甲状旁腺全切除术治疗难治性继发性甲状旁腺功能亢进

目的回顾性总结甲状旁腺全切除术治疗继发性甲状旁腺功能亢进的疗效。方法选择18例患者行甲状旁腺全切除术、终末期肾病（end stage renal disease,ESRD）且长期行血液透析,平均透析（114.06±50.38）个月,平均年龄（48.56±11.70）岁。收集患者术前、术后血液中全段甲状旁腺激素（intact parathyroid hormone,iPTH）,血清钙（Ca）、磷（P）和血清碱性磷酸酶（alkaline phosphatase,ALP）的结果,症状、术后并发症、死亡率和复发情况并判断其疗效。结果术后18例患者无一例死亡,2例患者发生一过性喉返神经损伤（11.1%）。低钙血症发生率高达72.2%（13/18）,血清钙术后1周内下降明显,6个月后渐回升至正常水平（P=0.000）,iPTH和血清磷明显降低（P=0.000）。患者的骨痛及皮肤瘙痒症状全部缓解,肌无力、失眠和纳差症状快速改善,全身营养状况好转。血清ALP在术后1周时有短暂升高,此后水平逐渐降低（P=0.449）。结论甲状旁腺全切除术治疗终末期肾病所致的难治性继发性甲状旁腺亢进是一种安全、有效的方法。     

甲状旁腺切除术治疗继发性甲状旁腺功能亢进

目的了解甲状旁腺切除术对继发性甲状旁腺功能亢进的治疗作用。方法回顾性总结11例继发性甲状旁腺功能亢进的慢性肾功能衰竭尿毒症期患者行甲状旁腺切除术的病例,比较术前、术后血甲状旁腺素(parat hyroidhormone,PTH)值和血钙值及临床表现的变化。结果术后11例患者中9例血PTH值恢复正常,2例正常偏高但较原来降低十倍;血钙值均恢复正常;骨痛、骨质疏松症状明显改善。结论甲状旁腺切除术对继发性甲状旁腺功能亢进的患者具有较好的治疗作用。     

Parathyroid surgery in primary hyperparathyroidism: an update

Summary The best approach to parathyroid removal in primary hyperparathyroidism (HPT) is still a major topic in neck surgery. The present report reviews our experiences with 71 patients operated by parathyroidectomy (PTX) between 1978 and 1987. Preoperative computed tomography, sonographic and double-tracer substraction scanning examination allowed a precise assessment of the number and the topography of the diseased glands. Consequently, 65 patients underwent partial selective PTX, with removal of one or two glands, while 6 patients underwent subtotal PTX. The surgical results can be summarized as follows: full success in 67 cases (94.4%); persistent hypercalcemic syndrome in 3 cases (4.2%); recurrence of HPT in 1 case (1.4%). One case of persistent hypercalcemia was solved by reoperation. Thus, the total success rate was definitively assessed at 95.8%. As a complication of surgery a long-lasting postoperative hypocalcemic syndrome was observed in only 2 patients following subtotal parathyroidectomy. Our overall findings show that an attentive preoperative study by means of modern imaging techniques usually allows a selective partial PTX with good results and a low risk of complications.Presented at the First European Congress of Oto-Rhino-Laryngology and Cervico-Facial Surgery, Paris, 26–29 September 1988     

原发性甲状旁腺功能亢进患者的外科治疗

目的 探讨原发性甲状旁腺功能亢进(primary hyperparathyroidism,PHPT)的漏诊预防及其外科治疗方法.方法 回顾性分析承德医学院附属医院及河北医科大学第四医院自2008年7月至2013年1月收治的26例PHPT手术患者的临床资料,对术前诊断、手术方式进行分析.术前均检测血钙及甲状旁腺素(parathyroid hormone,PTH),继行彩色超声波(简称彩超)、CT及99m锝-甲氧基异丁基异腈(99mTc-methoxy isobutylis onitrile,99mTc-MIBI)扫描检查确诊PHPT并定位,经药物治疗使血钙、PTH正常后接受手术治疗.结果 术中切除病变腺体后10 min快速检测PTH,其中1例PTH较术前下降不到50％,经再探查发现另一腺体病变后切除,26例均在PTH下降50％以上后终止手术.术后病理诊断甲状旁腺腺瘤23例,甲状旁腺增生2例,甲状旁腺腺癌1例.术后血钙及PTH均降至正常水平,无术后长期并发症,随访6个月至5年未见复发.16例有症状型患者10例原继发症状消失,6例改善.结论 对体检或疑诊PHPT者应行血钙、PTH及甲状腺彩超检查,阳性者彩超结合CT及99mTc-MIBI定位可减少PHPT漏诊率.术中运用快速PTH测定,可减少手术探查范围,缩短手术时间.     

