三种不同甲状旁腺切除术治疗继发性甲状旁腺功能亢进425例疗效比较

Efficacy comparison of the three parathyroidectomy methods in 425 patients with secondary hyperparathyroidism

目的 分析3种不同甲状旁腺切除术（parathyroidectomy,PTX）治疗慢性肾脏病（chronic kidney diseases,CKD）患者继发性甲状旁腺功能亢进症（secondary Hyperparathyroidism,SHPT）的短期和长期疗效。方法 回顾性总结接受3种不同PTX术的425例SHPT患者,收集术前、术后1周、3月、1年、4年血清全段甲状旁腺激素（intact parathyroid hormone,i PTH）、血钙、血磷、血碱性磷酸酶数值,观察临床症状及术后并发症、复发情况等。结果 所有患者顺利完成甲状旁腺切除术,术后骨痛、皮肤瘙痒、肌无力、不安腿等症状明显缓解,其中53例退缩人综合征患者停止身高缩短,35例Sagliker综合征患者停止脸部变形,30例严重骨骼畸形不能行走患者,在术后1年逐渐行动自理。术后1周血i PTH水平较术前显著下降[（1802.602±5.418）pg/ml比（25.838±0.190）pg/ml,F=24.526,P=0.000],并且长期维持在较低水平,4年后仍维持在（62.120±0.096）pg/ml。3种手术方式的近期成功率（χ2=2.655,P=0.265）、死亡率（χ2=2.548,P=0.280）以及术后1年复发率（χ2=0.236,P=0.889）、术后4年复发率（χ2=0.616,P=0.735）无统计学差异,术后1周低钙血症发生率也无显著差异（χ2=0.066,P=0.968）。远期疗效评价：甲状旁腺次全切除术（subtotal PTX,s PTX）术后高i PTH比例明显高于其他2组（χ~2=20.525,P=0.000）,高i PTH组患者长期随防的死亡率较高。结论 PTX是治疗CKD患者难治性SHPT安全、有效的手段,甲状旁腺全切除术有或没有自体移植与甲状旁腺次全切除术患者比较,术后血i PTH水平稳定,血清钙、磷可以长期维持在合理范围。

Objective To analyze the short and long-term effects of the three parathyroidectomy （PTX） methods in the treatment of chronic kidney diseases patients with secondary hyperparathyroidism （SHPT）. Methods A total of 425 SHPT patients treated with one of the three PTX methods were analyzed. Before the operation and after the operation for one week, 3 months, one years and 4 years, the data about serum intact parathyroid hormone （iPTH）, calcium, phosphorus, alkaline phosphatase, clinical symptoms, postoperative complications and relapse were collected. Results PTX was successfully operated in all of the patients. After the operation, symptoms such as bone pain, skin itching, myasthenia gravis, restless legs symptoms relieved significantly. Shrinkage of body height ceased in 53 cases with shrinking men syndrome, and facial deformities stopped progressing in 35 cases with Sagliker syndrome. Walking by themselves gradually became possi- ble after the operation for one year in 30 cases with severe skeletal deformities and inability to walk. Serum iPTH decreased significantly （1802.602±5.418 pg/ml vs. 25.838±0.190 pg/ml, F=24.526, P=0.000） after the operation for one week. Serum iPTH remained at low levels for a long time, and maintained at 62.120±0.096 pg/ml after the operation for 4 years. There were no statistical differences among the 3 PTXmethods in shortterm successful rate （x2=2.655, P=0.265）, mortality （x2=2.548, P=0.280）, prevalence of hypocalcemia in one week after the operation （x2=0.066, P=0.968）, relapse rate in one year after the operation （x2=0.236, P=0.889）, and relapse rate in 4 years after the operation （x2=0.616, P=0.735）. For long-term evaluation of PTX effects, the prevalence of higher serum iPTH was more in patients after subtotal PTX than those after total PTX with