch okruh\u016f:<\/p>\n<ul>\n<li>radikalita opera\u010dn\u00edho v\u00fdkonu,<\/li>\n<li>peropera\u010dn\u00ed sonografie,<\/li>\n<li>peropera\u010dn\u00ed monitorace \u2013 stimulace NLR,<\/li>\n<li>harmonick\u00fd skalpel,<\/li>\n<li>u\u017eit\u00ed automatick\u00e9ho rozv\u011bra\u010de,<\/li>\n<li>video-asistovan\u00e1 tyreoidektomie.<\/li>\n<\/ul>\n<h6>Radikalita<\/h6>\n<p style=\"text-align: justify;\">Za nejmen\u0161\u00ed opera\u010dn\u00ed v\u00fdkon je pova\u017eov\u00e1na jednostrann\u00e1 lobektomie \u010di tak\u0159ka tot\u00e1ln\u00ed lobektomie, kter\u00e1 je v p\u0159\u00edpad\u011b v\u00fdskytu karcinomu v uzlu sou\u010dasn\u011b i prevenc\u00ed p\u0159\u00edpadn\u00e9 reoperace na stran\u011b operovan\u00e9. Radikalitu up\u0159ednost\u0148ujeme i u benign\u00edch onemocn\u011bn\u00ed, kde riziko substitu\u010dn\u00ed l\u00e9\u010dby je daleko men\u0161\u00ed ne\u017e mo\u017enost recidivy p\u016fvodn\u00edho onemocn\u011bn\u00ed. Tot\u00e1ln\u00ed oboustrann\u00e1 tyreoidektomie jako nejradik\u00e1ln\u011bj\u0161\u00ed v\u00fdkon nen\u00ed zat\u00ed\u017eena vy\u0161\u0161\u00edm procentem komplikac\u00ed ne\u017e d\u0159\u00edve \u010dast\u011bji prov\u00e1d\u011bn\u00e1 subtot\u00e1ln\u00ed nebo t\u00e9m\u011b\u0159 tot\u00e1ln\u00ed tyreoidektomie.<\/p>\n<p style=\"text-align: justify;\">Radik\u00e1ln\u00ed v\u00fdkon mus\u00ed spl\u0148ovat z\u00e1kladn\u00ed po\u017eadavky:<\/p>\n<ol>\n<li>\u00fapln\u00e9 odstran\u011bn\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy,<\/li>\n<li>prevence poran\u011bn\u00ed nervus laryngeus recurrens (vizualizace, preparace, neurostimulace),<\/li>\n<li>prevence poran\u011bn\u00ed p\u0159\u00ed\u0161t\u00edtn\u00fdch t\u011bl\u00edsek.<\/li>\n<\/ol>\n<h6>Z\u00e1kladn\u00ed chirurgick\u00e9 v\u00fdkony na \u0161t\u00edtn\u00e9 \u017el\u00e1ze<\/h6>\n<p style=\"text-align: justify;\">Thyreoidectomia totalis (TTE) \u2013 odstran\u011bn\u00ed ve\u0161ker\u00e9 tk\u00e1n\u011b \u0161t\u00edtn\u00e9 \u017el\u00e1zy (obr. 4a, b).<\/p>\n<p style=\"text-align: justify;\">Thyreoidectomia near totalis (near total thyreoidectomy \u2013 n TTE) \u2013 ponech\u00e1n\u00ed zbytku tk\u00e1n\u011b 1\u20133 g, do 4 mm v pr\u016fm\u011bru.<\/p>\n<p style=\"text-align: justify;\">Lobectomia totalis (LT) \u2013 \u00fapln\u00e9 odstran\u011bn\u00ed jednoho laloku \u0161t\u00edtn\u00e9 \u017el\u00e1zy v\u010detn\u011b isthmu, lobus pyramidalis.<\/p>\n<p style=\"text-align: justify;\">Resectio isthmi \u2013 odstran\u011bn\u00ed isthmu \u0161t\u00edtn\u00e9 \u017el\u00e1zy, paliativn\u00ed v\u00fdkon p\u0159i \u00fatlaku pr\u016fdu\u0161nice, n\u011bkdy dopln\u011bn\u00e1 tracheostomi\u00ed.<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_222.png\"><img decoding=\"async\" title=\"Obr. 4a \u2013 Opera\u010dn\u00ed prepar\u00e1t odstran\u011bn\u00fdch obou lalok\u016f \u0161t\u00edtn\u00e9 \u017el\u00e1zy (Thyreoidectomia totalis)\" alt=\"Obr. 4a \u2013 Opera\u010dn\u00ed prepar\u00e1t odstran\u011bn\u00fdch obou lalok\u016f \u0161t\u00edtn\u00e9 \u017el\u00e1zy (Thyreoidectomia totalis)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_222.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 4a \u2013 Opera\u010dn\u00ed prepar\u00e1t odstran\u011bn\u00fdch obou lalok\u016f \u0161t\u00edtn\u00e9 \u017el\u00e1zy (Thyreoidectomia totalis)<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_224.png\"><img decoding=\"async\" title=\"Obr. 4b \u2013 Thyreoidectomia near totalis (n TTE) , na \u0159ezu je patrn\u00e1 uzlovit\u00e1 struktura obou lalok\u016f\" alt=\"Obr. 4b \u2013 Thyreoidectomia near totalis (n TTE) , na \u0159ezu je patrn\u00e1 uzlovit\u00e1 struktura obou lalok\u016f\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_224.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 4b \u2013 Thyreoidectomia near totalis (n TTE) , na \u0159ezu je patrn\u00e1 uzlovit\u00e1 struktura obou lalok\u016f<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">Lobectomia totalis (LT)Je jednostrann\u00fd identick\u00fd v\u00fdkon jako u TTE. Istmus je resekov\u00e1n na hranici s neposti\u017een\u00fdm druh\u00fdm lalokem \u0161t\u00edtn\u00e9 \u017el\u00e1zy.<\/p>\n<p>Opera\u010dn\u00ed p\u0159\u00edstup:<\/p>\n<p style=\"text-align: justify;\">Kol\u00e1rn\u00ed \u0159ez, poloobloukovit\u00e1 incize vedena soub\u011b\u017en\u011b s relaxa\u010dn\u00edmi liniemi. Zasahuje ve st\u0159edu 2 cm nadincisura jugularis a later\u00e1ln\u011b kon\u010d\u00ed v \u00farovni musculus sternocleidomastoideus.