可避免的原发性甲状旁腺功能亢进症再次手术临床分析

The clinical analysis of preventable reoperation for primary hyperparathyroidism

目的 探讨原发性甲状旁腺功能亢进症再次手术的诊断、定位及手术治疗策略.方法 回顾性分析2009年1月至2016年12月北京协和医院基本外科实施再次手术治疗的原发性甲状旁腺功能亢进症患者的临床资料,分析其相关的临床特征、术前定位诊断及手术结果.在此期间共有58例原发性甲状旁腺功能亢进症患者接受再次手术治疗,其中11例患者为单个甲状旁腺病变,首次手术后甲状旁腺功能亢进未能缓解,接受再次甲状旁腺切除术治疗.11例患者再次手术时的平均年龄为54.9岁,其中男性2例,女性9例.结果 本组患者再次手术前超声及99Tcm-甲氧基异丁基异腈扫描甲状旁腺定位的准确性均为10/11.2例患者需要进一步通过SPECT及CT增强扫描确定甲状旁腺位置,总体定位准确性为11/11.在全身麻醉或颈丛阻滞麻醉下,成功切除所有患者的甲状旁腺病变,术后病理报告9例为腺瘤,其余2例为增生.结论 原发性甲状旁腺功能亢进症应在有经验的医疗中心实施手术,结合准确的术前定位和术中系统性探查,尽量降低再次手术的风险.

Objective To discuss the diagnosis,preoperative imaging and surgical technique of patients who underwent reoperation for persistent hyperparathyroidism.Methods A prospective database about primary hyperparathyroidism in Department of General Surgery,Peking Union Medical College Hospital was searched for the patients who underwent reoperation for persistent hyperparathyroidism from January 2009 to December 2016.The information about the initial operation,preoperative imaging study and result of reoperations were collected and reviewed.A total of 58 patients underwent reoperation for hyperparathyroidism.Eleven of these patients were referred to this institute for reoperation after missing single parathyroid lesion in the initial parathyroidectomy.Nine patients were female,and the mean patient age at reoperation was 54.9 years.Results For this group,the accuracy of ultrasound neck scan and sestamibi scintigraphy was 10/11 in identifying diseased parathyroid gland before reoperation.Combined with enhanced CT and SPECT,all parathyroid lesions were localized before reoperations.With general anesthesia or cervical plexus block,all diseased parathyroid glands were removed in the reoperations.No signs of hyperparathyroidism appeared during follow-up.Conclusions The initial surgery for primary hyperparathyroidism should be performed in experienced center to avoid reoperations.Combining preoperative localization and cervical exploration will help to increase the success rate of reoperation.