甲状旁腺全切加前臂移植治疗难治性肾性甲状旁腺功能亢进的疗效观察

目的 观察甲状旁腺全切加前臂移植术（PTX+AT）治疗慢性肾脏病（CKD）患者严重继发性甲状旁腺功能亢进(SHPT)的临床疗效。方法 选择我院2011年2月~2012年7月难治性肾性SHPT行PTX+AT术并随访3个月以上的20例患者。观察手术前后甲状旁腺激素(iPTH)、血钙、磷、血红蛋白、相关临床症状的变化情况。结果 （1）20例患者顺利完成手术,18例患者行甲状旁腺全切加前臂移植术,2例患者术中仅发现并切除3枚甲状旁腺,未行前臂移植。（2）无一例出现手术并发症（喉神经损伤、呼吸困难、抽搐等）。所有患者术后第2天骨痛、皮肤瘙痒、乏力等临床症状均明显改善。（3）术后各时间点血钙、磷、iPTH较术前明显下降,术后3月红细胞压积（Hct）较术前显著提高,差异均有统计学意义。结论 PTX+AT对于治疗难治性肾性SHPT疗效明确,是一种安全、经济和有效的治疗手段,术前甲状旁腺的准确定位及术后及时调整血钙水平是治疗成功的关键。     

甲状旁腺全切除自体前臂移植术治疗肾功能不全继发性甲状旁腺功能亢进

目的:研究甲状旁腺全切除(PTX)自体前臂移植术治疗慢性肾功能衰竭继发性甲状旁腺功能亢进(SHPT)的疗效和安全性。方法:回顾性分析2011年12月—2015年12月接受PTX自体前臂移植的30例慢性肾功能衰竭终末期并SHPT患者的临床资料,观察患者术后临床症状改善情况、血清全段甲状旁腺激素(iPTH)、钙、磷及钙磷乘积的变化,以及术后并发症与复发情况。结果:所有患者均手术成功。术后患者临床症状均明显改善;血清iPTH、钙、磷及钙磷乘积水平均较术前明显降低(均P0.05)。12例患者出现一过性喉返神经损伤,均自行好转。术后8例(2.7%)复发,7例再次手术后症状缓解。结论:PTX自体前臂移植术是治疗慢性肾功能衰竭SHPT的一种安全有效的方法。     

甲状旁腺全切并自体前臂移植术治疗肾性难治性继发性甲状旁腺功能亢进疗效随访分析

目的观察甲状旁腺全切加自体前臂移植术(total parathyroidectomywith forearm autograft,PTX+AT)治疗肾性难治性继发性甲状旁腺功能亢进(secondary hyperparathyroidism,SHPT)的临床疗效。方法分析2011年2月至2013年12月安徽医科大学第二附属医院终末期肾脏疾病(end stage renal disease,ESRD)合并SHPT行PTX+AT随访6个月以上患者93例。收集患者术前和术后第1、3及6个月血钙、血磷、全段甲状旁腺素(intact parathyroid hormone,iPTH)、碱性磷酸酶(alkaline phosphatase,ALP)、血红蛋白(hemoglobin,Hb)及血细胞比容(hematocrit,Hct),测量相应时间患者血压,统计并分析结果;记录症状缓解、术后并发症及复发情况。结果①手术及并发症:成功手术93例,7例发生一过性喉返神经损伤,随访3个月均恢复。低钙血症发生率为80.6%(75/93),静脉或口服补钙有效。②症状缓解:大多数患者术后骨痛(74/76)、皮肤瘙痒(26/26)和失眠(18/18)症状次日即基本缓解,短期内仍有骨痛者2例,3个月后缓解。肌无力、纳差及全身营养状况逐渐改善。③血生化指标及血压:术后贫血改善,重组人红细胞生成素用量减少(P0.05)。与术前相比,患者术后血钙、血磷、iPTH水平下降,差异均有统计学意义(P0.01)。血钙、血磷及iPTH于术后第3个月开始缓慢升高,平均值达指南推荐水平。合并高血压病患者74例,49例术后血压得到有效控制,总有效率达66.2%。④复发及二次手术:7例复发,复发率为7.5%,其中3例为前臂种植部位复发,行种植部位甲状旁腺手术切除后缓解;4例为残留或异位甲状旁腺所致复发(其中3例已再次行PTX,1例手术失败,2例未再复发;1例因甲状旁腺异位于主动脉弓上方未再手术治疗)。结论 PTX+AT治疗肾性难治性SHPT疗效明确,骨痛、瘙痒及失眠症状迅速缓解,明显改善贫血、提高血压控制率并使血钙、血磷、iPTH达理想水平,是一种安全、经济和有效的治疗手段。     

