继发性甲状旁腺功能亢进症手术疗效分析

Surgical effect analysis of secondary hyperparathyroidism

目的探究甲状旁腺切除术对继发性甲状旁腺功能亢进症(secondary hyperparathyroidism,SHPT)的临床疗效,分析围手术期全片段甲状旁腺激素(intact parathyroid hormone,iPTH)、血钙、血磷的变化规律与趋势及术中甲状旁腺激素(intraoperative parathyroid hormone,ioPTH)测定对手术完成的预测价值,为SHPT的手术治疗提供切实的理论依据及术后治疗参考。方法回顾性分析2012年12月至2022年12月哈尔滨市第一医院普外四科收治的479例SHPT初次手术患者,根据纳入标准筛选出457例进行研究,根据术后iPTH水平是否降至正常将研究对象分为手术完成组与未完成组,对比分析术前、术中、术后iPTH变化特点,研究分析围手术期血钙、血磷水平的变化规律。采用SPSS 26.0统计学软件进行数据处理,计量资料以平均数±标准差(±s)进行描述,采用t检验;计数资料以百分率(%)表示,组间比较采用χ2检验,P<0.05表示差异有统计学意义。结果①本研究纳入457例中男261例,女196例,年龄(45.43±11.25)岁,透析龄(90.3±35.8)个月,伴高钙血症、高磷血症、高钾血症、高碱性磷酸酶水平分别占比41.79%、94.31%、20.35%、75.50%;术前骨量减少和骨质疏松分别占比35.45%和62.36%;不宁腿综合征发病率为7.67%。②手术完成组术中及术后iPTH水平均明显低于未完成组(P=0.001,Px<0.001),两组ioPTH下降至术前30%以下的比例分别为96.30%和58.33%。ioPTH≤150 pg/mL均能预测手术成功,58.33%的患者能通过ioPTH高于术前iPTH的30%预测手术失败。③两组术后血钙、血磷水平在术后3 h、术后2 d比较,差异具有统计学意义。手术完成组术后当日和3 d内低钙血症发生率分别为43.19%和82.49%。骨饥饿综合征发生率为62.12%。④术后高钾血症、动静脉瘘血栓、暂时性声音嘶哑、出血和院内死亡的发生率分别为43.33%、1.75%、0.66%、0.44%和0.22%。结论甲状旁腺切除术是SHPT安全有效的治疗方法,ioPTH对预测手术是否成功发挥重要作用。及时有效地补钙治疗是预防骨饥饿综合征出现严重并发症的重要措施。

ObjectiveTo investigate the clinical efficacy of parathyroidectomy for secondary hyperparathyroidism(SHPT),and to analyze the changes and trends of perioperative intact parathyroid hormone(iPTH),serum calcium and serum phosphorus,and the predictive value of intraoperative parathyroid hormone(ioPTH)measurement for surgical completion.To provide practical theoretical basis and reference for postoperative treatment of SHPT.MethodsData of 479 SHPT patients admitted to the First Hospital of Harbin from Dec.2012 to Dec.2022 were retrospectively analyzed.According to the admission criteria,457 patients were screened out and divided into PTX group and incomplete PTX group based on whether the level of postoperative parathyroid hormone was reduced to the normal standard.The levels of iPTH,serum calcium and phosphorus during the perioperative period in the two groups were statistically analyzed.SPSS 26.0 statistical software was used for data processing.P<0.05 indicated statistically significant difference.ResultsIn the analyzed group of 457 patients,the average age was(45.43±11.25)years and the average dialysis age was(90.3±35.8)months.Hypercalcemia,hyperphosphatemia,hyperkalemia and high alkaline phosphatase levels accounted for 41.79%,94.31%,20.35%and 75.50%,respectively.Bone loss and osteoporosis accounted for 35.45%and 62.36%,respectively.The incidence of restless leg syndrome was 7.67%.IoPTH and post-operative iPTH level in the PTX group were significantly lower than those in the incomplete PTX group(P=0.001,P<0.001).IoPTH≤150 pg/mL can predict surgical success,and 58.33%of cases can predict surgical failure by ioPTH being 30%higher than preoperative iPTH.There were significant differences in serum calcium and phosphorus levels between the two groups at 3 hours and 2 days after operation.The incidence of hypocalcemia was 43.19%and 82.49%on the day of operation and within 3 days after operation,and the incidence of hungry bone syndrome was 62.12%in the PTX group.The incidence of postoperative hyperkalemia,arteriovenous fistula thrombosis,temporary hoarseness,bleeding and in-hospital mortality was 43.33%,1.75%,0.66%,0.44%and 0.22%,respectively.ConclusionsParathyroidectomy is an effective and safe treatment for secondary hyperparathyroidism,and ioPTH plays an important role in predicting the success of surgery.Timely and effective calcium supplementation is an important measure to prevent the serious occurrence and morbidity of bone hunger syndrome.