经胸前入路无注气内镜下甲状腺手术与传统手术创伤比较的随机对照研究

目的 前瞻性随机对照研究经胸前人路的无注气内镜下甲状腺手术与传统甲状腺手术对机体的创伤大小.方法 选择2006年11月至2008年2月中山大学第二附属医院耳鼻咽喉头颈外科收治的甲状腺肿物患者采用系统随机化法将患者分为两组,内镜组:25例行经胸前人路的无注气内镜甲状腺手术;传统手术组:22例行传统甲状腺手术.统计分析两组患者围手术期不同时间血中白细胞计数(white blood cell count,WBC)、C反应蛋白(serum C-reative protein,CRP)、白细胞介素6(IL-6)水平的差异.结果 在术后12,24及48 h 3个时间点,两组间WBC的差异无统计学意义(t值分别为-0.172、1.774、2.039,P＞0.05),CRP的差异无统计学意义(t值分别为-0.927、-1.701、-1.813,P＞0.05),IL-6水平的差异无统计学意义(t值分别为0.098、-2.019、-1.121,P＞0.05).结论 经胸前人路的无注气内镜甲状腺手术对机体的创伤与传统手术相比虽未达到微创的标准,但并不增加对机体的创伤.     

肾性继发性甲状旁腺功能亢进外科手术疗效分析

目的 探讨并比较甲状旁腺次全切除术和甲状旁腺全切加前臂移植术治疗肾性继发性甲状旁腺功能亢进的临床疗效。方法 回顾性分析15例患者资料,其中 11例行甲状旁腺次全切除术（Ⅰ组）,4例行甲状旁腺全切加前臂移植术（Ⅱ组）,比较术前、术后第1天和6个月患者血PTH、血钙水平及临床症状改善情况。结果 Ⅰ、Ⅱ组患者术后第1天及6个月血PTH较术前均有显著下降,配对t检验差异有统计学意义（Ⅰ组：P值分别为0.0007、0.0002,P＜0.05;Ⅱ组：P值分别为0.0116、0.0196,P＜0.05）,两组PTH手术前后差值进行两独立样本t检验,差异无统计学意义（第1天：P＝0.2670＞0.05;6个月：P＝0.4920＞0.05）。结论 对内科治疗无效的肾性继发性甲状旁腺功能亢进患者,甲状旁腺次全切除术及甲状旁腺全切＋前臂移植术都是有效的治疗方法,且两种手术方式在术后短期内（术后1天及6个月）的治疗效果无统计学差异。     

Autotransplant tissue selection criteria with or without stereomicroscopy in parathyroidectomy for treatment of renal hyperparathyroidism

IntroductionSeveral methods have been proposed to improve operative success in renal hyperparathyroidism.ObjectiveTo evaluate stereomicroscopy in parathyroid tissue selection for total parathyroidectomy with autotransplantation in secondary (SHPT)/tertiary (THPT) hyperparathyroidism.Methods118 renal patients underwent surgery from April of 2000 to October 2009. They were divided into two groups: G1, 66 patients operated from April of 2000 to May of 2005, with tissue selection based on macroscopic observation; G2, 52 patients operated from March of 2008 to October 2009 with stereomicroscopy for tissue selection searching for the presence of adipose cells. All surgeries were performed by the same surgeon. Patients presented SHPT (dialysis treatment) or THPT (renal-grafted). Follow-up was 12–36 months. Intra-operative parathyroid hormone (PTH) was measured in 100/118 (84.7%) patients.ResultsData are presented as means. G1 included 66 patients (38 SHPT, 24 females/14 males; 40.0 years of age; 28 THPT, 14 females/14 males; 44 years of age). G2 included 52 patients (29 SHPT, 11 females/18 males; 50.7 years of age; 23 THPT, 13 females/10 males, 44.4 years of age). SHPT patients from G2 presented preoperative serum calcium higher than those of SHPT patients in G1 (p < 0.05), suggesting a more severe disease. Definitive hypoparathyroidism was found in seven of 118 patients (5.9%). Graft-dependent recurrence occurred in four patients, two in each group. All occurred in dialysis patients.ConclusionStereomicroscopy in SHPT/THPT surgical treatment may be a useful tool to standardize parathyroid tissue selection.     

Conservative three-quarter versus subtotal seven-eighths parathyroidectomy in secondary hyperparathyroidism

Objective

There is at present no consensus concerning surgical techniques for secondary hyperparathyroidism (SHPT) in end-stage renal disease (ESRD). Although both subtotal and total parathyroidectomy provide low rates of recurrence, they may induce hypoparathyroidism, damaging the bone and cardiovascular systems. The aim of our study was to compare 3/4 and 7/8 parathyroidectomy in this population and to discuss the potential benefit of more conservative treatment.

