Carneiro-Pla Denise M, Solorzano Carmen C, Irvin George L
Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA.
J Am Coll Surg. 2006 May;202(5):715-22. doi: 10.1016/j.jamcollsurg.2006.02.003.
After excision of an abnormal gland, the dynamics of intraoperative parathyroid hormone (PTH) levels signal whether or not more hypersecreting tissue is present. This quantitative assurance of operative success has led to targeted exploration of the hyperfunctioning gland(s). Some have questioned the need for intraoperative PTH monitoring (IPM) in the presence of positive nuclear scanning. The purpose of this study was to examine the accuracy of nuclear scans in correctly localizing and guiding the complete excision of all abnormal gland(s) in patients with sporadic primary hyperparathyroidism (SPHPT) and to demonstrate how IPM changed the operative management in these patients.
Five hundred nineteen consecutive patients with sporadic primary hyperparathyroidism had technetium 99-m-sestamibi scans (MIBI) as localization studies obtained before undergoing parathyroidectomy guided exclusively by IPM. All patients were either followed for more than 6 months, or their procedures were identified as operative failures. MIBI reports were correlated with operative findings, hormone dynamics, and postoperative outcomes.
Operative success was achieved in 506 of 519 patients (97%). MIBI correctly localized all involved glands in 411 patients (80%). Among the 105 patients (20%) with incorrect or negative scans, IPM changed the operative management in 86 of 105 (82%) by pointing out incomplete resection in patients with a single MIBI incorrect focus (21 of 28) or unrecognized multiglandular disease by scan (13 of 15); avoiding unnecessary exploration in patients with additional incorrect foci (20 of 21); and guiding the surgeon to successful excision or unilateral neck exploration in patients with negative MIBI (32 of 41).
MIBI as a single adjunct missed 87% of patients with multiglandular disease. Including patients with negative (8%) and incorrect (12%) MIBI, IPM changed the operative management in 17% of patients and led to operative success in 97%. We suggest that IPM should be used to guide parathyroid excision in every patient with sporadic primary hyperparathyroidism.
切除异常腺体后，术中甲状旁腺激素（PTH）水平的动态变化可提示是否存在更多分泌过多的组织。手术成功的这种定量保证促使人们对功能亢进的腺体进行有针对性的探查。一些人质疑在核扫描呈阳性的情况下进行术中PTH监测（IPM）的必要性。本研究的目的是检验核扫描在散发性原发性甲状旁腺功能亢进症（SPHPT）患者中正确定位并指导完全切除所有异常腺体的准确性，并证明IPM如何改变这些患者的手术管理。
519例连续的散发性原发性甲状旁腺功能亢进症患者在仅由IPM指导下接受甲状旁腺切除术之前，进行了锝99m-甲氧基异丁基异腈扫描（MIBI）作为定位研究。所有患者均随访超过6个月，或其手术被确定为手术失败。MIBI报告与手术结果、激素动态变化及术后结局相关。
519例患者中有506例（97%）手术成功。MIBI在411例患者（80%）中正确定位了所有受累腺体。在105例（20%）扫描结果不正确或为阴性的患者中，IPM改变了105例中的86例（82%）的手术管理，具体表现为：指出单个MIBI定位错误的患者存在切除不完全的情况（28例中的21例），或扫描未发现的多腺体疾病（15例中的13例）；避免对有额外定位错误的患者进行不必要的探查（21例中的20例）；并指导外科医生对MIBI阴性的患者成功切除或进行单侧颈部探查（41例中的32例）。
MIBI作为单一辅助手段遗漏了87%的多腺体疾病患者。包括MIBI阴性（8%）和不正确（12%）的患者，IPM改变了17%患者的手术管理，并使97%的患者手术成功。我们建议，对于每例散发性原发性甲状旁腺功能亢进症患者，均应使用IPM来指导甲状旁腺切除。
