From the Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, WI.
Ann Surg. 2014 Mar;259(3):563-8. doi: 10.1097/SLA.0000000000000207.
The purpose of this study was to determine whether the operative approach independently influenced recurrence and to identify perioperative predictors of recurrence.
Intraoperative parathyroid hormone (IoPTH) monitoring has enabled surgeons to perform minimally invasive parathyroidectomy (MIP). Yet, the long-term durability of this approach has recently been questioned.
A retrospective review was performed, and cases of initial neck surgery for nonfamilial primary hyperparathyroidism were selected for analysis. Cases were classified as either open parathyroidectomy (OP) when both sides of the neck were explored or MIP when only one side was explored. Kaplan-Meier estimates were plotted for disease-free survival, and a Cox proportional hazards model was developed to evaluate factors associated with recurrence for both the entire cohort and the MIP subset. Further comparisons were made between those who recurred and those who did not recur.
In the past 10-year period, 1368 parathyroid operations for primary hyperparathyroidism were performed at our institution. A total of 1006 were MIP whereas 380 were OP. There were no differences in recurrence between the MIP and OP groups (2.5% vs 2.1%; P = 0.68), and the operative approach (MIP vs OP) did not independently predict recurrent disease in our multivariate analysis. The percentage decrease in IoPTH was protective against recurrence for both the entire cohort (hazard ratio = 0.96; 95% confidence interval = 0.93-0.99; P = 0.03) and the MIP subset. A higher postoperative PTH also independently predicted disease recurrence.
Operative approach does not independently predict recurrent hyperparathyroidism. The percentage decrease in IoPTH is one of many adjuncts the surgeon can use to determine which patients are best served by bilateral exploration whereas the postoperative PTH can guide follow-up after parathyroidectomy.
本研究旨在确定手术方式是否独立影响复发，并确定与复发相关的围手术期预测因素。
术中甲状旁腺激素（IoPTH）监测使外科医生能够进行微创甲状旁腺切除术（MIP）。然而，这种方法的长期耐久性最近受到了质疑。
对初始颈部手术治疗非家族性原发性甲状旁腺功能亢进症的病例进行回顾性分析。病例分为开放甲状旁腺切除术（OP），即双侧颈部探查，或微创甲状旁腺切除术（MIP），即单侧颈部探查。绘制无病生存的 Kaplan-Meier 估计，并建立 Cox 比例风险模型，以评估整个队列和 MIP 亚组中与复发相关的因素。对复发组和未复发组进行进一步比较。
在过去的 10 年中，我院共进行了 1368 例原发性甲状旁腺功能亢进症的甲状旁腺手术。其中 1006 例为 MIP，380 例为 OP。MIP 组和 OP 组之间的复发率无差异（2.5%比 2.1%；P=0.68），且在多变量分析中，手术方式（MIP 与 OP）并不能独立预测疾病复发。整个队列（危险比=0.96；95%置信区间=0.93-0.99；P=0.03）和 MIP 亚组的 IoPTH 百分比降低均对复发具有保护作用。术后甲状旁腺素水平升高也独立预测疾病复发。
手术方式不能独立预测甲状旁腺功能亢进症的复发。IoPTH 的百分比降低是外科医生可以用来确定双侧探查更适合哪些患者的众多辅助手段之一，而术后甲状旁腺素水平可以指导甲状旁腺切除术后的随访。