<\/p>\n<p style=\"text-align: justify;\">N\u00e1sleduje protnut\u00ed podko\u017e\u00ed a m. platysma. Laminasuperfitialis fasciae cervicalis se prot\u00edn\u00e1 pod\u00e9ln\u011b nebop\u0159\u00ed\u010dn\u011b. Infrahyoidn\u00ed svaly se rozd\u011bluj\u00ed svisle bez prot\u011bt\u00ed nebo se v r\u016fzn\u00e9m rozsahu p\u0159eru\u0161uj\u00ed p\u0159\u00ed\u010dn\u011b. T\u00edmto je obna\u017een istmus a p\u0159edn\u00ed \u010d\u00e1st lalok\u016f \u0161t\u00edtn\u00e9 \u017el\u00e1zy.<\/p>\n<p style=\"text-align: justify;\">Opera\u010dn\u00ed v\u00fdkon mus\u00ed spl\u0148ovat:<\/p>\n<ul>\n<li>\u00fapln\u00e9 odstran\u011bn\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy,<\/li>\n<li>identifikace a ochrana nervus laryngeus recurrens,<\/li>\n<li>\u00a0identifikace p\u0159\u00ed\u0161t\u00edtn\u00fdch t\u011bl\u00edsek a ochrana jejich c\u00e9vn\u00edch z\u00e1soben\u00ed.<\/li>\n<\/ul>\n<p>Vlastn\u00ed opera\u010dn\u00ed postup: M\u016f\u017ee b\u00fdt odli\u0161n\u00fd od zvyklost\u00ed pracovi\u0161t\u011b, podstatav\u00fdkonu s ohledem na mo\u017en\u00e9 komplikace je stejn\u00e1:<\/p>\n<ul>\n<li style=\"text-align: justify;\">prot\u011bt\u00ed istmu a paratrache\u00e1ln\u00ed vazivov\u00e9 tk\u00e1n\u011b,<\/li>\n<li style=\"text-align: justify;\">preparace, uvoln\u011bn\u00ed horn\u00edho p\u00f3lu s podvazem vasathyreoidea superioria,<\/li>\n<li style=\"text-align: justify;\">mobilizace laloku z later\u00e1ln\u00ed strany a p\u0159eru\u0161en\u00ed v\u011btve v. thyreoidea media,<\/li>\n<li style=\"text-align: justify;\">uvoln\u011bn\u00ed doln\u00edho p\u00f3lu a p\u0159eru\u0161en\u00ed vv. thyreoideae\u00a0inferiores,<\/li>\n<li style=\"text-align: justify;\">uvoln\u011bn\u00ed p\u0159\u00ed\u0161t\u00edtn\u00fdch t\u011bl\u00edsek p\u0159i horn\u00edm i doln\u00edm\u00a0p\u00f3lu \u0161t\u00edtn\u00e9 \u017el\u00e1zy,<\/li>\n<li style=\"text-align: justify;\">pr\u016fb\u011b\u017en\u00e1 vizualizace\/preparace, neurostimulace\u00a0(NLR),<\/li>\n<li style=\"text-align: justify;\">p\u0159eru\u0161en\u00ed fixace laloku v m\u00edst\u011b ligamentum Berry\u00a0a odstran\u011bn\u00ed laloku.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\"><span style=\"text-align: justify;\">Ponechan\u00e1 tk\u00e1\u0148 velikosti hrachu (1\u20133 g), p\u0159i nep\u0159ehledn\u00fdch anatomick\u00fdch pom\u011brech, nap\u0159. u malign\u00edho onemocn\u011bn\u00ed. Zbyl\u00e1 tk\u00e1\u0148 je destruov\u00e1na z\u00e1\u0159en\u00edm.<\/span><\/p>\n<p style=\"text-align: justify;\">Tot\u00e1ln\u00ed tyreoidektomie + modifikovan\u00e1 radik\u00e1ln\u00ed kr\u010dn\u00ed disekceOpera\u010dn\u00ed v\u00fdkon p\u0159i zhoubn\u00e9m n\u00e1doru ve \u0161t\u00edtn\u00e9 \u017el\u00e1ze s posti\u017een\u00edm region\u00e1ln\u00edch lymfatick\u00fdch uzlin.Jde o odstran\u011bn\u00ed lymfatick\u00e9 tk\u00e1n\u011b spolu s tukovou a vazivovou tk\u00e1n\u00ed v rozsahu I.\u2013VI. kr\u010dn\u00edho sektoru.<\/p>\n<p>Tot\u00e1ln\u00ed tyreoidektomie + selektivn\u00ed kr\u010dn\u00ed direkce<\/p>\n<p style=\"text-align: justify;\">V p\u0159\u00edpad\u011b jedn\u00e9 zv\u011bt\u0161en\u00e9 uzliny se lymfadenektomieprov\u00e1d\u00ed v rozsahu jednoho a\u017e dvou kr\u010dn\u00edch sektor\u016f.<\/p>\n<p style=\"text-align: justify;\">U velk\u00fdch retrostern\u00e1ln\u00edch strum, mediastin\u00e1ln\u00edch strum, \u010dasto malign\u00edch, je indikov\u00e1na sternotomie. Kol\u00e1rn\u00ed \u0159ez je dopln\u011bn \u0159ezem nad sternem do tvaru p\u00edsmene T. P\u0159i parci\u00e1ln\u00ed resekci sah\u00e1 do v\u00fd\u0161e t\u0159et\u00edho mezi\u017eeb\u0159\u00ed. Operace na \u0161t\u00edtn\u00e9 \u017el\u00e1ze spojen\u00e9 s v\u00fdkony na okoln\u00edch org\u00e1nech (j\u00edcen, pr\u016fdu\u0161nice) jsou sp\u00ed\u0161e vz\u00e1cn\u00e9. Operace je ukon\u010dena zaveden\u00edm podtlakov\u00e9 Redonovy dren\u00e1\u017ee a uz\u00e1v\u011brem opera\u010dn\u00ed r\u00e1ny ve vrstv\u00e1ch. V\u00fdkony na \u0161t\u00edtn\u00e9 \u017el\u00e1ze, kter\u00e9 byly v minulosti m\u00e9n\u011b radik\u00e1ln\u00ed \u2013 enukleace adenomu nebo cysty, parci\u00e1ln\u00ed resekce laloku, subtot\u00e1ln\u00ed lobektomie, jsou v dne\u0161n\u00ed dob\u011b zcela opu\u0161t\u011bny. Proto i riziko reoperac\u00ed, a t\u00edm i riziko komplikac\u00ed se v\u00fdrazn\u011b sni\u017euje.<\/p>\n<h6>Peropera\u010dn\u00ed sonografie<\/h6>\n<p>Je p\u0159\u00ednosem ve chv\u00edli, kdy se jedn\u00e1 o p\u0159edopera\u010dn\u011b verifikovan\u00fd patologick\u00fd n\u00e1lez jednoho laloku, p\u0159i intaktn\u00edm laloku opa\u010dn\u00e9m (vyjma malignit). P\u0159i tomto odli\u0161n\u00e9m peropera\u010dn\u00edm n\u00e1lezu je sonografie pomoc\u00ed p\u0159i p\u0159esn\u00e9m, jednozna\u010dn\u00e9m ur\u010den\u00ed patologick\u00e9ho posti\u017een\u00ed druh\u00e9ho laloku roz\u0161\u00ed\u0159en\u00ed jednostrann\u00e9 lobektomie na v\u00fdkon oboustrann\u00fd. Peropera\u010dn\u00ed sonografie m\u00e1 sv\u00e9 opodstatn\u011bn\u00ed i p\u0159i kr\u010dn\u00ed lymfadenektomii.