颈丛阻滞麻醉下分期手术治疗继发性甲状旁腺功能亢进症的初步探索

Sequential parathyroidectomy under cervical plexus anesthesia for secondary hyperparathyroidism with renal function failure

目的探讨在颈丛阻滞麻醉下分期手术治疗继发性甲状旁腺功能亢进症的可行性。 方法回顾性分析2009年1月至2017年12月在北京协和医院基本外科接受手术治疗的32例继发性甲状旁腺功能亢进症患者的临床资料。男性11例，女性21例，平均年龄51.3岁。本组均为慢性肾功能不全长期接受血液滤过治疗的患者，术前血清全段甲状旁腺素（iPTH）均〉1 000 ng/L。11例接受双侧甲状旁腺探查切除术，21例接受计划性分期手术。分期手术组患者在颈丛阻滞麻醉下切除一侧颈部的增生甲状旁腺组织；并于首次手术6个月后，根据血iPTH及症状决定是否切除对侧甲状旁腺。组间资料比较采用Fisher精确概率检验。 结果双侧探查组中5例患者在首次手术后iPTH再次〉1 000 ng/L，其中3例实施二次手术。分期手术组中15例患者首次手术后iPTH再次〉1 000 ng/L，其中11例完成对侧甲状旁腺切除术，二次手术后仍有1例患者iPTH〉1 000 ng/L。完成双侧手术的患者中，分期手术组患者1例术后进入ICU，双侧探查组为6例（1/11比6/11，P＝0.063）。 结论在颈丛阻滞麻醉下对继发性甲状旁腺功能亢进症患者实施分期手术，是一种可行的治疗策略，但需要大样本对照研究进一步证实其长期疗效。

ObjectiveTo summarize the strategy of sequential parathyroidectomy for secondary hyperparathyroidism. MethodsBetween January 2009 and December 2017, 32 patients with secondary hyperparathyroidism underwent parathyroidectomy in Department of General Surgery, Peking Union Medical College Hospital. There were 11 male and 21 female patients with a mean age of 51.3 years. Eleven of them underwent bilateral neck exploration under general anesthesia, while the rest of them underwent sequential parathyroidectomy. For the patients with sequential parathyroidectomy, a unilateral neck exploration was performed in the initial operation under cervical plexus blocking anesthesia. Second operation for contralateral parathyroid lesions was performed if the serum intact parathyroid hormone （iPTH） was still higher than 1 000 ng/L or related symptoms were not relieved significantly 6 months later after initial surgery. Fisher exact test was used to compare the date between the 2 groups. ResultsIn the bilateral exploration group, the serum iPTH level gradually exceeded above 1 000 ng/L in 5 patients during follow-up, and reoperation were performed in 3 patients of them. In the group with sequential parathyroidectomy, the serum iPTH level after initial operation exceeded above 1 000 ng/L in 15 patients. Eleven of them underwent contralateral parathyroidectomy, which decreases the serum iPTH levels to less than 1 000 ng/L in 10 patients. Compared with the sequential parathyroidectomy group （1/11）, more patients needed to be treated in the intensive care unit after operation in bilateral exploration group （6/11）, although the difference was statistically insignificant （P=0.063）. ConclusionsSequential parathyroidectomy strategy is feasible for the secondary hyperparathyroidism with severe complications. Prospective controlled observation with large sample size is needed to confirm its effect.