儿童甲状腺全切术后低钙血症危险因素分析

Risk factors of post⁃total⁃thyroidectomic hypocalcemia in children and adolescents

目的探讨儿童甲状腺全切除术后低钙血症的发生率、危险因素和预后。方法收集2014年1月至2019年12月在上海交通大学医学院附属新华医院行甲状腺全切术的37例患儿的临床资料,其中,男15例,女22例;手术时的中位年龄为12岁(6~17岁)。分析手术方式、病变类型、原位甲状旁腺保留数(parathyroid glands remaining in situ,PGRIS)评分、围术期血钙、甲状旁腺激素(parathyroid hormone,PTH)等低钙血症的危险因素。结果病理改变为滤泡/乳头状甲状腺癌81.1%(30/37),结节性甲状腺肿13.5%(5/37),Graves病5.4%(2/37)。32.4%(12/37)的患儿行颈部中央组淋巴结清扫,16.2%(6/37)的患儿行颈部中央组+侧方组淋巴结清扫。10.8%(4/37)的患儿行甲状旁腺自体移植,40.5%(15/37)的标本中发现≥1个甲状旁腺腺体。29.7%(11/37)术后24 h内出现低钙血症,16.2%(6/37)出现低钙血症的临床症状。单因素分析提示手术方式、PGRIS评分、甲状腺最大径、术后2 h的PTH、术后24 h的PTH与术后低钙血症的发生率差异有统计学意义。经过治疗,无永久性低钙血症发生,6个月后血钙和PTH均恢复正常。结论儿童全甲状腺切除术后低钙血症的发生率较高,且均在术后24 h内发生。颈部中央组+侧方组淋巴结清扫、PGRIS评分低和术后2 h的PTH降低是术后低钙血症的危险因素。术后2 h监测PTH可帮助预测低钙血症的发生。

Objective To explore the incidence,risk factors and outcomes of hypocalcemia after total thyroidectomy in children and adolescents.Methods From January 2014 to December 2019,clinical data were retrospectively reviewed for post-total-thyroidectomic hypocalcemia in 37 operated children and adolescents.There were 15 boys and 22 girls with a median operative age of 12(6-17)years.Demographics,operative characteristics,parathyroid glands remaining in situ(PGRIS)score,perioperative serum calcium,parathyroid hormone(PTH),hypocalcemia and outcome data were analyzed.Results The pathological diagnoses were thyroid carcinoma(81.1%,30/37),multinodular goiter(13.5%,5/37)and Gravesdisease(5.4%,2/37).Central cervical lymph node dissection(32.4%,12/37),central&lateral cervical lymph node dissection(16.2%,6/37)and auto-transplantation(10.8%,4/37)were performed.And≥1 gland were detected in specimen(40.5%,15/37).Hypocalcemia within 24 h of thyroidectomy(n=11)and clinical symptoms of hypocalcemia(6.2%,6/37)were noted.Univariate analysis indicated that surgical approaches,GPRIS score,2 h post-operative PTH,maximal diameter of thyroid and 24 h post-operative PTH were significantly associated with hypocalcemia.There was no onset of permanent hypocalcemia.After 6 months,serum levels of calcium and PTH normalized.Conclusion Children are at a high risk of hypocalcemia within 24 h posttotal thyroidectomy.Central and lateral cervical lymph node dissection and low PGRIS score are risk factors for postoperative hypocalcemia.And PTH monitoring at 2 h postoperatively can help to predict the occurrence of hypocalcemia.