甲状旁腺切除加部分自体移植术后持续继发性甲状旁腺功能亢进症的外科治疗

薄少军; 徐先发; 邱传亚; 王田田; 宁玉东; 李洪跃

doi:10.13201/j.issn.1001-1781.2018.02.016

甲状旁腺切除加部分自体移植术后持续继发性甲状旁腺功能亢进症的外科治疗

- 1. 民航总医院耳鼻咽喉头颈外科(北京, 100025);
- 2. 民航总医院放射科

详细信息

通讯作者: 徐先发,E-mail:xuxianfa2012@163.com

中图分类号: R582.1

收稿日期: 2017-08-22

Re-operation treatment in uremic patients complicated with persistent secondary hyperparathyroidism after parathyroidectomy with autotransplantation

- 1. Department of Otorhinolaryngology Head and Neck Surgery, the Civil Aviation General Hospital, Beijing, 100025, China;
- 2. Department of Radiology, the Civil Aviation General Hospital

More Information

Corresponding author: XU Xianfa, E-mail: xuxianfa2012@163.com

Received Date: 22 August 2017

摘要

摘要: 目的：探讨甲状旁腺切除加自体移植（PTX+AT）术后持续继发性甲状旁腺功能亢进（SHPT）患者再次手术时的临床经验。方法：回顾性分析2014-01-2017-07期间12例PTX+AT术后持续SHPT患者再次接受残余甲状旁腺全切术的临床资料，术前常规行颈部多普勒超声、锝99-甲氧基异丁基异腈（⁹⁹Tc^m-MIBI）双时相显像、CT、MR等多种影像学检查定位残余甲状旁腺位置，术中切除原位甲状旁腺，同时探查胸腺、纵隔、气管食管沟、甲状腺腺体内等位置查找异位甲状旁腺，术中使用纳米碳染色辅助识别甲状旁腺，手术结束时进行快速甲状旁腺激素测定。术后观察患者临床症状改善情况，血清全段甲状旁腺激素（iPTH）、血钙、磷及钙磷乘积的变化，以及术后并发症及手术失败情况。结果： 12例患者均一次性手术成功，经术后病理证实共22枚甲状旁腺组织，颈部原位14枚，颈部异位8枚，分别异位于胸腺（4枚）、上纵隔（2枚）、甲状腺实质内（2枚）。术后患者骨痛、皮肤瘙痒、乏力等临床症状均明显减轻，术后患者血清iPTH较术前明显降低（P<0.05），术后1周血钙、磷及钙磷乘积水平均较术前明显降低（均P<0.05）。10例患者出现低钙血症，补钙后症状缓解。4例出现一过性声嘶，无进食呛咳、呼吸困难及死亡病例。术后随访1年无症状复发。结论：继发性甲状旁腺功能亢进患者术后持续再次手术时，术前需联合多种影像学方法准确定位残余旁腺位置，术中按照中央区清扫及纵隔清扫理念查找异位甲状旁腺，同时使用纳米碳辅助甲状旁腺负显影并进行iPTH快速测定，能明显提高手术成功率，降低手术并发症。
- 继发性甲状旁腺功能亢进症 /
- 术后持续 /
- 再次手术 /
- 甲状旁腺切除 /
- 甲状旁腺激素测定
Abstract: Objective: To analyze the clinical profile and therapeutic effect of re-operation treatment in uremic patients complicated with persistent secondary hyperparathyroidism(SHPT) after parathyroidectomy with autotransplantation.Method: Twelve persistent SHPT patients who were treated with reoperation of paramyroidectomy (PTX) were enrolled in this study during the period from Jan 2014 to Jul 2017 in our hospital. We evaluated the location of the remaining parathyroid glands by ultrasonography, dual-phase ⁹⁹Tc^m-sestamibi scintigraphy, CT and MR imaging of the neck before the operation. We resected the parathyroid gland tissue in situ, and the ectopic parathyroid glands hiding in thymus, mediastinal, tracheal esophageal groove, thyroid gland and other locations in the neck.During the surgery, nanocarbon imaging was used to help identify the parathyroid gland and parathyroid hormone assay (IOPTH) was measured at the end of the surgery.We observed the changes of clinical symptoms after the surgery and collected blood parameters including serum intact aramyroidhomone (i-PTH), calcium (Ca), phosphoms (P), calcium and phosphorus product before and after surgery. Complications and failure were also analyzed.Result: All the 12 patients underwented successful operation. The postoperative pathological results were hyperplastic parathyroid glands tissue. 22 parathyroid glands were resected, among which 14 were located at the neck in situ, 8 were ectopic, i.e., located at thymus in 4 cases, superior mediastinum in 2 cases and thyroid parenchyma in 2 cases. The clinical symptoms were significantly improved including osteoarthritis, skin itching and limb weakness. The levels of serum iPTH, calcium, phosphorus and calcium and phosphorus product were significantly lower than those before operation (P<0.05). Ten patients presented hypocalcemia after surgery and the level of calcium returned to normal after supplement of calcium. Temporary injury of laryngeal nerve was found in 4 cases, but there was no patient with transient bucking, dyspnea or death. No recurrence was found during 1 year follow-up.Conclusion: It was very important to locate the residual parathyroid gland accurately with a variety of imaging methods in uremic patients complicated with persistent or recurrent SHPT when they needed re-operation. Surgeons should explorate ectopic parathyroid gland according to the concept of the superior mediastinum dissection and the central compartment neck dissection. Meanwhile, the use of nanocarbon assisted parathyroid gland negative imaging and rapid IOPTH can significantly improve the success rate of surgery and reduce surgical complications.
- secondary hyperparathyroidism /
- persitent /
- re-opretion /
- parathyroidectomy /
- intraoperative parathyroid hormone assay

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