持续性和复发性肾性甲状旁腺功能亢进的外科治疗

Surgical management for persistent and recurrent renal hyperparathyroidism

目的探讨肾性甲状旁腺功能亢进接受甲状旁腺全切加甲状旁腺自体移植术(total parathyroidectomy with autotransplantation,tPTX+AT)后持续性和复发性甲状旁腺功能亢进的外科治疗策略。方法2009年10月至2018年10月,480例肾性甲状旁腺功能亢进患者在我院接受tPTX+AT,回顾性分析32例手术后持续性(31例)和复发性(1例)甲状旁腺功能亢进患者接受再次手术前后的临床资料。再次手术前将高频超声联合细针穿刺洗脱液PTH测定及SPECT/CT同机断层融合显像作为定性和定位诊断方法,收集患者初次手术和移植记录,术后甲状旁腺素变化及治疗情况,随访术后血清全段甲状旁腺素和临床症状变化情况判断疗效。结果32例患者28例接受1次再次手术,4例接受2次再次手术,共切除36枚甲状旁腺,2处移植物。31例患者术后骨骼疼痛、皮肤瘙痒明显减轻甚至消失,肌力较术前逐渐增强。随访6个月~2年,31例患者iPTH波动在15-90 ng/LJ例仍处于高iPTH状态(550-1 000 ng/L)。31例术后甲状旁腺素水平较术前显著下降(P<0.05)。结论高频超声联合FNA-iPTH及SPECT/CT同机断层融合显像可以作为PTPT或PHPT定性和定位诊断的方法,在术前精准定位的前提下,再次手术切除全部甲状旁腺是持续性和复发性肾性甲状旁腺功能亢进的一种有效的治疗手段。

Objective To investigate the surgical treatment strategies for persistent and recurrent parathyroidectomy after total parathyroidectomy plus autotransplantation(tPTX+AT)in cases of renal hyperparathyroidism.Methods From Oct 2009 to Oct 2018,480 patients with renal hyperparathyroidism received tPTX+AT in our hospital.32 patients suffered from post-op persistent(31)and recurrent(1)hyperparathyroidism.The high frequency ultrasonography combined with fine needle puncture eluent PTH determination and SPECT/CT co-computed tomography fusion imaging were used as qualitative and localizing diagnostic methods before reoperation.Results Of the 32 patients,28 cases underwent reoperation for once,and 4 underwent reoperations fort wice.36 parathyroid glands and 2 grafts were resected.In 31 patients the bone pain,skin pruritus relieved significantly or disappeared,and muscle strength gradually increased compared with that before operation.Level of iPTH in 31 patients fluctuated between 15 and 90 ng/L.Postoperative parathyroid hormone decreased compared with that before the operation(P<0.05).One patient was still with persistent hyperparathyroidism despite reoperation,whose iPTH fluctuated between 550 and 1 000 ng/L during 6 months to 2 years follow-up.Conclusion Ultrasonography,FNA-iPTH and SPECT/CT co-computed tomography can be used as methods for qualitative and localizing diagnosis of PTPT or PHPT.With accurate preoperative localization,resection of all parathyroid glands is an effective treatment for posto perative persistent and recurrent renal hyper parathyroidism.