<\/p>\n<h6>Peropera\u010dn\u00ed monitorace \u2013 neurostimulace\u00a0NLR (<i>nervus laryngeus recurrens<\/i>)<\/h6>\n<p style=\"text-align: justify;\">Jedn\u00e1 se o metodu, kter\u00e1 n\u00e1s p\u0159esn\u011b informuje b\u011bhem cel\u00e9ho opera\u010dn\u00edho v\u00fdkonu o poloze nervu, jeho integrit\u011b a jeho vztahu k okoln\u00edm struktur\u00e1m. Peropera\u010dn\u00ed neurostimulace pr\u016fb\u011bhu nervus laryngeus recurrens je jednoduchou metodou, kter\u00e1 pokud se stane rutinn\u00ed sou\u010d\u00e1st\u00ed v\u00fdkon\u016f na \u0161t\u00edtn\u00e9 \u017el\u00e1ze, sni\u017euje v\u00fdskyt peropera\u010dn\u00ed l\u00e9ze NLR na 0,005 %. Je mo\u017eno ji univerz\u00e1ln\u011b pou\u017e\u00edt p\u0159i v\u0161ech indikovan\u00fdch v\u00fdkonech na \u0161t\u00edtn\u00e9 \u017el\u00e1ze a p\u0159\u00ed\u0161t\u00edtn\u00fdch t\u011bl\u00edsk\u00e1ch. Jej\u00ed vyu\u017eit\u00ed je zejm\u00e9na opodstatn\u011bn\u00e9 p\u0159i reoperac\u00edch v nep\u0159ehledn\u00e9m ter\u00e9nu recidivy \u010di Hashimotovy thyreoiditidy (obr. 5,6, 7, 8a, b).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_226.png\"><img decoding=\"async\" title=\"Obr. 5 \u2013 P\u0159\u00edstroj k peropera\u010dn\u00edmu monitorov\u00e1n\u00ed pr\u016fb\u011bhu vratn\u00e9ho nervu s elektrodami\" alt=\"Obr. 5 \u2013 P\u0159\u00edstroj k peropera\u010dn\u00edmu monitorov\u00e1n\u00ed pr\u016fb\u011bhu vratn\u00e9ho nervu s elektrodami\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_226.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 5 \u2013 P\u0159\u00edstroj k peropera\u010dn\u00edmu monitorov\u00e1n\u00ed pr\u016fb\u011bhu vratn\u00e9ho nervu s elektrodami<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_227.png\"><img decoding=\"async\" title=\"Obr. 6 \u2013 V opera\u010dn\u00edm poli se obvykle transligament\u00f3zn\u011b zavede elektroda, kter\u00e1 sn\u00edm\u00e1 pohyb (stah) hlasivky\" alt=\"Obr. 6 \u2013 V opera\u010dn\u00edm poli se obvykle transligament\u00f3zn\u011b zavede elektroda, kter\u00e1 sn\u00edm\u00e1 pohyb (stah) hlasivky\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_227.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 6 \u2013 V opera\u010dn\u00edm poli se obvykle transligament\u00f3zn\u011b zavede elektroda, kter\u00e1 sn\u00edm\u00e1 pohyb (stah) hlasivky<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_228.png\"><img decoding=\"async\" title=\"Obr. 7 \u2013 Stimula\u010dn\u00ed elektroda dr\u00e1\u017ed\u00ed v opera\u010dn\u00edm poli pr\u016fb\u011bh NLR, to vede ke stahu hlasivky, kter\u00fd je registrov\u00e1n transligament\u00f3zn\u011b zavedenou elektrodou. Tento podn\u011bt je transformov\u00e1n na zvukov\u00fd sign\u00e1l. P\u00edp\u00e1n\u00ed sly\u0161\u00ed operat\u00e9r a je pro n\u011bho d\u016fkazem o neporu\u0161en\u00e9 vodivosti NLR\" alt=\"Obr. 7 \u2013 Stimula\u010dn\u00ed elektroda dr\u00e1\u017ed\u00ed v opera\u010dn\u00edm poli pr\u016fb\u011bh NLR, to vede ke stahu hlasivky, kter\u00fd je registrov\u00e1n transligament\u00f3zn\u011b zavedenou elektrodou. Tento podn\u011bt je transformov\u00e1n na zvukov\u00fd sign\u00e1l. P\u00edp\u00e1n\u00ed sly\u0161\u00ed operat\u00e9r a je pro n\u011bho d\u016fkazem o neporu\u0161en\u00e9 vodivosti NLR\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_228.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 7 \u2013 Stimula\u010dn\u00ed elektroda dr\u00e1\u017ed\u00ed v opera\u010dn\u00edm poli pr\u016fb\u011bh NLR, to vede ke stahu hlasivky, kter\u00fd je registrov\u00e1n transligament\u00f3zn\u011b zavedenou elektrodou. Tento podn\u011bt je transformov\u00e1n na zvukov\u00fd sign\u00e1l. P\u00edp\u00e1n\u00ed sly\u0161\u00ed operat\u00e9r a je pro n\u011bho d\u016fkazem o neporu\u0161en\u00e9 vodivosti NLR<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_229.png\"><img decoding=\"async\" title=\"Obr. 8a \u2013 Stah hlasivky, m\u016f\u017ee b\u00fdt registrov\u00e1n m\u00edsto transligament\u00f3zn\u011b zavedenou punk\u010dn\u00ed elektrodou samolep\u00edc\u00ed p\u00e1skou, kter\u00e1 je p\u0159ilepena na intuba\u010dn\u00ed kanylu\" alt=\"Obr. 8a \u2013 Stah hlasivky, m\u016f\u017ee b\u00fdt registrov\u00e1n m\u00edsto transligament\u00f3zn\u011b zavedenou punk\u010dn\u00ed elektrodou samolep\u00edc\u00ed p\u00e1skou, kter\u00e1 je p\u0159ilepena na intuba\u010dn\u00ed kanylu\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_229.