甲状旁腺切除术治疗难治性甲状旁腺功能亢进症89例疗效评价

目的回顾性总结难治性继发性甲状旁腺功能亢进症（Secondary Hyperparathyroidism,SHPT）患者行甲状旁腺切除术（parathyroidectomy,PTX）的短期和长期疗效。方法选择89例行PTX的终末期肾病患者（平均透析龄143±50.6月;平均年龄49.4±12岁）。收集患者术前、术后以及随访iPTH和生化（血清钙、磷和碱性磷酸酶）结果、症状及术后症状是否缓解、术后并发症和复发情况判断疗效。结果89例患者中,甲状旁腺次全切除术30例;甲状旁腺全切除＋自体移植11例;甲状旁腺全切除48例。手术成功率96.6%（86/89）。术后围手术期无死亡发生。5位患者发生喉返神经一过性损伤,发生率为5.6%。术后低钙血症发生率较高,达73%（65/89）,均经积极静脉补钙后有效控制。患者的骨痛及瘙痒症状全部缓解,肌无力、失眠和纳差症状快速改善、全身营养状况好转。术后iPTH（P〈0.001）、血清磷（P〈0.001）血清钙（P〈0.001）和血清ALP（P〈0.001）水平均较术前显著降低。长期随访3年以上患者27例,iPTH全部上升〉100pg/ml,9例SHPT复发（33.3%）,其中甲状旁腺次全切除术占7例。最长随访病例5年时间。结论PTX治疗终末期肾病所致的难治性SHPT是一种安全和有效手段,甲状旁腺次全切除术式的术后SHPT复发率较高,甲状旁腺全切除术后未见严重骨病发生。

Therapeutic evaluation of parathyroidectomy for 89 cases with refractory secondary hyperparathyroid-ism

Objective To retrospectively analyze the short-term and long-term outcome of parathyroidectomy （PTX） on patients with refractory secondary hyperparathyroidism （SHPT）. Methods A total of 89 cases （49.4 ± 12 years old） with end-stage renal disease and SHPT underwent hemodialysis （average dialysis age 143 ± 50.6 months） and PTX. Their serum iPTH, calcium, phosphorus and alkaline phosphatase in the preoperative, postoperative and follow-up periods were collected and compared. Their symptoms, postoperative complications and relapse were observed and analyzed to determine the efficacy of PTX. Results Thirty cases underwent subtotal PTX, 11 cases underwent PTX ＋ autologous parathyroid transplantation, and 48 cases underwent total PTX. PTX operation performed successfully in 86/89 patients （96.6%）, and no cases died in the perioperative period. Temporary injury of recurrent laryngeal nerve was found in 5 cases （5.6%）. postoperative hypocalcemia was frequently seen in 65/89 patients （73%）, and it was effectively controlled by intravenous calcium. After PTX, bone pain and itching were alleviated, weakness, insomnia and anorexia rapidly improved, and nutritional status also improved. The postoperative iPTH （P〈0.001）, serum phosphorus （P 〈0.001） serum calcium （P 〈0.001） and serum ALP （P 〈0.001） lowered significantly than those at preoperative period. A long-term follow-up over 3 years was carried out in 27 cases. All of their iPTH increased to more than 100pg/ml. SHPT recurred in 9 cases （33.3%）, of whom 7 cases were the patients with subtotal PTX. The longest follow-up period lasted for 5 years. Conclusion PTX is a safe and effective measure for the treatment of patients with end-stage renal disease and refractory SHPT. The postoperative relapse rate of SHPT was slightly higher in patients with subtotal PTX. No severe bone disease was found anymore during the follow-up period in patients with total PTX.