甲状腺手术中甲状旁腺显露及功能保护的临床研究

Clinic Investigation of Exposing and Functionally Protecting Parathyroid Glands During Thyroidectomy

目的探讨甲状腺术中直视下甲状旁腺的显露与定位、术中保护甲状旁腺及其血供的方法。方法对我院甲状腺手术患者行术中直视下显露并原位保护甲状旁腺及其血供,并观察术后甲状旁腺功能减退的发生情况。结果259例甲状腺手术中有12例未找到明确的甲状旁腺。术中见上甲状旁腺共242枚,其中221枚(91.32%)位置恒定于甲状腺背面甲状软骨下缘水平;确切显露61枚上甲状旁腺的血管,其中42枚(68.85%)由甲状腺下动脉上行支供血。下甲状旁腺共426枚,位置变异较大,212枚(49.77%)位于甲状腺背面下1/3部分,106枚(24.88%)位于甲状腺侧叶最下端近甲状腺下动脉入腺体处;确切显露128枚下甲状旁腺的血管,其中103枚(80.47%)的血供来自甲状腺下动脉或最下动脉的分支。术后发生低钙血症者27例,其中一侧叶全切除者1例(二次手术患者),一侧叶全切加对侧叶次全切除者3例,甲状腺全切除者4例,甲状腺全切加中央组颈淋巴结清扫者7例,甲状腺全切加一侧颈淋巴结清扫者11例,甲状腺全切加双侧颈淋巴结清扫者1例。无一例发生永久性甲状旁腺功能低下。结论甲状旁腺血供来源与其位置有密切关系。甲状腺术中完全可以直视下显露和保护甲状旁腺。预防术后甲状旁腺功能减退的关键是术中精细解剖,尽量原位保护甲状旁腺及其血供或行必要的甲状旁腺自体移植。

Objective To discuss how to identify and protect the parathyroid glands （PTGs） and their blood supplies during thyroidectomy. Methods Protective measure of PTGs and their blood supplies were observed during the operation by eyes, as well as the occurrence of hypoparathyroidism after operation. Patients with syndrome of hypocalcaemia were given calcium and vitamin Da supplementation until the serum calcium became normal. Results There was no PTG found in 13 cases （13/259）, 242 superior PTGs were found which were almost consistently （91.32%） located in the back sides of the thyroid glands and on the level of inferior edge of the thyroid cartilage. The blood supplies of 61 superior PTGs were often （68. 85 %） from the upper branch of inferior thyroid artery （ITA）. Total 426 inferior PTGs were found, and the locations of which were more variable. Approximately 49.77 % were located in the inferior 1/3 part of the back sides of the thyroids, 24.88 % were positioned immediately to the inferior thyroid, where the ITA branches inserted into the thyroid. The blood supplies of 128 inferior PTGs were also mostly （80.47 % ） from the inferior branches of ITA system. There was no permanent hypoparathyroidism occurred and hypocalcemia after operation was happened to 27 patients, in which one patient of reoperation was un- derwent unilateral thyroidectomy, 3 patients were underwent unilateral thyroidectomy and contralateral subtotal thyroidectomy, 4 patients were underwent total thyroidectomy, 7 patients were underwent total thyroidectomy plus bi- lateral central neck dissection, 11 patients were underwent total thyroidectomy plus unilateral neck dissection, and one patient was underwent total thyroidectomy plus bilateral neck dissection. Conclusion The blood supplies of PTGs are associated with their locations. The PTGs can be exposed and protected by eyes during operation. To prevent postoperative hypoparathyroidism, the PTGs should be protected in situ through meticulous dissection without jeopardizing their blood supplies, or parathyroid autotransplantation could be progressed.