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 8a \u2013 Stah hlasivky, m\u016f\u017ee b\u00fdt registrov\u00e1n m\u00edsto transligament\u00f3zn\u011b zavedenou punk\u010dn\u00ed elektrodou samolep\u00edc\u00ed p\u00e1skou, kter\u00e1 je p\u0159ilepena na intuba\u010dn\u00ed kanylu<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_230.png\"><img decoding=\"async\" title=\"Obr. 8b \u2013 Po intubaci pak p\u00e1skov\u00e1 elektroda registruje a d\u00e1le p\u0159en\u00e1\u0161\u00ed stah hlasivky \u2013 pohled do laryngu po intubaci\" alt=\"Obr. 8b \u2013 Po intubaci pak p\u00e1skov\u00e1 elektroda registruje a d\u00e1le p\u0159en\u00e1\u0161\u00ed stah hlasivky \u2013 pohled do laryngu po intubaci\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_230.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 8b \u2013 Po intubaci pak p\u00e1skov\u00e1 elektroda registruje a d\u00e1le p\u0159en\u00e1\u0161\u00ed stah hlasivky \u2013 pohled do laryngu po intubaci<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h6>Harmonick\u00fd skalpel<\/h6>\n<p style=\"text-align: justify;\">Speci\u00e1ln\u00ed p\u0159\u00edstroj prov\u00e1d\u011bj\u00edc\u00ed \u0159ez na principu ultrazvukov\u00e9ho kmit\u00e1n\u00ed opera\u010dn\u00edho n\u00e1stroje. Opera\u010dn\u00ed technologie je ur\u010dena pro \u0159ez tk\u00e1n\u00ed a stav\u011bn\u00ed krv\u00e1cen\u00ed. Aktivn\u00ed koncovka n\u00e1stroje je r\u016fzn\u011b modifikovan\u00e1. Termin\u00e1ln\u00ed vibrace na aktivn\u00ed \u010d\u00e1sti n\u00e1stroje maj\u00ed frekvenci 55 500 kmit\u016f za vte\u0159inu. Harmonick\u00fd skalpel zastav\u00ed krv\u00e1cen\u00ed a je velmi \u0161etrn\u00fd k okol\u00ed. Deklarovan\u00e1 z\u00f3na s mo\u017enost\u00ed po\u0161kodit okoln\u00ed tk\u00e1n\u011b je 1 mm. Je v\u00fdhodn\u00fd pro operace pacient\u016f s kardiostimul\u00e1torem, kde nelze pou\u017e\u00edt elektrickou koagulaci. Pro operace \u0161t\u00edtn\u00e9 \u017el\u00e1zy jej u\u017e\u00edv\u00e1me zcela ojedin\u011ble, \u00fa\u010deln\u011bj\u0161\u00ed podle na\u0161ich zku\u0161enost\u00ed je bipol\u00e1rn\u00ed koagulace. V p\u0159\u00edpad\u011b\u00a0pol\u00e1rn\u00edch c\u00e9v je nezastupiteln\u00e1 ligatura (obr. 9).<\/p>\n<table style=\"border-color: #ffffff; border-width: 0px; background-color: #ffffff; ; width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_233.png\"><img decoding=\"async\" title=\"Obr. 9 \u2013 U\u017eit\u00ed harmonick\u00e9ho skalpelu p\u0159i preparaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy\" alt=\"Obr. 9 \u2013 U\u017eit\u00ed harmonick\u00e9ho skalpelu p\u0159i preparaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_233.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 9 \u2013 U\u017eit\u00ed harmonick\u00e9ho skalpelu p\u0159i preparaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_232.png\"><img decoding=\"async\" title=\"Obr. 10a \u2013 Vyu\u017eit\u00ed automatick\u00e9ho rozv\u011bra\u010de p\u0159i operaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy\" alt=\"Obr. 10a \u2013 Vyu\u017eit\u00ed automatick\u00e9ho rozv\u011bra\u010de p\u0159i operaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_232.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 10a \u2013 Vyu\u017eit\u00ed automatick\u00e9ho rozv\u011bra\u010de p\u0159i operaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff; background-color: #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_234.png\"><img decoding=\"async\" title=\"Obr. 10b \u2013 Vyu\u017eit\u00ed automatick\u00e9ho rozv\u011bra\u010de p\u0159i operaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy\" alt=\"Obr. 10b \u2013 Vyu\u017eit\u00ed automatick\u00e9ho rozv\u011bra\u010de p\u0159i operaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/05\/Image_234.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 10b \u2013 Vyu\u017eit\u00ed automatick\u00e9ho rozv\u011bra\u010de p\u0159i operaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">\u00a0Tento rozv\u011bra\u010d byl c\u00edlen\u011b vyvinut pro pot\u0159eby kr\u010dn\u00ed chirurgie. Kloub se p\u0159izp\u016fsob\u00ed anatomick\u00e9mu tvaru t\u011bla, hv\u011bzdicovit\u00fdm rozm\u00edst\u011bn\u00edm h\u00e1\u010dk\u016f zp\u0159ehledn\u00ed opera\u010dn\u00ed pole a u\u0161et\u0159\u00ed pracovn\u00ed s\u00edlu 1\u20132 asistent\u016f. Je v\u0161ak nevhodn\u00fd u objemn\u00fdch strum nebo v kritick\u00fdch chv\u00edl\u00edch, nap\u0159\u00edklad p\u0159i krv\u00e1cen\u00ed, kdy je t\u0159eba rychle a \u00fa\u010deln\u011b m\u011bnit polohu h\u00e1\u010dk\u016f v opera\u010dn\u00edm poli. Rigidn\u011b p\u0159ipevn\u011bn\u00e9 h\u00e1\u010dky pak rychlou manipulaci sp\u00ed\u0161e zt\u011b\u017euj\u00ed (obr. 10a,b).