术前超声下位甲状旁腺定位新分型对术中寻找及保护甲状旁腺的作用

Role of preoperative ultrasound-guided inferior parathyroid gland localization and new classification to assist intraoperative search and protection of parathyroid glands

目的:探讨甲状腺手术前超声引导下下位甲状旁腺(IPTG)定位对术中甲状旁腺寻找及保护的作用及意义。方法:随机对照试验。纳入2021年3至10月于北京同仁医院耳鼻咽喉头颈外科初次行甲状腺切除+中央区淋巴结清扫手术的患者306例,共433侧腺叶切除术,计算机随机分为观察组153例(228侧)及对照组153例(205侧)。为更加快速有效地定位IPTG,本研究定义了IPTG的新分型及IPTG的象限位置分类。观察组术前行超声IPTG检查并测量定位IPTG与甲状腺下极及气管中线距离,术中依据定位寻找并保护IPTG,对照组未借用任何术前辅助定位方法进行常规手术。统计IPTG的分布比例、术中与超声定位的吻合率。结果:共纳入306例患者,男95例,女211例,中位年龄41岁(18~70岁)。Ⅱ、Ⅲ型IPTG占整体比例的77.2%(176/228)。IPTG按不同分组总吻合率为72.8%~79.4%,其中Ⅲ型及2象限吻合率最高,分别为92.4%(73/79)及92.9%(79/85)。观察组和对照组总原位保留率分别为82.0%(187/228)和73.2%(150/205)(χ^(2)=4.896, P=0.027),种植率分别为8.8%(20/228)和16.1%(33/205)(χ^(2)=5.393, P=0.020),差异均有统计学意义。观察组Ⅲ型IPTG原位保留率为94.9%(74/78),优于对照组的77.4%(48/62)(χ^(2)=7.898, P=0.005)。观察组和对照组暂时性甲状旁腺功能减低发生率分别为32.0%(24/75)和34.6%(18/52),差异无统计学意义(χ^(2)=0.095, P=0.758);两组均无永久性甲状旁腺功能减退。 结论:术前超声引导下IPTG定位检查对术中寻找及保护IPTG有良好的指导意义,明显增加IPTG的原位保留率,减少种植率。

Objective To investigate the role and significance of ultrasound-guided inferior parathyroid gland(IPTG)localization in searching and protecting parathyroid glands before thyroid surgery.Methods A randomized controlled trial study was conducted.A total of 306 patients(433 cases of lateral parathyroidectomy)who underwent primary thyroidectomy and central lymph node dissection in Beijing Tongren Hosipital from March to October 2021 were enrolled.In order to locate IPTG more quickly and effectively,new IPTG classification and the definition of quadrant position were carried out.The patients were divided into the study group(n=228)and the control group(n=205).The study group underwent ultrasound-guided IPTG examination before operation and measured the distance between the IPTG and the lower pole of the thyroid and the midline of the trachea.During the operation,the IPTG was found and protected depending on the localization.The control group did not use any auxiliary preoperative positioning method.The distribution ratio of IPTG and the coincidence rate between intraoperative validation and ultrasound localization were calculated.Results There were 306 patients enrolled in the final analysis(95 males and 211 females),with a median age of 41 years old(18-70).TypeⅡandⅢIPTG accounted for 77.2%(176/228)of the total cases.The total coincidence rate ranged from 72.8%to 79.4%in different IPTG groups.TypeⅢand quadrant 2 IPTG had the highest coincidence rate[92.4%(73/79)and 92.9%(79/85),respectively].The study group had better in situ retention rate[82.0%(187/228)vs 73.2%(150/205),χ^(2)=4.896,P=0.027]and less implantation rate[8.8%(20/228)vs 16.1%(33/205),χ^(2)=5.393,P=0.020]than those of the control group.The in situ retention rate were better in typeⅢIPTG group,compared with those of the control group[94.9%(74/78)vs 77.4%(48/62),χ^(2)=7.898,P=0.005].There was no permanent hypoparathyroidism in two groups and the temporary hypoparathyroidism rate was 32.0%(24/75)and 34.6%(18/52),respectively(χ^(2)=0.095,P=0.758).Conclusion Ultrasound-guided IPTG localization examination has important implications for searching and protecting IPTG during operation,which can significantly increase in situ retention rate of IPTG and decrease the implantation rate.