甲状旁腺全切除加前臂自体移植术治疗肾性继发性甲状旁腺功能亢进的长期疗效

目的: 探究甲状旁腺全切除加前臂自体移植术（total parathyroidectomy with forearm autotransplantation, TPTX+AT）治疗肾性继发性甲状旁腺功能亢进（secondary hyperparathyroidism, SHPT）术后长期疗效。方法: 我院1999年1月至2017年11月行TPTX+AT的SHPT病人124例,分析术后症状改善和血钙、磷、全段甲状旁腺激素（intact parathyroid hormones, iPTH）水平变化,以及术后复发率、持续性甲状旁腺功能低下发生率、死亡率等。结果: 术后病人临床症状均明显改善。术后1个月病人血钙、磷、iPTH及碱性磷酸酶水平均较术前明显降低（均P<0.05）,基本可长期控制在正常水平。随访至2018年5月,10例（8.06%）复发,7例（5.64%）发生持续性甲状旁腺功能低下,19例（15.32%）死亡。结论: TPTX+AT治疗SHPT能长期有效地缓解症状,改善钙磷代谢。术后复发率与持续性甲状旁腺功能低下发生率、死亡率均在较低水平。     

甲状旁腺切除及无水酒精注射治疗继发性甲状旁腺功能亢进

目的：探讨甲状旁腺切除及腺体内无水酒精注射两种方式治疗继发性甲状旁腺功能亢进（SHPT）的疗效及安全性。方法：17例SHPT患者分为甲状旁腺切除组7例及甲状旁腺无水酒精注射组10例,术后腺体送检病理,观察药物注射前后腺体超声信号变化及术后并发症,记录血清学指标并随访1年。结果：腺体长径大于1.0cm病理改变呈结节样增生,无水酒精注射后腺体血流信号减少。两组术后钙、磷、碱性磷酸酶及甲状旁腺激素水平变化差异存在统计学意义（P〈0.01）,两组术后患者症状均有改善,并发症少,但手术组疗效优于注射组。结论：甲状旁腺切除治疗严重继发性甲状旁腺功能亢进效果确切,临床作为首选,甲状旁腺无水酒精注射治疗可作为单一腺体增生或甲状旁腺切除后的补充治疗。     

微波消融治疗不宜手术切除继发性甲状旁腺功能亢进临床效果

目的观察微波消融(MWA)治疗不宜手术切除继发性甲状旁腺功能亢进症(SHPT)患者的有效性及安全性。方法回顾性分析51例接受MWA治疗的SHPT患者,对比消融前后单个增生结节最大径及血清全段甲状旁腺素(iPTH)、钙和磷水平,统计随访期间并发症、局部复发率及新发率。结果51例SHPT共83枚甲状旁腺增生结节均一次性完全消融。消融后3、6个月及随访结束时,单个增生结节最大径均较消融前缩小(P均<0.05),血清iPTH、钙、磷水平均低于消融前(P<0.05)。随访期间9例(9/51,17.65%)发生与MWA相关的轻微并发症,无严重并发症。随访结束时,局部复发率为5.88%(3/51),新发率7.84%(4/51)。结论MWA用于治疗不宜手术切除SHPT安全有效。     