<\/p>\n<h6>Video-asistovan\u00e1 tyreoidektomie<\/h6>\n<p style=\"text-align: justify;\">Jedn\u00e1 se o novou metodu, zav\u00e1d\u011bnou v posledn\u00edm desetilet\u00ed. Vyu\u017e\u00edv\u00e1 zku\u0161enost\u00ed miniinvazivn\u00ed chirurgie. Z miniincize v rozsahu 10\u201320 mm ve v\u00fd\u0161ce 2 cm nad jugulem se za pomoc\u00ed 5mm kamery prov\u00e1d\u00ed miniinstrument\u00e1riem lobektomie i tot\u00e1ln\u00ed tyreoidektomie. Skupina japonsk\u00fdch autor\u016f zve\u0159ejnila sv\u00e9 zku\u0161enosti s lobektomi\u00ed z axil\u00e1rn\u00edho p\u0159\u00edstupu, podko\u017en\u00edm tunelem \u2013 10mm tubusem. U\u017eit\u00ed metody je vhodn\u00e9 jen pro \u00fazkou skupinu n\u00e1lez\u016f:<\/p>\n<ul>\n<li>uzel nen\u00ed v\u011bt\u0161\u00ed ne\u017e 30 mm ve sv\u00e9m nej\u0161ir\u0161\u00edm rozm\u011bru,<\/li>\n<li>objem laloku nen\u00ed v\u011bt\u0161\u00ed ne\u017e 20 ml,<\/li>\n<li>nejedn\u00e1 se o karcinom,<\/li>\n<li>nejedn\u00e1 se o tyreoiditidu.<\/li>\n<\/ul>\n<p>V\u00fdhody metody:<\/p>\n<ul>\n<li>krat\u0161\u00ed doba hospitalizace,<\/li>\n<li>men\u0161\u00ed poopera\u010dn\u00ed bolest,<\/li>\n<li>kosmetick\u00fd efekt.<\/li>\n<\/ul>\n<h4>5.6 Komplikace po operac\u00edch \u0161t\u00edtn\u00e9 \u017el\u00e1zy<\/h4>\n<p>V 19. stolet\u00ed se \u00famrtnost v chirurgii \u0161t\u00edtn\u00e9 \u017el\u00e1zy pohybovala kolem 40 %. Nej\u010dast\u011bj\u0161\u00edmi p\u0159\u00ed\u010dinami \u00famrt\u00ed byla infekce a krv\u00e1cen\u00ed. N\u00e1stupem aseptick\u00fdch opera\u010dn\u00edch postup\u016f, celkov\u00e9 anestezie a zlep\u0161uj\u00edc\u00ed se opera\u010dn\u00ed technice se stalo riziko \u00famrt\u00ed p\u0159i operaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy vz\u00e1cn\u00fdm (tab. 5).<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\"><span style=\"color: #ffffff;\">Tabulka 5<\/span> <span style=\"color: #ffffff;\">Komplikace operace na \u0161t\u00edtn\u00e9 \u017el\u00e1ze<\/span><\/td>\n<\/tr>\n<tr>\n<td>\n<ul>\n<li>poran\u011bn\u00ed vratn\u00e9ho nervu\n<ul>\n<li>jednostrann\u00e9 \u2013 chrapot \u2013 foniatrick\u00e1 l\u00e9\u010dba<\/li>\n<li>oboustrann\u00e9 \u2013 dyspnoe \u2013 tracheostomie<\/li>\n<\/ul>\n<\/li>\n<li>poran\u011bn\u00ed \u010di odstran\u011bn\u00ed p\u0159\u00ed\u0161t\u00edtn\u00fdch t\u011bl\u00edsek\n<ul>\n<li>hypoparatyre\u00f3za<\/li>\n<li>implantace p\u0159\u00ed\u0161t\u00edtn\u00fdch t\u011bl\u00edsek<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: justify;\">I kdy\u017e se v\u00fdskyt komplikac\u00ed v\u00fdznamn\u011b sn\u00ed\u017eil, bylo by chybou v\u00fdkon zleh\u010dovat a pova\u017eovat za snadn\u00fd. Chirurg m\u016f\u017ee minimalizovat toto riziko precizn\u00ed znalost\u00ed anatomie a opera\u010dn\u00ed techniky. V\u00fdskyt komplikac\u00ed je \u010dast\u011bj\u0161\u00ed u reoperac\u00ed ne\u017e u prim\u00e1rn\u00edch v\u00fdkon\u016f, \u010dast\u011bj\u0161\u00ed u karcinom\u016f ne\u017e u n\u00e1lez\u016f benign\u00edch. V p\u0159\u00edpad\u011b vzniku komplikace ji chirurg mus\u00ed \u0159e\u0161it tak, aby dopad na pacienta byl co nejmen\u0161\u00ed.Komplikac\u00ed m\u016f\u017ee b\u00fdt serom v r\u00e1n\u011b, stehov\u00fd granulom \u010di kosmetick\u00fd vzhled jizvy, fixovan\u00e1 \u010di keloidn\u00ed jizva. Tyto komplikace vznikaj\u00ed v souvislosti s ne\u0161etrnou preparac\u00ed v podko\u017e\u00ed, rozs\u00e1hlou elektrokoagulac\u00ed, p\u0159i ischemizaci ko\u017en\u00edho laloku, p\u0159i ned\u016fsledn\u00e9 hemost\u00e1ze, p\u0159i nedodr\u017een\u00ed z\u00e1sad asepse. Svou \u00falohu hraj\u00ed i dispozice pacienta. Problemati\u010dt\u00ed v hojen\u00ed jsou p\u0159edev\u0161\u00edm diabetici a lid\u00e9 s imunodeficitem. Mezi z\u00e1va\u017en\u00e9 komplikace v\u0161ak pat\u0159\u00ed p\u0159edev\u0161\u00edm krv\u00e1cen\u00ed, poran\u011bn\u00ed p\u0159\u00ed\u0161t\u00edtn\u00fdch t\u011bl\u00edsek a poran\u011bn\u00ed vratn\u00e9ho nervu. V p\u0159\u00edpad\u011b krv\u00e1cen\u00ed opera\u010dn\u00edho pole, kter\u00e9 se vyskytuje v rozmez\u00ed 0,2\u20131,0 %, je nutn\u00e1 urgentn\u00ed chirurgick\u00e1 revize a o\u0161et\u0159en\u00ed krv\u00e1cen\u00ed.<\/p>\n<p style=\"text-align: justify;\">Hypoparatyre\u00f3za z d\u016fvod\u016f po\u0161kozen\u00ed p\u0159\u00ed\u0161t\u00edtn\u00e9ho t\u011bl\u00edska b\u00fdv\u00e1 p\u0159echodn\u00e1 s rychlou \u00fapravou. V p\u0159\u00edpad\u011b odstran\u011bn\u00ed t\u011bl\u00edska je mo\u017en\u00e9 prov\u00e9st implantaci do m. sternocleidomastoideus nebo radi\u00e1ln\u00edch sval\u016f p\u0159edlokt\u00ed. Konzervativn\u011b se pod\u00e1vaj\u00ed prepar\u00e1ty kalcia a deriv\u00e1ty vitaminu D. Nejv\u00edce ob\u00e1vanou komplikac\u00ed je poran\u011bn\u00ed, p\u0159eru\u0161en\u00ed nervus laryngeus recurrens.