Wahl R A, Hentschel F, Vorländer C, Schabram J
Chirurgische Klinik, Bürgerhospital Frankfurt, Frankfurt am Main, Germany.
Langenbecks Arch Surg. 2000 Dec;385(8):515-20. doi: 10.1007/s004230000171.
From 1986 to 1998, 190 patients presented for first-time operations for sporadic, non-malignant, non-multiple endocrine neplasia primary hyperparathyroidism. Of these patients, 54% had been classified as "asymptomatic", 41% as symptomatic and 5% as acute. One hundred and thirty-five patients (71%) were referred to us for parathyroid surgery. Fifty-five patients (29%) were referred for thyroid surgery with hitherto unknown hyperparathyroidism. This corresponds to a prevalence of primary hyperparathyroidism of 1% in patients referred for thyroid surgery (5450 patients during the same period of time).
PATIENTS/METHODS: Patients referred for parathyroid surgery (group I, n=135) were compared with patients originally referred for thyroid surgery (group II, n=55). Group II was divided into group IIa: hyperparathyroidism preoperatively biochemically evident (n=26), and group IIb: borderline biochemistry, parathyroid enlargement evident at the operation (n=29). The groups were compared regarding clinical manifestations, serum calcium and parathyroid hormone, pathologic-anatomical substrates, operative complications and outcome.
Renal, osseous and gastrointestinal manifestations were more frequent in group I than in groups IIa and IIb (P<0.05). However, cardiovascular and neuromuscular symptoms were present in groups IIa and IIb in more than one-third of patients. Patients from group IIb were younger (49+/-12 years) than patients from groups IIa (60+/-13 years) and I (60+/-14 years). Adenomas were found in 85% of group I patients, in 45% of group IIa patients and in 21% of group IIb patients (P<0.01). In all other cases, hyperplasia was confirmed histologically. Serum calcium was higher in group I (3.0+/-0.42 mmol/l) than in groups IIa (2.63+/-0.16 mmol/l) and IIb (2.46+/-0.14 mmol/l) (P<0.01). Serum PTH was higher in group I (median 11.0 pmol/l) than in groups IIa and IIb (median 7.1 and 6.4 pmol/l, respectively) (P<0.05). Postoperatively, hypercalcemia persisted in two patients (1.1%) belonging to group I, with mediastinal adenomas. Serum calcium at discharge showed no differences between groups (group I: 2.22+/-0.16; group IIa: 2.22+/-0.15; group IIb: 2.20+/-0.11 mmol/l). Recurrent laryngeal nerve paralysis occurred early (4.2% of "nerves at risk") and remained permanent (0.8% of "nerves at risk") without significant differences between groups.
Diagnostic efforts regarding parathyroid function should be mandatory before thyroid operations. "Asymptomatic" patients frequently (more than 30%) present with cardiovascular and neuromuscular, "unspecific" symptoms. Simultaneous parathyroid exploration is obvious in cases with biochemically evident primary hyperparathyroidism, but should also be performed in patients with borderline biochemistry.
1986年至1998年，190例患者因散发性、非恶性、非多发性内分泌腺瘤病原发性甲状旁腺功能亢进首次接受手术。在这些患者中，54%被归类为“无症状”，41%为有症状，5%为急性。135例患者（71%）被转诊至我们这里接受甲状旁腺手术。55例患者（29%）因此前未知的甲状旁腺功能亢进被转诊接受甲状腺手术。这相当于在接受甲状腺手术的患者中（同期5450例患者）原发性甲状旁腺功能亢进的患病率为1%。
患者/方法：将转诊接受甲状旁腺手术的患者（I组，n = 135）与最初转诊接受甲状腺手术的患者（II组，n = 55）进行比较。II组又分为IIa组：术前生化检查明显提示甲状旁腺功能亢进（n = 26），以及IIb组：生化指标临界，手术中可见甲状旁腺肿大（n = 29）。比较各组的临床表现、血清钙和甲状旁腺激素、病理解剖学基础、手术并发症及结局。
I组的肾脏、骨骼和胃肠道表现比IIa组和IIb组更常见（P < 0.05）。然而，IIa组和IIb组超过三分之一的患者出现心血管和神经肌肉症状。IIb组患者（49±12岁）比IIa组患者（60±13岁）和I组患者（60±14岁）更年轻。I组85%的患者发现腺瘤，IIa组为45%，IIb组为21%（P < 0.01）。在所有其他病例中，经组织学证实为增生。I组的血清钙（3.0±0.42 mmol/L）高于IIa组（2.63±0.16 mmol/L）和IIb组（2.46±0.14 mmol/L）（P < 0.01）。I组的血清甲状旁腺激素（中位数11.0 pmol/L）高于IIa组和IIb组（分别为中位数7.1和6.4 pmol/L）（P < 0.05）。术后，I组有2例（1.1%）患有纵隔腺瘤的患者持续性高钙血症。出院时血清钙在各组之间无差异（I组：2.22±0.16；IIa组：2.22±0.15；IIb组：2.20±0.11 mmol/L）。喉返神经麻痹早期发生率（有风险神经的4.2%）且为永久性（有风险神经的0.8%），各组之间无显著差异。
甲状腺手术前应强制进行甲状旁腺功能的诊断性检查。“无症状”患者经常（超过30%）出现心血管和神经肌肉方面的“非特异性”症状。对于生化检查明显提示原发性甲状旁腺功能亢进的病例，同时进行甲状旁腺探查是显而易见的，但对于生化指标临界的患者也应进行探查。
