McCoy Kelly L, Chen Naomi H, Armstrong Michaele J, Howell Gina M, Stang Michael T, Yip Linwah, Carty Sally E
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, Pittsburgh, PA, 15213, USA,
World J Surg. 2014 Jun;38(6):1274-81. doi: 10.1007/s00268-014-2450-1.
Over decades, improvements in presymptomatic screening and awareness of surgical benefits have changed the presentation and management of primary hyperparathyroidism (PHPT). Unrecognized multiglandular disease (MGD) remains a major cause of operative failure. We hypothesized that during parathyroid surgery the initial finding of a mildly enlarged gland is now frequent and predicts both MGD and failure.
A prospective database was queried to examine the outcomes of initial exploration for sporadic PHPT using intraoperative PTH monitoring (IOPTH) over 15 years. All patients had follow-up ≥6 months (mean = 1.8 years). Cure was defined by normocalcemia at 6 months and microadenoma by resected weight of <200 mg.
Of the 1,150 patients, 98.9 % were cured and 15 % had MGD. The highest preoperative calcium level decreased over time (p < 0.001) and varied directly with adenoma weight (p < 0.001). Over time, single adenoma weight dropped by half (p = 0.002) and microadenoma was increasingly common (p < 0.01). MGD risk varied inversely with weight of first resected abnormal gland. Microadenoma required bilateral exploration more often than macroadenoma (48 vs. 18 %, p < 0.01). When at exploration the first resected gland was <200 mg, the rates of MGD (40 vs. 11 %, p = 0.001), inadequate initial IOPTH drop (67 vs. 79 %, p = 0.002), operative failure (6.6 vs. 0.7 %, p < 0.001), and long-term recurrence (1.6 vs. 0.3 %, p = 0.007) were higher.
Single parathyroid adenomas are smaller than in the past and require more complex pre- and intraoperative management. During exploration for sporadic PHPT, a first abnormal gland <200 mg should heighten suspicion of MGD and presages a tenfold higher failure rate.
几十年来，症状前筛查的改善以及对手术益处的认识改变了原发性甲状旁腺功能亢进症（PHPT）的表现和管理。未被识别的多腺体疾病（MGD）仍然是手术失败的主要原因。我们假设在甲状旁腺手术期间，最初发现的轻度增大的腺体现在很常见，并且可预测MGD和手术失败。
查询一个前瞻性数据库，以检查15年间使用术中甲状旁腺激素监测（IOPTH）对散发性PHPT进行初次探查的结果。所有患者均有≥6个月的随访（平均 = 1.8年）。治愈定义为6个月时血钙正常，微腺瘤定义为切除重量<200 mg。
在1150例患者中，98.9% 治愈，15% 患有MGD。术前最高血钙水平随时间下降（p < 0.001），并与腺瘤重量直接相关（p < 0.001）。随着时间的推移，单个腺瘤重量下降了一半（p = 0.002），微腺瘤越来越常见（p < 0.01）。MGD风险与首次切除的异常腺体重量呈负相关。微腺瘤比大腺瘤更常需要双侧探查（48% 对18%，p < 0.01）。当探查时首次切除的腺体<200 mg时，MGD发生率（40% 对11%，p = 0.001）、初始IOPTH下降不足率（67% 对79%，p = 0.002）、手术失败率（6.6% 对0.7%，p < 0.001）和长期复发率（1.6% 对0.3%，p = 0.007）更高。
单个甲状旁腺腺瘤比过去更小，需要更复杂的术前和术中管理。在探查散发性PHPT时，首次发现的异常腺体<200 mg应增加对MGD的怀疑，并预示失败率高出十倍。
