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目的甲状旁腺切除术(parathyroidectomy,PTX)是继发性甲状旁腺功能亢进患者(secondary hyperparathyroidism,SHPT)的有效治疗方式,然而由于甲状旁腺位置和数目异常的存在,部分患者术后SHPT仍持续存在。本研究探讨PTX患者术中及围手术期血清全段甲状旁腺激素(intact parathyroid hormone,iPTH)监测对手术效果精准诊断的意义。方法记录501例行甲状旁腺全切+自体前臂移植术(不伴胸腺切除)的慢性肾脏病患者的术中及围手术期血清iPTH值。术后一周内患者血清iPTH≤50 pg/ml为手术成功;若>50 pg/ml则在6月内进行随访,随访血清iPTH<300 pg/mL即为手术成功,否则为SHPT持续存在。结果 433例(86.4%)患者手术成功,49例(9.8%)患者SHPT持续存在,19例(3.8%)患者缺乏有效随访归为手术效果未知组。肝炎(n=204)与非肝炎(n=297)患者比较,基线血清iPTH水平及术中血清iPTH下降百分比无显著统计学差异(P>0.05)。受试者工作特征(receiver operating characteristic,ROC)曲线结果表明术后20分钟血清iPTH下降≥88.9%提示手术成功(曲线下面积0.909,敏感度78.6%,特异度88.5%)。术后4天血清iPTH≥147.4 pg/ml提示SHPT持续存在(曲线下面积0.998,敏感度100%,特异度99.5%)。结论甲状旁腺切除术中血清iPTH监测能提示甲状旁腺切除是否彻底,避免对患者不必要的探查,降低手术并发症的发生率。围手术期血清iPTH监测提示SHPT是否持续存在,对此类患者需密切随访、及时开始药物治疗或必要时再次手术。
Objective Parathyroidectomy (PTX) is an effective treatment for secondary hyperparathyroidism (SHPT). However, due to the presence of abnormal parathyroid gland location and number, some postoperative SHPT continue living. This study was aimed to investigate the significance of intact parathyroid hormone (iPTH) monitoring in patients with PTX during surgery and perioperative period in the precise diagnosis of surgical outcomes. Methods 501 cases of patients with chronic kidney disease undergoing total parathyroidectomy + autologous forearm transplantation (without thymectomy) were collected for intraoperative and perioperative serum iPTH. Patients with iPTH ≤50 pg / ml within a week after surgery were successfully operated; if> 50 pg / ml was followed up within 6 months, follow-up serum iPTH <300 pg / mL was successful, otherwise SHPT persisted. Results 433 patients (86.4%) had successful operation, and 49 patients (9.8%) had persistent SHPT. The lack of effective follow-up in 19 patients (3.8%) was classified as unknown effect. There were no significant differences in baseline serum iPTH levels and intraoperative serum iPTH percentage between hepatitis (n = 204) and non-hepatitis (n = 297) patients (p> 0.05). The receiver operating characteristic (ROC) curve showed that the serum iPTH decreased by 88.9% at 20 minutes after operation, which indicated the successful operation (area under the curve 0.909, sensitivity 78.6%, specificity 88.5%). Serum iPTH ≥147.4 pg / ml at 4 days postoperative suggests that SHPT persisted (area under the curve 0.998, sensitivity 100%, specificity 99.5%). Conclusions Serum iPTH monitoring during parathyroidectomy can indicate whether parathyroidectomy is complete or not, avoid unnecessary exploration of patients and reduce the incidence of surgical complications. Perioperative serum iPTH monitoring prompted the persistence of SHPT, for these patients need close follow-up, timely medication or reoperation if necessary.