甲状腺术后症状性低钙血症的危险因素分析

Analysis of risk factors for symptomatic hypocalcemia after thyroid surgery

目的观察甲状腺术后患者症状性低钙血症(SH)的发生与多种潜在影响因素之间的关系,根据甲状腺切除范围进行分层并探讨全段甲状旁腺激素(iPTH)对术后SH的预测价值。方法回顾性选取2020年1月—2021年2月郑州大学第一附属医院收治的3379例甲状腺术后患者中发生SH的122例患者,设为SH组。用系统抽样法抽取同年余3200例中未发生SH的100例患者,设为对照组。用Pearson相关性分析评估两组患者的年龄、术前钙、术后钙、术前iPTH、术后iPTH、中央区淋巴结数目、出血量、手术时间、性别、淋巴结清扫方式、甲状腺切除范围、术后病理类型等潜在影响因素。正态分布的计量资料以均数±标准差(Mean±SD)表示,组间比较采用t检验;计数资料组间比较采用χ^2检验。通过绘制受试者操作特征曲线(ROC)研究术前/术后(不同术式)SH组和对照组患者的iPTH水平,预测其iPTH诊断临界值,灵敏度及特异度。结果3379例甲状腺术后患者中,发生SH者122例,发病率为3.6%。SH组和对照组的性别(SH组:男8例,女114例;对照组:男27例.女73例),是否行侧区清扫(SH组:清扫58例,非清扫64例;对照组:清扫7例,非清扫93例),甲状腺切除范围(SH组:单侧14例,双侧108例;对照组:单侧73例,双侧27例).年龄(40.1岁比43.2岁),中央区淋巴结清扫数目(8.6枚比4.6枚),颈侧区淋巴结清扫数目(12.3枚比0.7枚)出血量(22.8 mL比11.0 mL),手术时间(1.7 h比0.8 h),术后iPTH(16.4 pe/mL比41.9 pg/mL),术前iPTH(39.4 pg/mL比47.8 pg/mL)和术后钙水平(1.9 mmol/L比2.2 mmol/L)比较,差异具有统计学意义(P<0.05)。而两组患者的术后病理类型(SH组:毒性甲状腺肿4例,甲状腺髓样癌3例,甲状腺滤泡癌1例,甲状腺乳头状癌114例;对照组:甲状腺髓样癌1例,甲状腺滤泡癌1例,甲状腺乳头状癌98例。P=0.25)及术前钙(2.3 mmol/L比2.3 mmol/L,P=0.10)之间差异无统计学意义。甲状腺双侧切除患者的术后iPTH若<20.08 pg/ml,则容易出现SH,其灵敏度为74.07%,特异度为96.30%;而对于甲状腺单侧切除患者,术后iPTH<24.00 pg/mL.时容易有SH发生。结论性别、年龄、术后钙、术前iPTH、术后iPTH、中央区淋巴结数目、出血量、手术时间、淋巴结清扫方式、甲状腺切除范围是甲状腺术后发生SH的重要影响因素。随着手术范围的扩大,预测SH发生的术后iPTH水平逐渐降低。为避免术后SH的发生,需要根据手术范围及术后iPTH水平及时补钙。

Objective To observe the relationship between the occurrence of symptomatic hypocalcemia(SH)and various potential influencing factors in patients after thyroidectomy,stratify according to the scope ofthyroidectomy,and explore the predictive value of intact parathyroid hormone(iPTH)for postoperative SH.Methods Among 3379 patients with thyroidectomy who admitted into the First Affiliated Hospital of ZhengzhouUniversity from January 2020 to February 2021,122 patients with SH after thyroidectomy were collectedretrospectively and set as SH group.100 patients of the remaining 3200 patients who did not suffer from SH in thesame year were selected by systematic sampling method and set as control group.Pearson correlation analysis wasused to analyze the potential influencing factors such as age,preoperative calcium,postoperative calcium,ptreoperative iPTH,postloperative iPTH,central lynuph node number,blood loss,operation duration,gender,lymphnode dissection methol,thy roidectomy range,postoperative patbological type and other.Amosng them,themreasurement data of normal distribution were expresed by mean+stanodard deviatin(Mean±SD),t-test was used for the eomparison between the two groupe,and Chi-square test was used for eount data.By trawing the necriveroperating characteristie curve(ROC),the iPTH levels in puatients with and without SH before/after peration(different surgical methods)were studlied,and the dliagrsoetic threshold,sensitivity and specificity of iPTH werepeedicted.Results Among 3379 patients,122 patients suffered from SH after thy roidlectomy,with the incitencerale of 3.6%,There were significant dlillerences in gendker(8 msales ansdl 114 females in SH group;27 males and73 females in control group),whethber lateral urea dissection was perfotmed(58 cases with dissexction and 64 caseswithaut dissection in SH proup;7 cases with dissection and 93 cases without disection in control group).thayroidectoeny range(14 cases with ane side and 108 cases with both sides in SH group;73 camses with one sidle and 27 cases with both siles in control prup),age(40.1 years old vs 43.2 years old),dlisect ion number of oemtrallymph noles(8.6 vs 4.6),dissection mumaber of oervical lymph novdes(12.3 vs 0.7),blood loss(22.8 mL.vs 11.0 mL.),aperation thuration(1.7 h vs 0.8 h),postoperanive iPTH(16.4 pg/mL.vs 41.9 pg/mL.),preoperalive iPTH(39.4 pg/mL vs 47.8 pg/mL.)in SH protzp;and postoperative calciurmn level(1.9 mmol/L.vs 2.2 mmol/L.).There was significant differences hetween the two gruups(P<0.05).However,there was no significant differencesletween them with postoperative pathological type(4 cases with toxic goiter,3 cases with merdullary thyroidcarcinoma,1 case with thyraid folicular carcinoma,114 cases with papillary thyroid carcinoma in SH group;1 casewith medluallary thyroid carecinoria,1 case of thyroid follicalar earcinoma,98 cases with papillary thyroid carcinomain econtnol proup,P=0.25)and presperative caleium(2.3 mmol/L vs 2.3 mmol/L,P=0.10).For patients withbilsateral thyroidlectormy,SH was easy to occur when postoperative iPTH<20.08 pg/mL,and its sensitivity arlspecificity were 74.07%and 96.30%;however,fur puatients wih anilateral thynoidectomy,SH was easy to occur when iPTH<24.00 pe/mL.after operation.Conclusions Gendler,age,posloperative cralciuma,preoperative iPTH,peotoperative iPTH,central lymghnode number,bload loss,nperation duration,lymph node dissevtionmctlsol and tlayroidectony range are important factors affecting the occurence of SH after thyroidlecstonay.Wwith theexpuansionm of surgieal range,the posloperative iPTH level graulully decmeases,which predicts the occurrence ofsymuptomnstic hypocalcemia.ln order to avoid the oceurence of symptomatic hypocalcemia after operation,it is necessary to supplement ealcium in time according to the range of operation and postoperative iPTH level.