手术治疗继发性甲状旁腺功能亢进症的临床疗效分析

发布时间：2019-04-22 17:51

【摘要】：目的回顾性分析浙江大学附属第一医院肾脏病中心2009年7月至2016年2月期间290例行甲状旁腺切除术的慢性肾脏病患者的临床资料,分析及评估手术的疗效、术后的钙磷代谢、手术的安全性等。方法收集我中心行甲状旁腺切除术治疗患者的一般情况(包括姓名,性别,接受手术时的年龄,有无进行肾替代治疗及其方式和时间,肾脏原发病),术前的临床症状体征,钙、磷、PTH及血管骨组织软组织情况评估等。统计手术的方法,切除甲状旁腺的颗数,患者术后的症状改善情况,术后的钙、磷、PTH指标变化,统计患者的手术成功率、低钙血症发生率、甲状旁腺功能低下率、持续性甲状旁腺功能亢进率、复发率等。结果本中心共有290例继发性甲状旁腺功能亢进患者纳入研究,其中男性155(53.45%)例,女性135(46.55%)例。平均年龄为46.89±11.31岁(15～77)280例行全切+前臂种植术,10例行次全切手术。74例患者因合并甲状腺肿瘤或者甲状腺结节行甲状腺切除术。284例患者术后1周的血甲状旁腺激素明显下降(下降幅度术前血甲状旁腺激素的50%),即手术成功率为97.93%。术后250(86.21%)例患者的骨痛、瘙痒症状较术前明显改善。术前的血钙、磷、甲状旁腺激素与术后1周相比均有显著差异(p0.001),但术前的碱性磷酸酶与术后1周无明显差异(p=0.128)。271(93.45%)例患者术后有低钙血症,14(4.18%)例患者术后有明显麻木／抽搐,2(0.69%)例患者因低钙血症再次住院。34(11.50%)例患者有明显声音嘶哑／呛咳,4(1.38%)例患者因手术区出血再次行清创止血术。1(0.34%)例患者因甲状腺功能低下再次住院。无围手术期死亡病例。5例为肾移植状态患者,另3例为未行透析治疗的患者。8例患者术前术后的血肌酐值并无显著差异(P0.05)。次全切组8例有随访数据,全切组224例有随访数据。次全切组与全切±种植组,两组的术后低钙血症发生率有显著差异(p0.0001)。次全切组有4(50.00%)例为持续性甲状旁腺功能亢进,3(37.50%)例复发；全切+种植组有36(16.07%)例为持续性甲状旁腺功能亢进,51(22.77%)例复发。术后总的持续性甲旁亢率为17.24%,总的复发率为23.28%。两组间的持续性甲旁亢发生率有明显差异(P=0.032)；两组间的复发率无明显差异(P=0.393)。结论甲状旁腺切除术能有效治疗终末期肾病患者的继发性甲旁亢,改善钙磷代谢紊乱。手术成功率较高,术后有一定持续性甲旁亢发生率和复发率,持续性甲状旁腺功能低下发生率较低。术后最常见的并发症为低钙血症,需术后密切监测和加强随访。对肾移植后患者和未进行替代治疗的CKD患者,甲状旁腺切除术对肾功能影响较小。
[Abstract]:Objective to analyze retrospectively the clinical data of 290 patients with chronic renal disease who underwent parathyroid resection from July 2009 to February 2016 in the Center of Nephropathy of the first affiliated Hospital of Zhejiang University, and to analyze and evaluate the curative effect of the operation and the metabolism of calcium and phosphorus after operation. The safety of surgery, etc. Methods the general situation (including name, sex, age at the time of operation, renal replacement therapy and its mode and time, primary disease of kidney), clinical symptoms and signs before operation were collected in our center. Evaluation of calcium, phosphorus, PTH, vascular bone tissue and soft tissue. The methods of operation, the number of parathyroid glands removed, the improvement of symptoms after operation, the changes of calcium, phosphorus and PTH after operation, the successful rate of operation, the incidence of hypocalcemia and the rate of hypoparathyroidism were counted. Persistent hyperparathyroidism rate, recurrence rate, etc. Results 290 patients with secondary hyperparathyroidism were included in the study, including 155 males (53.45%) and 135 females (46.55%). The average age was 46.89 卤11.31 years (15 / 77). Ten patients underwent subtotal thyroidectomy. 74 patients underwent thyroidectomy due to thyroid tumors or thyroid nodules. Serum parathyroid hormone decreased significantly in 284 patients 1 week after operation (50% of pre-operative serum parathyroid hormone). The success rate of the operation was 97.93%. Bone pain and pruritus were improved in 250 (86.21%) patients after operation. There were significant differences in serum calcium, phosphorus and parathyroid hormones before operation compared with one week after operation (p0.001), but there was no significant difference in alkaline phosphatase before operation and one week after operation (p = 0.128). 271 (93.45%) patients had hypocalcemia after operation, and there was no significant difference in serum calcium, phosphorus and parathyroid hormones at one week after operation (p0.001). 14 (4.18%) patients had obvious numbness / convulsions, 2 (0.69%) patients were re-hospitalized because of hypocalcemia, 34 (11.50%) patients had obvious hoarseness / choking cough. 4 (1.38%) patients were re-treated with debridement and hemostasis because of bleeding in the operation area, and 1 (0.34%) patients were re-hospitalized because of hypothyroidism. There were no perioperative death cases. 5 cases were renal transplantation patients and 3 cases were not dialyzed. There was no significant difference in blood creatinine levels between pre-and post-operation in 8 cases (P0.05). Follow-up data were found in 8 cases of subtotal resection group and 224 cases of total resection group. There was a significant difference in the incidence of hypocalcemia between the subtotal resection group and the total cut 卤implant group (p0.0001). There were 4 (50.00%) cases of persistent hyperparathyroidism and 3 (37.50%) cases of recurrence in subtotal resection group and 36 (16.07%) cases of persistent hyperparathyroidism and 51 (22.77%) cases of persistent hyperparathyroidism in total resection group. The total persistent hyperparathyroidism rate and recurrence rate were 17.24% and 23.28% respectively. There was a significant difference in the incidence of persistent hyperparathyroidism between the two groups (P = 0.032), while there was no significant difference in recurrence rate between the two groups (P = 0.393). Conclusion Parathyroidectomy can effectively treat secondary hyperparathyroidism and improve calcium and phosphorus metabolism disorder in patients with end-stage renal disease. The rate of postoperative persistent hyperparathyroidism was higher and the incidence of persistent hypoparathyroidism was lower. Hypocalcemia is the most common complication after operation and should be closely monitored and followed up. Parathyroid resection had little effect on renal function in patients with renal transplantation and in patients with CKD without replacement therapy.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R653

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