Warren Alpert School of Medicine, Brown University, Rhode Island Hospital, 154 Waterman Street, Providence, RI 02906, USA.
World J Surg. 2010 Jun;34(6):1318-24. doi: 10.1007/s00268-010-0557-6.
Elevation of parathyroid hormone (PTH) levels is commonly seen in patients with primary hyperparathyroidism (PHPT) who have undergone parathyroidectomy. This study evaluates differences in 2-week postoperative PTH levels in patients having focused-approach surgery versus four-gland exploration.
Over 6 years, patients at Rhode Island Hospital (RIH) and the Cleveland Clinic (CCF) who had PHPT and underwent localization studies suggestive of single adenoma were analyzed. At RIH patients underwent focused-approach surgery, and at CCF routine four-gland exploration was performed. Postoperative calcium supplementation was routine at RIH and selective at CCF.
There were 308 patients at RIH and 370 at CCF. They were similar in age (59.2 +/- 13.0 years at RIH and 60.4 +/- 12.9 years at CCF), and sex (76.9 and 80.0% female at RIH and CCF, respectively). The mean preoperative serum calcium measured 10.9 +/- 0.7 mg/dl at RIH and 11.1 +/- 0.7 mg/dl at CCF (P < 0.001). Preoperative PTH values were similar, measuring 143.8 +/- 104.8 pg/ml in the focused-approach group (RIH) and 157.6 +/- 150.3 pg/ml in the four-gland exploration group (CCF). Preoperative 25-hydroxyvitamin D (vitamin D-25) levels were 24.1 +/- 12.0 ng/ml at RIH and 27.4 +/- 10.6 ng/ml at CCF; and the prevalence of vitamin D-25 deficiency (level <20 ng/ml) was 43.9% at RIH and 27% at CCF (P = 0.017). The proportion of patients whose intraoperative PTH value dropped by >or=50% prior to completion of surgery was 95.0% at RIH and 95.5% at CCF. The total gland weight resected per patient was 942 mg at RIH versus 1,394 mg at CCF (P = 0.003). The 2-week postoperative serum PTH was >65 pg/ml in 18.8% at RIH and in 38.7% at CCF (P < 0.001). The 2-week postoperative serum calcium values dropped to 9.2 +/- 0.6 mg/dl at RIH and to 9.5 +/- 0.8 mg/dl at CCF (P < 0.001). The incidence of multigland disease was 5.8% at RIH and 21.9% at CCF (P <or= 0.001).
Among patients with PHPT who underwent a localizing study indicating unilateral disease, a significant proportion had eucalcemic PTH elevation 2 weeks after parathyroidectomy. The elevation was more frequent in the four-gland exploration group and correlated most strongly with greater adenoma mass.
甲状旁腺激素（PTH）水平升高在接受甲状旁腺切除术的原发性甲状旁腺功能亢进症（PHPT）患者中很常见。本研究评估了聚焦手术与四腺探查术后 2 周时 PTH 水平的差异。
在 6 年的时间里，对罗德岛医院（RIH）和克利夫兰诊所（CCF）的 PHPT 患者进行了分析，这些患者进行了定位研究，提示为单腺瘤。在 RIH 患者接受了聚焦手术，而在 CCF 则进行了常规的四腺探查术。RIH 常规进行术后补钙，而 CCF 则选择性补钙。
RIH 有 308 例患者，CCF 有 370 例患者。他们的年龄（RIH 为 59.2 +/- 13.0 岁，CCF 为 60.4 +/- 12.9 岁）和性别（RIH 和 CCF 分别为 76.9%和 80.0%的女性）相似。RIH 的术前血清钙平均值为 10.9 +/- 0.7 mg/dl，CCF 为 11.1 +/- 0.7 mg/dl（P < 0.001）。术前 PTH 值相似，聚焦手术组（RIH）为 143.8 +/- 104.8 pg/ml，四腺探查组（CCF）为 157.6 +/- 150.3 pg/ml。术前 25-羟维生素 D（维生素 D-25）水平分别为 24.1 +/- 12.0 ng/ml 在 RIH 和 27.4 +/- 10.6 ng/ml 在 CCF；维生素 D-25 缺乏（水平 <20 ng/ml）的发生率分别为 43.9%在 RIH 和 27%在 CCF（P = 0.017）。在完成手术前，术中 PTH 值下降>或=50%的患者比例在 RIH 为 95.0%，在 CCF 为 95.5%。每位患者切除的总腺体重量在 RIH 为 942 mg，而在 CCF 为 1,394 mg（P = 0.003）。RIH 术后 2 周时血清 PTH >65 pg/ml 的比例为 18.8%，CCF 为 38.7%（P < 0.001）。RIH 术后 2 周时血清钙值降至 9.2 +/- 0.6 mg/dl，CCF 降至 9.5 +/- 0.8 mg/dl（P < 0.001）。多腺体疾病的发生率在 RIH 为 5.8%，在 CCF 为 21.9%（P <or= 0.001）。
在接受定位研究提示单侧疾病的 PHPT 患者中，甲状旁腺切除术后 2 周时，相当一部分患者出现血钙正常的 PTH 升高。在四腺探查组中更为常见，且与更大的腺瘤质量相关性最强。
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