围手术期应用糖皮质激素对双侧甲状腺全切及中央区淋巴清扫术后甲状旁腺功能减退和低血钙的影响

Effect of perioperative application of glucocorticoid on postoperative hypoparathyroidism and hypocalcemia in patients with total thyroidectomy plus central compartment dissection

目的探讨围手术期糖皮质激素的应用对甲状腺乳头状癌甲状腺全切除术加双侧中央区淋巴清扫术或者联合一侧或双侧颈侧区淋巴清扫术后甲状旁腺功能减退及低血钙的影响。方法对2015年11月至2017年3月期间首都医科大学附属北京同仁医院117例甲状腺乳头状癌患者进行回顾性分析,其中男36例,女81例,年龄21~74(47.8±12.5)岁。其中81例(69.2%)患者行甲状腺全切并双侧中央区淋巴清扫术,36例(30.8%)同时行一侧或双侧颈侧区淋巴清扫术。术前及术后均检测甲状旁腺激素(parathyroid hormone,PTH)及血钙。所有患者分成4组:A组40例,术中及术后均未应用糖皮质激素治疗;B组36例,仅术中气管两侧创面给予喷洒地塞米松磷酸钠注射液各5 mg治疗;C组21例,仅术后给予甲泼尼龙40 mg每日1次静脉滴注3 d;D组20例,术中气管两侧创面给予喷洒地塞米松磷酸钠注射液各5 mg,术后给予甲泼尼龙40 mg每日1次静脉滴注3 d。术后第1、2、3天检测PTH及血钙,比较各组术后低PTH以及低血钙发生率的差异。以SPSS 19.0统计学软件处理数据。结果术后B组在无低血钙同时无低PTH患者比例(61.1%)、低PTH发生率(2.8%)与A组(35.0%和15.0%)比较差异均有统计学意义(χ^2分别为5.182、3.885,P值均<0.05),低血钙(5.6%)与A组(12.5%)比较差异无统计学意义(P>0.05);D组无低血钙同时无低PTH患者比例(70.0%)与A组比较差异有统计学意义(χ^2=6.530,P<0.05),低PTH发生率(5%)、低血钙(5.0%)与A组比较差异无统计学意义(P值均>0.05);而C组中各项发生率与A组比较差异均无统计学意义(P值均>0.05);B组无低血钙同时无低PTH的发生率、低PTH发生率与C组(23.8%和23.8%)比较差异有统计学意义(χ^2分别为7.402、6.229,P值均<0.05),低血钙发生率比较差异无统计学意义(P>0.05);术后低血钙、低PTH多发生在术后1~2 d。所有患者均未发生永久性低血钙。结论糖皮质激素在甲状腺全切除术加双侧中央区淋巴清扫术中或术中术后同时应用,能够减少术后甲状旁腺功能低下的发生率。

Objective To evaluate the effect of glucocorticoid used in perioperative period of total thyroidectomy(TT)plus central compartment lymph node dissection(CCLND)or combining with lateral neck dissection on postoperative hypoparathyroidism(HPT)and hypocalcemia(HPC).Methods The data of 117 patients with papillary thyroid carcinoma(PTC)undergone the surgeries in Tongren Hospital between Nov 2015 and Mar 2017 were retrospectively analyzed.There were 36 males and 81 females,and their ages ranged from 21 to 74 years old,average age of 47.8±12.5.TT and CCLND were performed in 81(69.2%)patients,and TT,CCLND and unilateral or bilateral lateral neck dissection were performed in 36(30.8%)patients.The patients were divided into 4 groups:Group A(40 patients),no glucocorticoid was applied;Group B(36 patients),5 mg dexmethasone sodium phosphate was sprayed on the surface of wound on both sides of trachea during operation;Group C(21 patients),40 mg methylprednisolone was applied by intravenous injection after operation,one time per day for 3 days;Group D(20 patients),5 mg dexmethasone sodium phosphate was sprayed on the surface of wound on both sides of trachea during operation and 40 mg methylprednisolone were applied by intravenous injection after operation,one time per day for 3 days.Serum parathyroid hormone and calcium were tested before operation and at the 1st,2nd and 3rd day after operation.Spss19.0 was used to analyze the data.Results There were statistically significant differences in the incidences of both no HPT and no HPC and the incidence of HPT alone between Group A and B(35.0%vs 61.1%,15.0%vs 2.8%,χ^2 were 5.182 and 3.885,respectively,P<0.05),but not in the incidence of HPC alone between the two groups.There were statistically significant difference in the incidences of both no HPT and no HPC between Group A and D(35%vs 70.0%,χ^2=6.530,P<0.05),but not in the incidences of HPT or HPC between the two groups.There were not statistically significant differences in the individual incidences between Groups A and C(P>0.05).There were statistically significant differences in the incidence of both no HPT and no HPC and the incidence of HPT alone between Groups B and C(61.1%vs 23.8%,2.8%vs 23.8%,χ^2 were 7.402 and 6.229,respectively,P<0.05),but not in the incidence of HPC between the two groups(P>0.05).HPT and HPC often occurred on the 1st or 2nd day after operation.Permanent hypocalcemia did not occur in all cases.Conclusions Intraoperative especially plus post-operative application of glucocorticoid can decrease the incidence of HPT after operation.