Moore F D, Mannting F, Tanasijevic M
Department of Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
Ann Surg. 1999 Sep;230(3):382-8; discussion 388-91. doi: 10.1097/00000658-199909000-00011.
To evaluate a method of limited parathyroid exploration for primary hyperparathyroidism.
Although preoperative localization of parathyroid adenomas has become sensitive enough for clinical practice, it has not achieved success as the basis for limited parathyroid exploration, because multiglandular disease is routinely underdiagnosed. The rapid intraoperative parathyroid hormone assay is sensitive for multiglandular disease, because hormone levels will not fall within 10 minutes of adenoma removal if additional abnormal tissue is present. A combination technique in which the exploration is limited according to the localization studies and the success is confirmed with the parathyroid hormone assay has promise for producing a high rate of curative limited parathyroid explorations.
Forty-eight consecutive patients with primary hyperparathyroidism and indications for surgery underwent preoperative localization. After tests, 45 patients underwent unilateral parathyroid exploration and confirmation of the success of unilateral exploration during surgery using the rapid parathyroid hormone assay. The intraoperative management of these patients and their follow-up to 3 months was recorded.
Thirty-two of the 48 patients (67%) had successful unilateral exploration as gauged by a marked drop in parathyroid hormone levels during the procedure and by 3-month clinical follow-up. Of the 16 patients who ultimately underwent bilateral exploration, 7 had parathyroid hormone levels that did not fall after adenoma removal. Of these seven, five were found to have a second adenoma and two had slow metabolism of hormone with no additional abnormal tissue found. In 5 of the 16 patients, bilateral exploration was performed for erroneous localization. Four additional patients underwent bilateral exploration for improved exposure or negative results on localization tests.
These results show that unilateral parathyroid exploration is limited by the intrinsic 15% rate of multiglandular primary hyperparathyroidism, combined with the imperfections of preoperative localizing techniques. Although an 85% rate of unilateral exploration can theoretically be obtained for unselected cases, the other vagaries of the technique make a 70% rate a more reasonable expectation.
评估一种用于原发性甲状旁腺功能亢进症的有限甲状旁腺探查方法。
尽管甲状旁腺腺瘤的术前定位已足够敏感，可应用于临床实践，但作为有限甲状旁腺探查的基础，其仍未取得成功，因为多腺体疾病常被漏诊。术中快速甲状旁腺激素测定对多腺体疾病敏感，因为如果存在额外的异常组织，腺瘤切除后10分钟内激素水平不会下降。一种结合技术，即根据定位研究限制探查范围，并通过甲状旁腺激素测定确认成功，有望实现高治愈率的有限甲状旁腺探查。
48例连续的原发性甲状旁腺功能亢进症且有手术指征的患者接受了术前定位。检查后，45例患者接受了单侧甲状旁腺探查，并在手术中使用快速甲状旁腺激素测定法确认单侧探查的成功。记录这些患者的术中处理情况及其至3个月的随访情况。
48例患者中有32例（67%）通过术中甲状旁腺激素水平显著下降及3个月的临床随访判定单侧探查成功。在最终接受双侧探查的16例患者中，7例在腺瘤切除后甲状旁腺激素水平未下降。在这7例患者中，5例发现有第二个腺瘤，2例激素代谢缓慢，未发现额外的异常组织。在16例患者中的5例，因定位错误而进行了双侧探查。另外4例患者因改善暴露或定位检查结果阴性而接受了双侧探查。
这些结果表明，单侧甲状旁腺探查受到多腺体原发性甲状旁腺功能亢进症固有的15%发生率以及术前定位技术不完善的限制。尽管对于未经选择的病例，理论上单侧探查成功率可达85%，但该技术的其他不确定因素使70%的成功率成为更合理的预期。
