McHenry C R, Pollard A, Walfish P G, Rosen I B
Department of Surgery, Mount Sinai Hospital, University of Toronto, Ontario, Canada.
Surgery. 1990 Oct;108(4):801-7; discussion 807-8.
To investigate the potential use of intraoperative intact parathormone measurements to predict curative parathyroidectomy, we measured ionized calcium (Cai) levels and parathormone levels in 33 patients with hyperparathyroidism who underwent exploratory bilateral neck surgery. Nineteen patients each had a solitary adenoma, 13 patients had hyperplasia, and one patient had four normal parathyroid glands. These results were compared to the results for 37 patients who underwent either thyroid lobectomy (TL) (n = 10) or near-total thyroidectomy (NTT) (n = 27) and of 14 control patients who underwent miscellaneous operations. Parathormone decline after curative parathyroidectomy was 86.4 +/- 1.2% (mean +/- SE), which was significantly greater than a decline of 25.7% +/- 9.8% in three patients with persistent postoperative hyperparathyroidism (p less than 0.01). Declines were 38.5% +/- 8.7% after TL (p less than 0.01), 52.2% +/- 5.9% after NTT (p less than 0.01), and 8.3% +/- 4.3% (p less than 0.01), in the control patients. An intraoperative Cai decline of 4.0% +/- 0.6% after curative parathyroidectomy did not differ significantly from the results after TL, NTT, or miscellaneous operations in the control patients. Patients with persistent postoperative hyperparathyroidism had the greatest decline in Cai levels (7.1% +/- 2.3%; p less than 0.05). From these data we conclude that (1) a decline in parathormone level of 70% or more 20 minutes after parathyroidectomy is predictive of cure, (2) thyroidectomy, even unilaterally, produces a significant decline in parathormone level that affects interpretation of intraoperative parathormone level changes, (3) Cai level because of its slow decline is not useful in predicting effective parathyroidectomy, and (4) measurement of intraoperative parathormone level changes should not be used as a substitute for exploratory bilateral neck surgery.
为了研究术中完整甲状旁腺激素测量用于预测甲状旁腺切除疗效的潜在价值，我们对33例接受双侧颈部探查手术的甲状旁腺功能亢进患者测量了离子钙（Cai）水平和甲状旁腺激素水平。19例患者各有一个孤立性腺瘤，13例患者有增生，1例患者有4个正常甲状旁腺。将这些结果与37例接受甲状腺叶切除术（TL）（n = 10）或近全甲状腺切除术（NTT）（n = 27）的患者以及14例接受其他手术的对照患者的结果进行比较。治愈性甲状旁腺切除术后甲状旁腺激素下降86.4±1.2%（平均值±标准误），这显著大于3例术后持续性甲状旁腺功能亢进患者25.7%±9.8%的下降幅度（p<0.01）。TL术后下降38.5%±8.7%（p<0.01），NTT术后下降52.2%±5.9%（p<0.01），对照患者下降8.3%±4.3%（p<0.01）。治愈性甲状旁腺切除术后术中Cai下降4.0%±0.6%，与TL、NTT或对照患者的其他手术后结果无显著差异。术后持续性甲状旁腺功能亢进患者的Cai水平下降最大（7.1%±2.3%；p<0.05）。根据这些数据，我们得出结论：（1）甲状旁腺切除术后20分钟甲状旁腺激素水平下降70%或更多可预测治愈；（2）甲状腺切除术，即使是单侧手术，也会使甲状旁腺激素水平显著下降，影响术中甲状旁腺激素水平变化的解读；（3）由于Cai水平下降缓慢，其对预测有效的甲状旁腺切除术无用；（4）术中甲状旁腺激素水平变化的测量不应替代双侧颈部探查手术。