<\/p>\n<h6>Poran\u011bn\u00ed NLR<\/h6>\n<p style=\"text-align: justify;\">Ob\u00e1van\u00e1 komplikace v chirurgii \u0161t\u00edtn\u00e9 \u017el\u00e1zy pro ka\u017ed\u00e9ho chirurga. P\u0159\u00ed\u010diny jsou v\u0161eobecn\u011b zn\u00e1m\u00e9, nerv m\u016f\u017ee b\u00fdt p\u0159eru\u0161en, rozdrcen, stla\u010den ligaturou. P\u0159i zji\u0161t\u011bn\u00e9m jednozna\u010dn\u00e9m p\u0159eru\u0161en\u00ed nervu b\u011bhem operace je na m\u00edst\u011b prim\u00e1rn\u00ed sutura nervu nebo u\u017eit\u00ed autotransplant\u00e1tu, ale jejich v\u00fdsledky jsou problematick\u00e9. Ani mikrochirurgickou technikou nen\u00ed mo\u017en\u00e9 spojit adduktorov\u00e1 i abduktorov\u00e1 vl\u00e1kna a p\u0159i regeneraci m\u016f\u017ee doch\u00e1zet k paradoxn\u00edm pohyb\u016fm hlasivek.\u0158e\u0161en\u00ed jednostrann\u00fdch par\u00e9z NLR ponech\u00e1v\u00e1me a\u017e do \u0161est\u00e9ho poopera\u010dn\u00edho m\u011bs\u00edce, kdy je\u0161t\u011b trv\u00e1 mo\u017enost spont\u00e1nn\u00ed \u00fapravy.Existuj\u00ed dva z\u00e1kladn\u00ed zp\u016fsoby, jak \u0159e\u0161it jednostrannou par\u00e9zu NLR:<\/p>\n<ul>\n<li>medializace,<\/li>\n<li>reinervace.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Medializace se prov\u00e1d\u00ed bu\u010f u\u017eit\u00edm injektovan\u00e9ho vst\u0159ebateln\u00e9ho Gelfoamu, jeho\u017e efekt neb\u00fdv\u00e1 trval\u00fd a proceduru je t\u0159eba n\u011bkolikr\u00e1t opakovat. Je mo\u017en\u00e9 u\u017e\u00edt i teflonov\u00e9ho \u010di silikonov\u00e9ho implant\u00e1tu.<\/p>\n<p style=\"text-align: justify;\">Reinervace je mo\u017en\u00e1 dekompres\u00ed nervu (hematom, ligatura) nebo r\u016fzn\u00fdmi typy spojkov\u00fdch operac\u00ed (anastom\u00f3za abduktorov\u00e9 v\u011btve NLR s n. vagus \u010di n. phrenicus).<\/p>\n<p style=\"text-align: justify;\">P\u0159i oboustrann\u00e9 par\u00e9ze NLR je ve v\u011bt\u0161in\u011b p\u0159\u00edpad\u016f nutn\u00e1 tracheotomie, dal\u0161\u00edm \u0159e\u0161en\u00edm je fonochirurgick\u00e1 operace: laterofixace, chordotomie a jin\u00e9. Sv\u00e9 m\u00edsto m\u00e1 i kvalitn\u00ed foniatrick\u00e1 reeduka\u010dn\u00ed p\u00e9\u010de.<\/p>\n<h6>Opera\u010dn\u00ed technika a taktika v prevenci poran\u011bn\u00ed NLR<\/h6>\n<p style=\"text-align: justify;\">Nervus laryngeus recurrens inervuje v\u0161echny vnit\u0159n\u00ed svaly laryngu krom\u011b krikothyroid\u00e1ln\u00edho svalu, kter\u00fd je inervov\u00e1n n. laryngeus superior. Porucha funkce NLR je n\u00e1sledkem jeho p\u0159eru\u0161en\u00ed, rozdrcen\u00ed, stla\u010den\u00ed ligaturou, kompres\u00ed nebo jin\u00e9ho poran\u011bn\u00ed. Je-li p\u0159\u00ed\u010dinou par\u00e9zy struma, jedn\u00e1 se p\u0159edev\u0161\u00edm o strumu retrostern\u00e1ln\u00ed, kde obrna nervu je zp\u016fsobena tlakem a tahem za nerv. Par\u00e9za NLR v\u0161ak m\u016f\u017ee b\u00fdt i prvn\u00edm projevem malignity, n\u00e1doru mediastina \u010di metast\u00e1z, karcinomu j\u00edcnu, bronchi\u00e1ln\u00edho stromu nebo aneuryzmatu aorty. P\u0159\u00ed\u010dinou m\u016f\u017ee b\u00fdt i neuritida nervu. Vzhledem ke sv\u00e9 anatomick\u00e9 poloze je tento nerv nejsledovan\u011bj\u0161\u00ed strukturou p\u0159i preparaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy. Riziko jeho l\u00e9ze je d\u00e1no rozsahem opera\u010dn\u00edho v\u00fdkonu, reoperac\u00ed, biologickou povahou onemocn\u011bn\u00ed. \u010cast\u011bji je poran\u011bn nerv u nod\u00f3zn\u00edch strum, kdy je povrch d\u00edky nodozit\u00e1m m\u00e9n\u011b p\u0159ehledn\u00fd ne\u017e u strum difuzn\u00edch. Mechanick\u00e1 manipulace v bezprost\u0159edn\u00ed bl\u00edzkosti nervu, zvl\u00e1\u0161t\u011b pak n\u00e1siln\u00e1 luxace strumy, m\u016f\u017ee v\u00e9st k jeho p\u0159etr\u017een\u00ed. \u010cast\u011bji je v\u0161ak nerv poran\u011bn zachycen\u00edm peanem, b\u00fdv\u00e1 zavzat do stehu \u010di ligatury v\u011bt\u0161inou p\u0159i podvazu arteria tyreoidea inferior nebo jejich v\u011btv\u00ed. Operace recidivuj\u00edc\u00edch strum je pro poran\u011bn\u00ed hlasov\u00e9ho nervu nebezpe\u010dn\u011bj\u0161\u00ed. NLR b\u00fdv\u00e1 \u010dast\u011bji dislokov\u00e1n a rozhoduj\u00edc\u00edm \u010dinitelem pro dislokaci je nov\u00e9 formov\u00e1n\u00ed zbytk\u016f \u0161t\u00edtn\u00e9 \u017el\u00e1zy. Nebezpe\u010d\u00ed poran\u011bn\u00ed u recidivy je 8\u00d7 v\u011bt\u0161\u00ed ne\u017e p\u0159i operaci prost\u00e9 strumy. V pozdn\u00edm poopera\u010dn\u00edm obdob\u00ed, trv\u00e1-li chrapot n\u011bkolik t\u00fddn\u016f, je nutn\u00e9 myslet na po\u0161kozen\u00ed nervu tahem jizvy, fibr\u00f3zou tk\u00e1n\u00ed, stehov\u00fdmi granulomy. Vzhledem ke gracilit\u011b nervu m\u016f\u017ee ka\u017ed\u00fd n\u00e1siln\u00fd postup vyvolat ochrnut\u00ed NLR. N\u00e1sledkem po\u0161kozen\u00ed nervus laryngeus recurrens jsou poruchy fonace a d\u00fdch\u00e1n\u00ed, r\u016fzn\u00e9ho stupn\u011b i trv\u00e1n\u00ed, mohou si vy\u017e\u00e1dat p\u0159echodn\u011b i trvale tracheostomii.