原发性甲状旁腺功能亢进症的术前诊断与外科治疗策略  

Preoperative diagnosis and surgical strategies of primary hyperparathyroidism

作　　者：张翔[1] 胡亚[1] 王梦一[1] 粟喆 廖泉[1] 赵玉沛[1] Zhang Xiang;Hu Ya;Wang Mengyi;Su Zhe;Liao Quan;Zhao Yupei(Department of General Surgery,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences ＆ Peking Union Medical College,Beijing 100730,China)

机构地区：[1]中国医学科学院北京协和医院基本外科,北京100730

出　　处：《中华内分泌外科杂志》2018年第4期274-277,共4页Chinese Journal of Endocrine Surgery

基　　金：中国医学科学院医学与健康科技创新工程（2017-12M-1-001）;北京协和医学院协和学者与创新团队发展计划创新团队项目

摘　　要：目的探讨我国原发性甲状旁腺功能亢进症（primary hyperparathyroidism，pHPT）的术前诊断与外科治疗策略。方法回顾性分析2009年1月至2017年4月在北京协和医院进行首次手术治疗的pHPT的临床资料，探讨pHPT的术前定位诊断策略及手术方案选择。结果在此期间，共有902例完成手术治疗，其中女性674例，男性228例。患者在术前完成甲状旁腺超声和99Tcm-甲氧基异丁基异腈（99Tcm-sestamibi，MIBI）显像定位检查，其中超声定位诊断的敏感性是97.18%，阳性预测值是98.40%。MIBI检查诊断敏感性是94.24%，阳性预测值是98.00%。超声联合MIBI行术前定位的敏感性及阳性预测值分别为92.39%和97.37%。MIBI显像阴性患者51例（5.65%），其中男性患者或甲状旁腺合并囊性变更易出现MIBI显像阴性（P〈0.05）。89例术前超声与MIBI结果双阴性或不一致，其中有39例进一步行颈部CT，17例行正电子发射断层显像（positron emission tomography，PET）/CT检查，9例行超声引导下穿刺活检明确定位。800例（88.69%）接受了颈丛阻滞麻醉下小切口甲状旁腺切除术（minimally invasive parathyroid surgery，MIP）。656例（72.72%）患者术后第1天甲状旁腺激素（parathyroid hormone，PTH）下降到正常水平，140例（15.52%）术后第1天血清总钙低于正常值下限，234例（25.94%）术后3 d内出现了低钙血症相关症状，均可通过口服或静脉补钙缓解。通过随访发现，800例MIP手术患者中，4例出现复发，1例手术失败。结论甲状旁腺超声和MIBI显像具有较高的定位诊断价值，颈部CT或PET/CT是重要的补充定位手段。对于定位诊断明确的pHPT，颈丛阻滞麻醉下MIP是一种简单可行的手术策略。ObjectiveTo investigate the preoperative localizaion diagnosis and surgical strategies of primary hyperparathyroidism （pHPT） . MethodsThe clinical data of pHPT patients who underwent initial parathyroid surgery at the Peking Union Medical College Hospital from Jan. 2009 to Apr. 2017 were retrospectively analyzed to explore preoperative localization and surgical options. ResultsThere were a total of 902 surgical cases included in the study with 674 women and 228 men. All had preoperative parathyroid ultrasonography （US） （sensitivity 97.18%, positive predictive value （PPV） 98.40%） and 99Tcm-sestamibi （MIBI） scan （sensitivity 94.24%, PPV 98.00%） . The combination of US and MIBI scan had a sensitivity of 92.39% and PPV of 97.37%. MIBI scan showed negative results in 51 cases. We found that male patients with cystic lesions were more likely related to negative MIBI scan （P〈0.05） . Among 89 patients with negative MIBI and/or US, 39 received neck CT, 17 received positron emission tomography （PET） /CT, and 9 received ultrasound-guided biopsy for further localization. 800 patients （88.69%） underwent minimally invasive parathyroid surgery （MIP） with anesthesia of cervical plexus block. 656 patients （72.72%） had normal parathyroid hormone （PTH） level on the first post-operative day, 140 patients （15.52%） had postoperative hypocalcaemia and 234 patients （25.94%） presented hypocalcaemic symptoms within 3 days after operation, which could be relieved by intravenous calcium or continuous medicine taken by mouth. During the follow-up of the 800 MIP patients, 4 had recurrence and one patient was not cured.ConclusionsParathyroid US and MIBI scan are of good value in localizaion diagnosis. Neck CT or PET/CT should be used as supplementary approaches in patients with negative US and/or MIBI scan. MIP with anesthesia of cervical plexus block is simple and feasiable for pHPT cases with accurate localization.

关 键 词：原发性甲状旁腺功能亢进症 定位诊断 超声 ^99TC^M-甲氧基异丁基异腈 甲状旁腺切除术 

分 类 号：R653[医药卫生—外科学]