肿瘤性甲状旁腺功能亢进的手术治疗

目的 探讨肿瘤性甲状旁腺功能亢进的临床表现及手术疗效.方法 回顾性分析22例甲状旁腺肿瘤致甲状旁腺功能亢进患者的临床表现、治疗经过及疗效.22例患者中男9例,女13例.首次接受手术治疗15例,均在正常组织内切除肿瘤,如提示恶性肿瘤,则在解剖喉返神经后将肿瘤同邻近的甲状腺组织及同侧气管食管沟淋巴结一并切除.对7例外院术后复发性甲状旁腺癌患者切除局部肿瘤同时行不同区域淋巴清扫术.对术后缺损器官一期修复.术中行甲状旁腺素(parathyroid hormone,PTH)监测,5例患者行预防性气管切开.结果 术后病理示甲状旁腺瘤14例,甲状旁腺癌8例,其中伴淋巴转移4例.22例次手术后PTH于术后2h内恢复正常,高钙血症均于术后48 h内消失,1例肿瘤定位困难而行试验性颈部手术者PTH值无下降.术后发生左颈部淋巴管瘘和食管瘘1例,保守治疗后痊愈,另有胸骨愈合不良1例.预防性气管切开者出院时均拔管.首治患者除1例甲状旁腺瘤患者出院后1周死于低钙血症亡外,其余随诊12 ～ 40个月,PTH和血钙均在正常值范围.6例外院术后多次复发且侵犯上消化呼吸道患者中3例随诊16 ～ 34个月PTH和血钙均在正常范围,2例分别于术后6个月和8个月再次局部复发,另1例复发性甲状旁腺癌患者术后PTH及血钙维持正常44个月后再次升高,术后52个月死于高钙血症.结论 甲状旁腺肿瘤宜行局部扩大切除并常规术中监测PTH.     

甲状腺切除术中双极电凝与钳扎止血的应用比较

目的探讨双极电凝法在甲状腺手术止血中的应用及其替代传统的血管钳扎法的可能性。方法甲状腺(单侧)行次全和全切手术患者78例,其中38例采用双极电凝法,40例采用传统钳扎法。统计术中出血量、术后第1天引流量、手术时间等进行比较。结果术中、术后出血量两组间无统计学差异,术后第1天引流量双极电凝组较钳扎组少。结节性甲状腺肿组中双极电凝组的手术出血量为(54±14)ml,钳扎组为(63±10)ml,两组间无统计学差异;术后第1天引流量双极电凝组较钳扎组少,有显著性差异(P<0.05)。钳扎组中1例甲状腺乳头状癌患者出现术后喉返神经麻痹并发症。两组均无甲状旁腺功能减退并发症。结论双极电凝法可缩短手术时间,减少术腔内的结扎线异物,减少医疗费用并使局麻开展甲状腺手术成为可能。     

Primary hyperparathyroidism in pregnancy: a case series and review

Objectives/Hypothesis: To review the clinical significance of primary hyperparathyroidism during pregnancy including the maternal, fetal, and neonatal sequelae. Additionally, to discuss treatment options and describe three cases where surgical parathyroidectomy was successful for treatment of hyperparathyroidism refractory to medical management during pregnancy. Study Design: Retrospective. Methods: We reviewed three cases of hyperparathyroidism during pregnancy and reviewed the literature. Results: Three women underwent surgical parathyroidectomy during their second and third trimester of pregnancy without any maternal, fetal, or neonatal complications. Conclusions: Hyperparathyroidism during pregnancy may be safely treated with surgical parathyroidectomy if refractory to medical management with low operative risk when performed during the second trimester. This surgical option should be considered in light of the known maternal, fetal, and neonatal risks because of the hypercalcemic state in pregnancy.     

PTHi value in the surgical treatment of hyperparathyroidism

The prevalence of hyperparathyroidism as increased in the last 20 years due to a longer number of biochemical determinations, in which we observe in many cases hipercalcemia by casualty. The simptomatology of the primary hyperparathyroidism is very subtile and sometimes none in an 80% of the patients. Between november 1996 and march 2003 we have operated 55 parathyroidectomies. 36 patients (65,4%) had primary hyperparathyroidism, 16 (29,1%) secondary hyperparathyroidism and the rest (5,4%) tertiary hyperparathyroidism. Our hospital has a device of rapid detection of the parathyroid hormone level since february 2000, allowing us its satisfactory intraoperative determination in few minutes, evaluating the decrease to values inferior to the half of its basal level.     

