目的:肾性甲状旁腺功能亢进(RHPT)患者的甲状旁腺全切除术(tPTX)旨在完全切除所有功能亢进的甲状旁腺组织。每当甲状旁腺切除术被称为“完全”时,“预计术后第一周内无法检测到术后甲状旁腺激素(PTH)水平。这项研究的目的是评估使用根治性外科手术在技术上是否可以进行tPTX。
方法:在109例连续RHPT患者中(血液透析:n=50;肾移植后n=59),去除所有可见的甲状旁腺组织,双侧胸腺切除术,双侧中央颈夹层(VI级),并立即进行自体移植(AT)。在术后第一周测量完整的PTH(iPTH)水平。当iPTH降至10pg/ml以下时,PTX被归类为“总”,10至65pg/ml之间的“小计”,和“不足”,其中水平保持在65pg/ml以上。
结果:根据术后PTH值,109例患者中有80例(73.4%)实现了tPTX(血液透析n=27,肾功能正常:n=43,限制性:n=10)。PTX在25例患者中“小计”(22.9%),19关于血液透析,2正常,4例肾移植功能受限。4名患者(3.7%)的PTX不足;他们都在进行血液透析。在肾移植患者中未观察到PTX不足。术后暂时性喉神经发病率为1.8%(无永久性麻痹)。
结论:尽管在RHPT患者中应用了一个非常激进的概念,PTX的“总数”仅为73.4%。91.7%的人避免了疾病的持续性,并记录了低发病率。总之,似乎很难从颈部切除所有甲状旁腺组织,这在选择外科手术时必须考虑。
OBJECTIVE: Total parathyroidectomy (tPTX) in patients with renal hyperparathyroidism (RHPT) aims at the complete removal of all hyperfunctioning parathyroid tissue. Whenever parathyroidectomy is termed \"total,\" undetectable postoperative parathyroid hormone (PTH) levels within the first postoperative week are expected. The aim of this study was to evaluate if tPTX is technically possible using a radical surgical procedure.
METHODS: In 109 consecutive patients with RHPT (on hemodialysis: n = 50; after kidney grafting n = 59), removal of all visible parathyroid tissue, bilateral thymectomy, bilateral central neck dissection (level VI), and immediate autotransplantation (AT) was performed. Intact PTH (iPTH) levels were measured in the first postoperative week. PTX was classified \"total\" when iPTH dropped below 10 pg/ml, \"subtotal\" between 10 and 65 pg/ml, and \"insufficient\" where levels stayed above 65 pg/ml.
RESULTS: According to the postoperative PTH value, tPTX was achieved in 80 of 109 (73.4%) patients (hemodialysis n = 27, normal kidney function: n = 43, restricted: n = 10). PTX was \"subtotal\" in 25 patients (22.9%), 19 on hemodialysis, 2 had normal, and 4 had restricted kidney graft function. PTX turned out to be insufficient in four patients (3.7%); all of them were on hemodialysis. Insufficient PTX was not observed in kidney-grafted patients. Postoperative temporary laryngeal nerve morbidity was 1.8% (no permanent paresis).
CONCLUSIONS: Although applying a very radical concept in patients with RHPT, PTX was \"total\" in only 73.4%. Persistence of disease was avoided in 91.7%, and low morbidity was documented. In conclusion, it seems difficult to remove all parathyroid tissue from the neck which has to be considered when choosing the surgical procedure.