<\/p>\n<h4>5.7 P\u0159\u00ed\u0161t\u00edtn\u00e1 t\u011bl\u00edska<\/h4>\n<p>P\u0159\u00ed\u0161titn\u00e1 t\u011bl\u00edska pro svou anatomickou lokalizaci mohou b\u00fdt necht\u011bn\u011b odstran\u011bna jako komplikace operace \u0161t\u00edtn\u00e9 \u017el\u00e1zy. Z hlediska opera\u010dn\u00edho p\u0159\u00edstupu a techniky operace se i jejich dal\u0161\u00edmi poruchami zpravidla zab\u00fdvaj\u00ed chirurgov\u00e9 se zku\u0161enostmi s operacemi \u0161t\u00edtn\u00e9 \u017el\u00e1zy. P\u0159\u00ed\u0161t\u00edtn\u00e1 t\u011bl\u00edska produkuj\u00ed parathormon, kter\u00fd reguluje metabolismus a hladinu v\u00e1pn\u00edku a fosforu v krvi. Zv\u00fd\u0161en\u00e1 hladina tohoto hormonu vede k hyperparatyre\u00f3ze, sn\u00ed\u017een\u00e1 hladina zp\u016fsobuje hypoparatyre\u00f3zu.<\/p>\n<h6>Hyperparatyre\u00f3za a jej\u00ed formy<\/h6>\n<ul>\n<li><strong>Prim\u00e1rn\u00ed hyperparatyre\u00f3za<\/strong> je vyvol\u00e1na nadprodukc\u00ed parathormonu. P\u0159\u00ed\u010dinou b\u00fdv\u00e1 \u010dast\u011bji adenom a hyperplazie p\u0159\u00ed\u0161t\u00edtn\u00e9ho t\u011bl\u00edska. M\u00e9n\u011b \u010dasto karcinom. Adenomy mohou b\u00fdt lokalizov\u00e1ny i atypicky, nap\u0159. v mediastinu.<\/li>\n<li>P\u0159\u00edznaky\n<ul>\n<li style=\"text-align: justify;\">dlouhodob\u011b m\u016f\u017ee prob\u00edhat bez p\u0159\u00edznak\u016f (vysok\u00e1 hladina v\u00e1pn\u00edku v krvi),<\/li>\n<li style=\"text-align: justify;\">osteodystrofie, bolesti kost\u00ed, kloub\u016f, osteopenie,\u00a0osteopor\u00f3za, chondrokalcin\u00f3za,<\/li>\n<li style=\"text-align: justify;\">posti\u017een\u00ed ledvin, nefroliti\u00e1za, nefrokalcin\u00f3za,<\/li>\n<li style=\"text-align: justify;\">gastrointestin\u00e1ln\u00ed pot\u00ed\u017ee, nauzea, zvracen\u00ed, z\u00e1cpa, \u017e\u00edze\u0148, pocen\u00ed, v\u0159edov\u00e1 choroba, pankreatitida,<\/li>\n<li style=\"text-align: justify;\">kardi\u00e1ln\u00ed pot\u00ed\u017ee, poruchy srde\u010dn\u00edho rytmu, hypertenze.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\">Sekund\u00e1rn\u00ed hyperparatyre\u00f3za vznik\u00e1 p\u0159i n\u00edzk\u00e9\u00a0hladin\u011b v\u00e1pn\u00edku v krvi a zp\u011btnou vazbou doch\u00e1z\u00ed ke stimulaci sekrece parathormonu. Nej\u010dast\u011bji tomu tak b\u00fdv\u00e1 u onemocn\u011bn\u00ed ledvin.<\/li>\n<li style=\"text-align: justify;\">Terci\u00e1rn\u00ed hyperparatyre\u00f3za se objevuje p\u0159i chronick\u00e9m onemocn\u011bn\u00ed ledvin v souvislosti s hemodialyza\u010dn\u00edm programem. U n\u011bkter\u00fdch nemocn\u00fdch tak doch\u00e1z\u00ed k autonomn\u00ed hyperplazii p\u0159\u00ed\u0161t\u00edtn\u00fdch t\u011bl\u00edsek.<\/li>\n<\/ul>\n<h6>Diagnostika<\/h6>\n<p style=\"text-align: justify;\">Zejm\u00e9na se op\u00edr\u00e1 o laboratorn\u00ed vy\u0161et\u0159en\u00ed, stanoven\u00ed hladiny v\u00e1pn\u00edku, parathormonu. Z paraklinick\u00fdch vy\u0161et\u0159ovac\u00edch metod se u\u017e\u00edv\u00e1 zejm\u00e9na sonografie, n\u011bkdy dopln\u011bna punkc\u00ed, v\u00fdpo\u010detn\u00ed tomografie, scintigrafie.<\/p>\n<h6>L\u00e9\u010dba<\/h6>\n<p style=\"text-align: justify;\">L\u00e9\u010den\u00ed je p\u0159ev\u00e1\u017en\u011b chirurgick\u00e9, spo\u010d\u00edvaj\u00edc\u00ed v odstran\u011bn\u00ed p\u0159\u00ed\u0161t\u00edtn\u00e9ho t\u011bl\u00edska nebo t\u011bl\u00edsek \u2013 paratyreoidektomie. Opera\u010dn\u00ed p\u0159\u00edstup je stejn\u00fd jako p\u0159i operaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy z kol\u00e1rn\u00edho \u0159ezu na krku. Laloky \u0161t\u00edtn\u00e9 \u017el\u00e1zy uvol\u0148ujme a odklopujeme medi\u00e1ln\u011b. Variabilita po\u010dtu i ulo\u017een\u00ed p\u0159\u00ed\u0161t\u00edtn\u00fdch t\u011bl\u00edsek je rozmanit\u00e1. Konzervativn\u00ed l\u00e9\u010dba, p\u0159edopera\u010dn\u00ed vy\u0161et\u0159en\u00ed, p\u0159\u00edprava i poopera\u010dn\u00ed p\u00e9\u010de je v rukou endokrinologa.