摘要
目的探讨慢性肾脏病继发性甲状旁腺功能亢进(secondary hyperparathyroidism,SHPT)患者术后持续或复发再次手术的治疗经验。方法回顾性分析民航总医院2012年8月~2016年12月14例慢性肾脏病合并SHPT患者术后持续或复发再次接受残余甲状旁腺全切术(paramyroidectomy,PTX)或颈部及前臂移植物切除术的临床资料,术前根据颈部多普勒超声、锝99-甲氧基异丁基异腈(methoxy isobutylisonitrible,^(99)Tc^(m)-MIBI)双时相显像、多排螺旋CT增强扫描(computed tomography,CT)、核磁共振扫描(magnetic resonance,MR)等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及复发移植物,同时按上纵膈清扫、中央区清扫切除异位甲状旁腺及脂肪淋巴组织。术后观察患者临床症状改善情况,血清全段甲状旁腺激素(intact parathyroid hormone,i PTH)、血钙、磷及钙磷乘积、碱性磷酸酶、血红蛋白、红细胞比容的变化,以及术后并发症及复发情况。结果 14例患者均手术成功,术后病理均为增生甲状旁腺组织,共切除甲状旁腺27枚,颈部原位14枚,移植灶复发6枚,颈部异位7枚,分别异位于胸腺、上纵膈、甲状腺实质内。颈部超声、^(99)Tc^(m)-MIBI双时相显像、增强CT、MR对异位甲状旁腺的检出率分别为33%、72%、56%、60%。术后患者骨关节痛、皮肤瘙痒、肢体乏力等症状均明显改善,血清i PTH在术后各时间点(术后20min、24h、48h、1月、6月、1年)均较术前明显降低,差异有统计学意义(t值分别为t=5.264、t=4.836、t=5.091、t=5.183、t=5.398、t=5.217;相应P值分别为P<0.001、P=0.001、P<0.001、P<0.001、P<0.001、P<0.001),术后1周血钙、磷及钙磷乘积水平均较术前明显降低(t值分别为t=6.984、t=2.979、t=4.983;相应P值分别为P<0.001、P=0.011、P<0.001),术后1周碱性磷酸酶、血红蛋白及红细胞比容情况无明显变化(t值分别为t=0.693、t=1.048、t=1.693;相应P值分别为P=0.501、P=0.319、P=0.129)。13例患者出现低钙血症,补钙后症状缓解。5例出现一过性声嘶,2例短暂性进食呛咳,无呼吸困难及死亡病例。术后随访1年无复发。结论慢性肾脏病合并继发性甲状旁腺功能亢进术后持续或复发再次手术时术前需要精确定位残留甲状旁腺位置,术中按照上纵隔清扫、中央区清扫理念探查异位甲状旁腺,彻底切除全部残余甲状旁腺。
Objective To analyze the clinical effect of re-operation treatment for uremic patients complicated with persistent or recurrent secondary hyperparathyroidism （SHPT）. Methods A total of 14 persistent or recurrent SHPT patients treated with re-operation of parathyroidectomy （PTX） or resection of the gratis in neck or forearm in our hospital during the period from Aug. 2012 to Dec. 2016 were enrolled in this study. Be- fore re-operation, location of the remaining parathyroid gland in neck was identified by ultrasonography, dual- phase 99Tcm-sestamibi scintigraphy （99Tcm-MIBI）, computed tomography （CT） and magnetic resonance im- aging （MRI）. We resected the parathyroid gland in situ and grafts, especially the ectopic parathyroid gland and lymphatic adipose tissue by superior mediastinal and central compartment dissection. The changes of clinical symptoms, intact parathyroid hormone （iPTH）, calcium （Ca）, phosphorus （P）, calcium and phosphorus prod- uct （CaxP）, alkaline phosphatase （ALP）, hemoglobin （HB） and hematocrit （HCT） after the surgery were ob- served. Surgery complications and recurrence of SHPT were also analyzed. Results All of the 14 patients un- derwent the operation successfully. Pathological examination of the surgical samples found hyperplastic parathyroid issues. We resected 27 parathyroid glands, including 14 glands in situ in neck, 6 recurrent grafts and 7 ectopic glands in thymus, which located in thymus, superior mediastinum or thyroid parenchyma. The detection rates of ectopic parathyroid glands in neck by ultrasonography, 99Tcm-MIBI, CT and MRI were 33%, 72%, 56% and 60%, respectively. After the operation, clinical symptoms including ostealgia, skin itching and limb weakness improved significantly. Serum iPTH levels after the operation for 20 minutes, 24 hours, 48 hours, one month, 6 months and one year were significantly lower than the levels before operation （t=5.264, P〈0.001 after 20 minutes; t=-4.836, P=0.001 after 24 hours; t=-5.091, P〈0.001 after 48 hours; t=5.183, P〈 0.001 after one month; t=5.398, P〈0.001 after 6 months; t=-5.217, P〈0.001 after one year）. After the operation for one week, serum Ca, P and Ca x P decreased significantly as compared those before the operation （t= 6.984, P〈0.001 for Ca; t=-2.979, P=0.011 for P; t=-4.983, P〈0.001 for Ca x P）, but ALP, HB and HCT changed insignificantly （t=0.693, P=0.501 for ALP; t=1.048, P=0.319 for HB; t=-1.693, P=0.129 for HCT）. Af- ter the operation, hypocalcemia appeared in 13 patients and improved after calcium supplement. Temporary in- jury of laryngeal nerve was found in 5 cases and 2 of them had transient bucking. There was no dyspnea and death. No recurrence was found in a follow-up period of one year. Conclusion In uremic patients complicated with persistent or recurrent SHPT, accurate localization of residual parathyroid glands is essential before reoperation. During operation, ectopic parathyroid glands are explored according to the concept of superior mediastinum and central compartment dissection. The success rate of re-operation will be significantly increased after complete resection of all residual parathyroid glands.
出处
《中国血液净化》
2018年第1期35-40,共6页
Chinese Journal of Blood Purification