继发性甲状旁腺功能亢进患者术后临床评估

目的探讨继发性甲状旁腺功能亢进患者行甲状旁腺全切除或次全切除术后的预后。方法选择2009年1月至2012年12月在深圳市人民医院行慢性肾替代治疗合并继发性甲状旁腺功能亢进症手术治疗后的88例患者进行1~4年随访观察。术中留取血液样本送检测全段甲状旁腺素(immunoreactive parathyroid hormone,iPTH)水平(电化学发光法),根据测定的iPTH水平,由外科医生决定手术方式为次全切除或全切除术。根据手术方法将88例患者分为次全切除组和全切除组。次全切除组64例,男35例,女29例;全切除组24例,男女各12例;比较2组患者术后的复发率及预后。另外根据术后随访及血清iPTH的检测,将88例患者复发分为复发组和未复发组。复发组11例,男6例,女5例;未复发组77例,男41例,女36例;应用Log-rank检验对复发情况进行分析,并对可能影响复发的因素进行分析。结果 88例患者进行了(21±11.3)个月的随访研究,复发患者术后第2天iPTH水平(111.20±81.4)ng/L高于未复发患者iPTH(24.4±35.8)ng/L,2组比较有统计学差异(t=-3.486,P0.01);随访期间次全切除组10人复发,全切除组1人复发,经Log-rank检验不同手术组的未复发率无统计学差异(χ~2=0.33,P=0.57)。全部88例患者术后第12、26、36个月累积未复发率分别为98.8%、91.3%及67.1%。结论维持性透析继发性甲状旁腺功能亢进患者行甲状旁腺全切除或次全切除术后的1~4年内复发率无显著差异,术后患者症状明显改善,术后第二天的iPTH水平可能与复发相关。     

甲状旁腺全切＋自体移植术治疗继发性甲状旁腺功能亢进症疗效分析

目的探讨甲状旁腺全切＋自体移植术(tPTX＋AT)治疗维持性血液透析患者继发性甲状旁腺功能亢进症(SHPT)的有效性、安全性以及术后低钙的危险因素。 方法纳入我院2013年1月至2016年11月因SHPT行tPTX＋AT手术的维持性血液透析患者93例,收集术前术后症状、血钙、磷、碱性磷酸酶(ALP)、全段甲状旁腺激素(iPTH)、病理类型、并发症等临床资料。依据术后24 h血钙水平分为正常血钙组(Ca≥2.11 mmol/L)及低钙血症组(Ca<2.11 mmol/L),应用单因素分析及逐步Logistic回归分析术后早期低钙血症的危险因素。 结果手术成功率92.5%。切除360枚甲状旁腺腺体,异位甲状旁腺10枚。病理结果多为腺瘤样增生(96.4%)。同术前相比,术后血清iPTH、磷、ALP明显下降(P<0.05)。低钙血症是术后最常见并发症,发生率82.8%,血钙水平与术前血钙、年龄正相关(r＝0.300, P<0.01;r＝0.265, P<0.01),与术前iPTH、ALP水平负相关(r＝－0.461, P<0.01;r＝－0.477, P<0.01)。术前低血钙(OR＝0.113, P＝0.045)、高ALP水平(OR＝1.050, P<0.001)、高iPTH水平(OR＝1.002, P＝0.004)是术后早期低钙血症发生的独立危险因素。 结论tPTX＋AT可以安全、有效、快速的降低维持性血液透析患者血清iPTH水平,改善机体的钙磷代谢紊乱,但需重视并积极纠正术后低钙血症。针对存在术前低血钙、高iPTH及高ALP水平等高危因素的患者,术前积极纠正低钙血症可能是预防术后低钙的有效干预方式。     

超声引导下微波消融治疗异位继发性甲状旁腺功能亢进症

目的观察超声引导下微波消融(MWA)治疗异位继发性甲状旁腺功能亢进症(SHPT)的安全性及有效性。方法对36例异位SHPT患者行超声引导下MWA治疗。术后定期随访,观察症状改善情况,记录不良反应。检测术前、术后第1天及末次随访时血清全段甲状旁腺激素(iPTH)、钙、磷及碱性磷酸酶(ALP)水平。结果 36例共40枚异位SHPT结节均完全消融。术后第1天血清iPTH、钙、磷均低于术前(P均0.05);末次随访时iPTH、磷、ALP均较术前降低(P均0.01)。术中4例出现短暂轻至中度疼痛,均自行缓解;1例发生血肿,经静脉注射血凝素后出血得到控制。术后1～3天10例出现低钙血症,经补钙治疗后8例血钙恢复正常,2例至随访结束时仍为轻度低钙血症;2例术后声音嘶哑,1～3个月内恢复;1例出现轻度霍纳综合征,未予特殊处理,随访期间症状逐渐改善后消失。结论超声引导下MWA治疗异位SHPT结节安全、有效。     

