Westerdahl Johan, Bergenfelz Anders
Department of Surgery, Lund University Hospital, Lund, Sweden.
Ann Surg. 2007 Dec;246(6):976-80; discussion 980-1. doi: 10.1097/SLA.0b013e31815c3ffd.
To compare long-term patient outcome in a prospective randomized controlled trial between unilateral and bilateral neck exploration for primary hyperparathyroidism (pHPT).
Minimal invasive and/or focused parathyroidectomy has challenged the traditional bilateral neck exploration for pHPT. Between 1997 and 2001, we conducted the first unselected randomized controlled trial of unilateral versus bilateral neck exploration for pHPT. The results showed that unilateral exploration is a surgical strategy with distinct advantages in the early postoperative period. However, concerns have been raised that limited parathyroid exploration could increase the risk for recurrent pHPT during long-term follow-up.
Ninety-one patients with the diagnosis of pHPT were randomized to unilateral or bilateral neck exploration. Preoperative scintigraphy and intraoperative parathyroid hormone measurement guided the unilateral exploration. Gross morphology and frozen section determined the extent of parathyroid tissue resection in the bilateral group. Follow-up was performed after 6 weeks, 1 year, and 5 years postoperatively.
Seventy-one patients were available for 5-year follow-up. There were no differences in serum ionized calcium and parathyroid hormone, respectively, between patients in the unilateral and bilateral group. Overall 6 patients have been found to have persistent (n = 3) or recurrent (n = 3) pHPT; 4 patients in the unilateral group (3 of these 4 patients were bilaterally explored) and 2 patients in the bilateral group. Three of 6 failures were unexpectedly found to have multiple endocrine neoplasia mutations. One patient with solitary adenoma in the bilateral group still required vitamin D substitution 5 years after surgery.
Unilateral neck exploration with intraoperative parathyroid hormone assessment provides the same long-term results as bilateral neck exploration, and is thus a valid strategy for the surgical treatment of pHPT.
在一项前瞻性随机对照试验中，比较单侧与双侧颈部探查术治疗原发性甲状旁腺功能亢进症（pHPT）的长期患者预后。
微创和/或聚焦甲状旁腺切除术对传统的双侧颈部探查术治疗pHPT提出了挑战。1997年至2001年期间，我们开展了第一项关于单侧与双侧颈部探查术治疗pHPT的非选择性随机对照试验。结果显示，单侧探查术在术后早期具有明显优势。然而，有人担心有限的甲状旁腺探查可能会增加长期随访期间复发性pHPT的风险。
91例诊断为pHPT的患者被随机分为单侧或双侧颈部探查术组。术前闪烁扫描和术中甲状旁腺激素测量指导单侧探查术。大体形态和冰冻切片确定双侧组甲状旁腺组织切除范围。术后6周、1年和5年进行随访。
71例患者可进行5年随访。单侧组和双侧组患者的血清离子钙和甲状旁腺激素水平分别无差异。总体而言，已发现6例患者患有持续性（n = 3）或复发性（n = 3）pHPT；单侧组4例患者（这4例患者中有3例进行了双侧探查），双侧组2例患者。6例治疗失败患者中有3例意外发现有多发性内分泌肿瘤基因突变。双侧组1例孤立性腺瘤患者术后5年仍需要维生素D替代治疗。
术中进行甲状旁腺激素评估的单侧颈部探查术与双侧颈部探查术具有相同的长期效果，因此是治疗pHPT的有效手术策略。