Brown tumor of the maxilla associated with primary hyperparathyroidism

Brown tumors represent the terminal stage of the remodeling processes during primary or secondary hyperparathyroidism. During the last three decades primary hyperparathyroidism has been recognized much more commonly and the increase has generally been attributed to the routine determination of calcium by new automated methods and the advent of new and more objective parathyroid hormone radioimmunoassay techniques. Early diagnosis and successful treatment of the disease have made clinical evidence of bone disease uncommon. While, the mandible is the most frequently involved bone in the head and neck region, maxillary involvement is extremely rare. A case of brown tumor on the maxilla associated with primary hyperparathyroidism is reported. This patient presented multiple skeletal lesions, which are uncommonly seen nowadays. The diagnosis was suggested by the clinical history and confirmed by biochemical, radiological and histopathological determinations. Excision of a parathyroid adenoma normalized the metabolic status. Excision of the maxillary mass led both histopathological confirmation of the disease and early masticator rehabilitation.     

原发性甲状旁腺功能亢进的诊治

简而言之,原发性甲状旁腺功能亢进是指由于甲状旁腺组织自身病变所致甲状旁腺过度分泌甲状旁腺激素.其本质是甲状旁腺细胞钙受体对血清游离钙敏感性下降而降低了对甲状旁腺激素分泌的抑制作用.     

甲状腺手术喉返神经损伤危险因素及应对策略

目的 探讨甲状腺手术出现喉返神经损伤的危险因素及避免损伤的方法.方法 回顾性分析1902例甲状腺患者,按手术科别、性别、麻醉方法、病变性质、术中是否常规解剖喉返神经、手术次数及手术范围分组,观察喉返神经损伤率,进行单因素分析及多因素回归分析.结果 喉返神经总损伤率为1.84％.单因素分析显示,在甲状腺恶性病变患者、多次手术及甲状腺广泛性手术中喉返神经损伤率升高有统计学意义(x2分别为1.096、1.893、1.467,P＜0.05).在甲状腺广泛性手术中,术中显露喉返神经可有效降低喉返神经损伤率(x2=1.758,P＜0.05);而在保守性手术中,术中是否显露喉返神经,喉返神经损伤率的差异无统计学意义(x2=0.638,P＞0.05).Logistic回归分析显示,多次手术及甲状腺广泛性手术是喉返神经损伤的重要危险因素.结论 对于病变范围较小的甲状腺良性肿瘤,术中不显露喉返神经、保留部分甲状腺背侧组织是安全可靠的.而对于广泛性甲状腺切除手术,术中应常规解剖喉返神经.     

经胸乳入路的内镜甲状腺切除术500例

目的探讨经胸乳入路内镜甲状腺手术的技术方法、安全性和优缺点。方法2002年3月至2006年12月行胸乳入路内镜甲状腺切除术500例，其中原发性甲状腺机能亢进（简称甲亢）76例、甲状腺腺瘤111例、结节性甲状腺肿291例（10例有1～2次开放手术史）和甲状腺癌22例。结果成功完成手术492例，手术时间40～270min（平均74．5min）。其中行甲状腺肿瘤切除50例，甲状腺单叶次全切除214例，双叶次全切除212例（含原发性甲亢手术治疗73例）。22例甲状腺癌中，单叶腺体次全切除4例，根治性切除16例，另2例转开放手术。甲状腺肿块长径最大8．0em。术中失血3～250ml（平均5．5m1），未输血。术后2～3d拔除引流管。术后住院时间3～8d（平均4．2d），住院费用为7600～13500元（平均10510元），本院同期开放甲状腺手术患者住院费用平均为5700元，两者差异比较有统计学意义（t=13．755，P〈0．05）。术后并发症方面，术后手术通道出血3例，皮肤灼伤1例，切口感染2例，皮肤淤血3例，皮下积液6例，1例出现甲亢危象，暂时性喉返神经麻痹2例，无神经或甲状旁腺永久性损伤等严重并发症，并发症发生率为3．6％（18／492）。术后随访，失访42例，458例随访3～57个月（中位时间27个月），3例结节性甲状腺肿术后复发小结节，1例原发性甲亢术后复发。患者均对手术的美容效果满意。8例因为出血、腺体过大、甲状腺癌侵犯气管等原因中转为开放手术。22例甲状腺癌目前仍生存，1例甲状腺乳头状癌术后半年出现同侧颈淋巴转移，行开放颈清扫术后已无瘤生存至今3年，并继续随访。结论经胸乳入路内镜甲状腺切除术是一种安全而可行的手术方法，手术视野清晰，显露神经清楚，且具有显著的美容效果。此外，该方法仍有一定的并发症发生率，且费用较开放手术高。因此，本方法有待进一步改进。