继发性甲状旁腺功能亢进的治疗策略

继发性甲状旁腺功能亢进(SHPT)已成为慢性肾脏病(CKD)常见的并发症之一,严重影响患者生活质量。其治疗策略包括药物、手术和介入。药物包括非选择性和选择性活性维生素D、拟钙剂(西那卡塞),药物治疗期间强调动态观察血清全段甲状旁腺激素(iPTH)和血清钙、磷的变化,以及时调整药物剂量。药物治疗无效且具备手术指征者,可考虑甲状旁腺切除手术(PTX)或超声介入治疗。PTX前需要高频彩超和(或)⁹⁹Tc^m-MIBI双时相显像用于甲状旁腺的定位诊断。PTX有三种术式,其中甲状旁腺全切除加移植是目前最常用的术式。对于不能耐受手术和需要再次PTX的患者可以选择一种新的治疗策略,即彩色超声介导下甲状旁腺热消融术。     

甲状旁腺切除术对尿毒症患者难治性继发性甲旁亢的疗效观察

目的回顾性统计尿毒症难治性继发性甲状旁腺功能亢进患者进行甲状旁腺切除术的临床疗效。方法监测并统计12例人组患者术前及术后1个月、3个月、半年、1年的血钙、磷、全段甲状旁腺素及临床症状。结果全切＋自体移植7例,次全切5例。次全切患者均复发,改用药物保守治疗仍部分有效。全切＋自体移植中5例术后1年持续低全段甲状旁腺素,为（61．31±21．11）pg／ml（38～89．91pg／ml）。常见足跟疼痛以及下肢承重关节相关的临床表现。术后无论何种术式及是否复发,患者除不宁腿综合征以外的症状均改善或明显改善,且其3个月、6个月及1年时症状及生化指标均较术前有明显改变。结论手术能明显缓解难治性患者的症状及生化水平,但长期来看存在可能复发及长期低全段甲状旁腺素的问题。     

Total parathyroidectomy with forearm autograft in the treatment of uremic patients with secondary hyperparathyroidism

Objective To analyze the efficacy and safety of total parathyroidectomy (PTX) with forearm autograft in uremic patients with secondary hyperparathyroidism (SHPT). Methods One hundred and eighteen cases undergoing PTX with forearm autograft in our hospital from 2001-2010 were included in this study. Their preoperative and postoperative serum intact parathyroid hormone (iPTH), biochemistry tests (total calcium,inorganic phosphate and alkaline phosphate) were collected and postoperative symptom relief, complications and recurrence were investigated. Results Of all the 118 cases, 32 underwent endoscopic surgery and 86 open surgery. The surgery was performed successfully in 110 cases (93.2%) and one case died in perioperative period. Thyroid carcinoma was diagnosed during surgery in 2 cases and radical operation was performed at the same time. Temporary injury of recurrent laryngeal nerve was found in nine cases (7.6%). Postoperative hypocalcemia was frequently seen in 108 cases (91.5%) and it was effectively controlled by postoperative calcium administration. After operation, bone pain and itching were alleviated, and weakness, anemia and malnutrition status were improved in all the cases who received successful surgery. The postoperative levels of serum iPTH (P＜0.01), calcium (P＜0.01), phosphorus (P＜0.01) and calcium×phosphorus (P＜0.01) were decreased significantly than those in preoperative period. A long-term follow-up of over 3 years was carried out in 21 cases. Six cases recurred, among them, 4 cases relieved after removal of autografted parethroid tissue, and another two cases received the second operation. The longest follow-up period lasted for 9 years in two cases without recurrence. Conclusions PTX with forearm autograft is safe and effective in the treatment for uremic patients with SHPT. No severe complication is found during the long-term follow-up period.     

