Siperstein Allan, Berber Eren, Mackey Richard, Alghoul Mohammed, Wagner Kristin, Milas Mira
Department of General Surgery, the Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
Surgery. 2004 Oct;136(4):872-80. doi: 10.1016/j.surg.2004.06.024.
The aim of this study was to determine the ability of localizing studies and rapid intraoperative parathyroid hormone (PTH) to predict the success of a limited approach in patients who then underwent bilateral exploration.
Preoperative sestamibi-iodine subtraction scan and neck ultrasonography (US) were used to direct a focal (1-gland) and unilateral (1-sided) parathyroid exploration by using rapid intraoperative PTH determinations in 350 patients with sporadic primary hyperparathyroidism. Regardless of the findings, the contralateral side was then explored.
A single gland was predicted by sestamibi in 290 patients (83%), US in 298 patients (85%), and concordance of both in 205 patients (59%). Unilateral parathyroid exploration, directed by these studies, would correctly identify single-gland disease in only 68%, 74%, and 79%, respectively. The addition of intraoperative PTH would increase the success rate to 73%, 77%, and 82%, respectively. The finding of 2 normal or 2 abnormal glands on 1 side would force bilateral exploration, and additional unsuspected pathology was found in 13%, 13%, and 9%, respectively. This failure rate would increase to 21%, 18%, and 15%, respectively, if the analysis assumed a focal rather than unilateral approach to the initial exploration.
Even in patients with concordant sestamibi and US scans, and an appropriate PTH drop, additional abnormal parathyroid glands were found on complete exploration in 15%. A bilateral approach offers the best opportunity for the long-term cure of primary hyperparathyroidism.
本研究的目的是确定定位检查和术中快速甲状旁腺激素（PTH）检测对预测随后接受双侧探查的患者采用有限手术方法成功与否的能力。
对350例散发性原发性甲状旁腺功能亢进患者，术前使用锝-99m甲氧基异丁基异腈-碘减影扫描和颈部超声（US），并通过术中快速PTH检测指导进行局灶性（单腺体）和单侧（单侧）甲状旁腺探查。无论检查结果如何，随后均对另一侧进行探查。
锝-99m甲氧基异丁基异腈预测单腺体病变的有290例患者（83%），超声预测的有298例患者（85%），两者结果一致的有205例患者（59%）。由这些检查指导的单侧甲状旁腺探查分别仅能正确识别单腺体疾病的比例为68%、74%和79%。术中PTH检测的加入可使成功率分别提高到73%、77%和82%。一侧发现2个正常或2个异常腺体将促使进行双侧探查，分别有13%、13%和9%的患者发现了额外的意外病变。如果分析假设初始探查采用局灶性而非单侧方法，该失败率将分别增至21%、18%和15%。
即使在锝-99m甲氧基异丁基异腈和超声扫描结果一致且PTH下降适当的患者中，完全探查时仍有15%的患者发现了额外的异常甲状旁腺腺体。双侧手术方法为原发性甲状旁腺功能亢进的长期治愈提供了最佳机会。