<\/p>\n<h6>Hypoparatyre\u00f3za<\/h6>\n<p style=\"text-align: justify;\">Jde o sn\u00ed\u017eenou hladinu kalcia \u00a0a zv\u00fd\u0161enou hladinu fosforu. M\u016f\u017ee vzniknout v souvislosti s operac\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy, poran\u011bn\u00edm nebo odstran\u011bn\u00edm t\u011bl\u00edsek. Vz\u00e1cn\u011b vznik\u00e1 na podklad\u011b autoimunitn\u00edho onemocn\u011bn\u00ed, kdy vznikaj\u00edc\u00ed protil\u00e1tky p\u016fsob\u00ed proti p\u0159\u00ed\u0161t\u00edtn\u00fdm t\u011bl\u00edsk\u016fm. \u010casto jsou posti\u017eeny i jin\u00e9 \u017el\u00e1zy s vnit\u0159n\u00ed sekrec\u00ed.<\/p>\n<h6>P\u0159\u00edznaky<\/h6>\n<ul>\n<li>zn\u00e1mky tetanie (Chvostk\u016fv p\u0159\u00edznak),<\/li>\n<li>\u00fazkost, labilita, deprese u chronick\u00fdch stav\u016f se zv\u00fd\u0161enou pohotovost\u00ed ke svalov\u00fdm k\u0159e\u010d\u00edm,<\/li>\n<li>such\u00e1 k\u016f\u017ee, zm\u011bny neht\u016f, vlas\u016f.<\/li>\n<\/ul>\n<h6>L\u00e9\u010dba<\/h6>\n<p>Je \u0159\u00edzena endokrinologem. Dle laboratorn\u00edch n\u00e1lez\u016f se pod\u00e1vaj\u00ed prepar\u00e1ty v\u00e1pn\u00edku a vitaminu D.<\/p>\n<h4>5.8 Pou\u017eit\u00e1 a doporu\u010den\u00e1 literatura<\/h4>\n<p>&nbsp;<\/p>\n<ol>\n<li style=\"text-align: justify;\">Dralle H. Rekurensparese nach Schilddrusenoperationen.\u00a0Chirurg. 2005;76:797\u2013800.<\/li>\n<li style=\"text-align: justify;\">Dvo\u0159\u00e1k J. \u0160t\u00edtn\u00e1 \u017el\u00e1za, chirurgick\u00e1\u00a0anatomie, opera\u010dn\u00ed technika. Monografie. Praha: Sefira; 2000.<\/li>\n<li style=\"text-align: justify;\">Dvo\u0159\u00e1k J. Rakovina \u0161t\u00edtn\u00e9 \u017el\u00e1zy. Praha: Libri; 1997.<\/li>\n<li style=\"text-align: justify;\">L\u00edmanov\u00e1 Z, N\u011bm\u011bc J, Zamrazil V. Nemoci \u0161t\u00edtn\u00e9\u00a0\u017el\u00e1zy &#8211; diagnostika a terapie. Praha: Gal\u00e9n; 1995.<\/li>\n<li style=\"text-align: justify;\">Vyhn\u00e1nek J, Duda M, R\u00fdznar V, Hobza J, Myslive\u010dek V, Voj\u00e1\u010dek K. Thyroid Surgery In Advanced\u00a0Age. Acta Univ. Palacki Olomouc, Fac. Med. 1989;\u00a0123:169\u2013175.<\/li>\n<li style=\"text-align: justify;\">Vyhn\u00e1nek J, Duda M, R\u00fdznar V, Hobza M, Mysli- ve\u010dek M, Koranda P. V\u00fdsledky chirurgick\u00e9ho l\u00e9\u010den\u00ed\u00a0karcinomu \u0161t\u00edtn\u00e9 \u017el\u00e1zy u 195 operovan\u00fdch. Klinick\u00e1 onkologie. 1990;3(5):135\u2013139.<\/li>\n<li style=\"text-align: justify;\">Vyhn\u00e1nek J, Duda M. Problematika operac\u00ed a reoperac\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy (49. Chirurgick\u00fd de\u0148 Kostliv\u00e9ho) Bratislavsk\u00e9 l\u00e9k. listy. 1996;97(12)750\u2013756.<\/li>\n<li style=\"text-align: justify;\"><em id=\"__mceDel\">Moc\u0148\u00e1kov\u00e1 M, Vyhn\u00e1nek J, Duda M. Neurostimu-lace\u2013prevence poran\u011bn\u00ed n. laryngeus recurrens p\u0159i\u00a0<\/em><em id=\"__mceDel\"><em id=\"__mceDel\"><em id=\"__mceDel\">tyreoidektomii. Rozhledy v chirurgii. 2006;\u00a0<\/em><\/em><\/em><em id=\"__mceDel\"><em id=\"__mceDel\"><em id=\"__mceDel\"><em id=\"__mceDel\">85(9):441\u2013445.<\/em><\/em><\/em><\/em><\/li>\n<li style=\"text-align: justify;\"><em id=\"__mceDel\"><em id=\"__mceDel\"><em id=\"__mceDel\"><em id=\"__mceDel\">Vyhn\u00e1nek J, Moc\u0148\u00e1kov\u00e1 M, Duda M. Reoperace\u00a0na \u0161t\u00edtn\u00e9 \u017el\u00e1ze a prevence poran\u011bn\u00ed n. laryngeus\u00a0recurrens. Slovensk\u00e1 chirurgie. 2006;3(5):8\u201311.<\/em><\/em><\/em><\/em><\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>5.1 \u00davod Onemocn\u011bn\u00ed \u0161t\u00edtn\u00e9 \u017el\u00e1zy je nej\u010dast\u011bj\u0161\u00edm endokrinn\u00edm posti\u017een\u00edm v na\u0161\u00ed i sv\u011btov\u00e9 populaci. I v dne\u0161n\u00ed dob\u011b existuje cel\u00e1 \u0159ada rozporupln\u00fdch n\u00e1zor\u016f na indikaci k operaci \u0161t\u00edtn\u00e9 \u017el\u00e1zy, na techniku i taktiku opera\u010dn\u00edho v\u00fdkonu. Interdisciplin\u00e1rn\u00ed spolupr\u00e1ce, zejm\u00e9na mezi endokrinology a chirurgy, sm\u011b\u0159uje v posledn\u00edch patn\u00e1cti letech ke zv\u00fd\u0161en\u00e9 radikalit\u011b opera\u010dn\u00edch v\u00fdkon\u016f. Stoupaj\u00edc\u00ed radikalita v [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":2447,"menu_order":5,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-2596","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2596","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=2596"}],"version-history":[{"count":15,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2596\/revisions"}],"predecessor-version":[{"id":3127,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2596\/revisions\/3127"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/2447"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=2596"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}