Ӱ��̷��Լ�״���ٹ��ܿ���������Ч������ط���

??Correlation factor analysis of influencing the operative effect of secondary hyperparathyroidism YIN Zhao-cai*, ZHAO Wan-jun, SHENG Yong, et al. *Department of Thyroid and Breast Surgery, Yijishan Hospital Affiliated to Wannan Medical College, Wuhu 241000, China
Corresponding author: YIN Zhao-cai, E-mail??yinzc200@163.com
Abstract Objective To analyze the correlation factors of influencing the operative effect of secondary hyperparathyroidism??SHPT????and to provide evidence for the improvement of postoperative effect and the reduction of postoperative complications. Methods The data of 59 cases of Yijishan Hospital Affiliated to Wannan Medical College of SHPT operation were reviewed retrospectively. According to the level of the serum intact parathyroid hormone??iPTH?? within 6 months after operation??patients were divided into group A??iPTH??150 ng/L?? and group B ??iPTH??150 ng/L??. The factors were compared between two groups, including the preoperative clinical data, the number of parathyroid glands which were exposed during the operation, the number of parathyroid glands which were cut during the operation, preoperative serum intact parathyroid hormone??iPTH0??and intraoperative serum intact parathyroid hormone (io-iPTH) and others. Logistic regression model was used to select the correlation factors of influencing the surgical outcome of SHPT. Those data were recorded, such as iPTH0??10 and 20 min after removing the last parathyroid on the left side and right side ??io-iPTH10L??io-iPTH20L??io-iPTH10R and io-iPTH20R????the mean of io-iPTH10L and io-iPTH10R ??io-iPTH10M????and the mean of io-iPTH20L and io-iPTH20R ??io-iPTH20M??. Results The surgical outcome was more satisfactory in 49 cases ??group A????but less satisfactory in 10 cases ??group B??. Single factor analysis showed that io-iPTH10M??io-iPTH20M??io-iPTH10M/ iPTH0??io-iPTH20M/ iPTH0 and the number of parathyroid glands explosed additionally during the operation were significantly correlated with operative effect ??P??0.05??, while the others were not??P??0.05??. Logistic regression analysis showed the number of parathyroidglands explored additionally during the operation was a protective factor influencing the operative effect??OR=0.109??95%CI??0.015-0.795????while io-iPTH10M was a risk factor influencing the operative effect??OR=2.560??95%CI??1.444-4.541??. Conclusion The number of parathyroid glands explored additionally during the operation and io-iPTH which was used to be a guidance for surgical exploration and a prediction about the end of operation were the key factors influencing the operative effect of SHPT.     

21例尿毒症患者甲状旁腺全切加前臂移植对改善透析患者肾性贫血的临床观察

目的探讨甲状旁腺全切除加部分前臂自体移植术（parathyroidectomy＋forearyauto—transplantation,PTX＋FAT）纠正重度继发性甲状旁腺功能亢进（secondaryhyperparathyroidism,SHPT）对维持性透析（maintenancehemodialysis,MHD）患者并发难治性肾性贫血的影响。方法选择MHD并发重度SHPT及难治性肾性贫血患者21例,均为经规范的药物治疗无效者行PTX＋FAT治疗,观察术前、术后第3、6、12个月时患者的血清全段甲状旁腺素（intactparathyroidhormone,i盯H）、钙（Ca）、磷（P）、血红蛋白（Hb）、红细胞压积（Hct）、血清铁蛋白（SF）、转铁蛋白饱和度（TSAT）、血清白蛋白（Alb）、KT／V等指标变化,同时记录患者的促红细胞生成素（recombinanthu—manerythropoietin,rHuEPO）用量。结果所有患者与术前相比血清iPTH、Ca、P迅速下降,从术后第3个月开始贫血得到逐步改善,术后第12个月Hb和Hct较术前显著升高（P〈0．05）,术后第6个月rHuEPO用量减少,与术前相比差异显著（P〈0．01）,术后第12个月rHuEPO用量大幅减少,与术前相比有显著性差异（P〈O．01）。手术前、后SF、TSAT、Alb、KT／V等指标差异无统计学意义（P〉0．05）。结论重度SHPT维持性血液透析患者在PTX＋FAT术后可迅速降低iPTH水平并显著改善MHD患者的难治性肾性贫血,减少rHuEPO用量,提示重度SHPT是影响肾性贫血的一个重要因素,其作用可能部分与rHuEPO抵抗有关。