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Analysis of Diagnosis and Treatment of Primary Hyperparathyroidism

目的　探讨原发性甲状旁腺功能亢进症(PHPT)的诊治经验。 方法　回顾性分析我院近15年间18例手术治疗的PHPT患者的临床资料。结果　初诊病例术前核素99Tcm-sestamibi扫描和B超检查阳性定位诊断率分别为100%（9/9）和88%（15/17）。18例均经手术治疗，其中1例为再手术病例。术后病理诊断甲状旁腺腺瘤13例，其中1例为双腺瘤； 甲状旁腺增生4例； 甲状旁腺腺癌1例。首次手术治愈率为88%（15/17）。2例甲状旁腺增生病例未治愈。再手术1例因损伤了单侧喉返神经致术后声音嘶哑。结论　术前核素99Tcm-sestamibi扫描和B超检查对制定手术方案有重要意义，大多数PHPT病例适合行单侧颈部探查术。甲状旁腺增生病例的手术治愈率低。

Effect of γ-detector guided total parathyroidectomy and auto transplantation in treatment of secondary hyperparathyroidism

Objective To explore the application value of intraoperative gamma detector in patients with chronic kidney disease secondary hyperparathyroidism (sHPT) undergoing total parathyroidectomy (tPTX)+auto transplantation (AT). Methods A retrospective analysis of the clinical data of 110 sHPT patients who received tPTX+AT at Northern Jiangsu Province People’s Hospital from July 2014 to June 2019 was performed. Among them, 80 patients underwent tPTX+AT guided by the gamma detector during the operation (observation group), 30 patients underwent tPTX+AT under routine exploration (control group). We compared the operation time, number of parathyroid glands removed, serum intact parathyroid hormone (iPTH) concentration, serum calcium and phosphorus levels, as well as the occurrence of postoperative complications and recurrence rate were compared between the two groups. Results The number of parathyroid glands removed of the control group was lower than that of the observation group [(3.87±0.35) per case vs. (4.01±0.11) per case, P<0.05], but the operation time of the control group was longer [(115±25) min vs. (75±27) min, P<0.05]. Postoperative iPTH, serum calcium and serum phosphorus levels were significantly reduced in all patients. After the operation, the symptoms of pruritus, bone pain, and muscle weakness were relieved or disappeared. There was no death, dysphagia, drinking water choking cough, and superior laryngeal nerve injury occurred. One patient in the observation group and one patient in the control group had hoarseness, and one patient in the control group had cervical incision bleeding; one patient in the observation group and four patients in the control group suffered short-term postoperative recurrence due to incomplete parathyroidectomy. There was no significant difference in the incidence of complications (χ2=2.413, P>0.05), but the short-term postoperative recurrence rate of the observation group was lower than that of the control group (χ2=7.342, P<0.05). Conclusion Gamma detector is helpful for rapid identification of typical hyperplasia and ectopic parathyroid glands during operation, and can improve the accuracy of tPTX , save operation time, and reduce the recurrence.

Diagnosis and Treatment of Asymptomatic Primary Hyperparathyroidism Duo to Parathyroid Adenoma（A Retrospective Analysis of 24 Cases）

目的　探讨甲状旁腺腺瘤所致无症状原发性甲状旁腺功能亢进症（PHPT）的诊断和治疗。方法　回顾性分析中国医科大学附属第一医院1990年1月至2013年4月期间收治的24例甲状旁腺腺瘤所致无症状PHPT患者的临床资料。结果　24例甲状旁腺腺瘤所致无症状PHPT患者中男9例，女15例；年龄（47.92±12.96）岁。均无骨关节疼痛、病理性骨折、泌尿系结石或胃肠道症状等典型PHPT的临床表现，均为体检和并存或误诊为甲状腺疾病时发现。24例患者术前血钙升高18例，正常6例；血磷降低7例，正常17例；16例术前行血甲状旁腺激素检测患者中11例升高，正常5例；22例患者术前测定血碱性磷酸酶升高9例，正常13例。血钙与甲状旁腺激素均正常者4例，其中1例为体检时超声发现甲状旁腺病变，3例为手术治疗甲状腺疾病术中探查发现。24例患者术前均行超声检查，15例行甲状旁腺ECT检查，14例行甲状旁腺增强CT检查，阳性率分别为66.67% （16/24）、93.33% （14/15）及78.57% （11/14）。15例术前定性定位检查获得明确诊断，5例定性或定位检查高度怀疑甲状旁腺病变，4例术前误诊为甲状腺病变。均行甲状旁腺腺瘤切除，其中甲状旁腺腺瘤位于左侧上位2例、左侧下位9例、右侧上位2例、右侧下位11例。肿瘤最大径为（2.22±0.88） cm。24例患者中13例合并甲状腺病变。本组患者术后有8例出现手足、口周麻木，给予静脉或口服补钙后缓解，其余患者均无自觉症状。术后血钙及甲状旁腺激素均有不同程度下降，术后2周均降至正常范围。结论　甲状旁腺腺瘤所致无症状PHPT临床症状不典型，血清钙和甲状旁腺激素同步升高即可诊断，具有手术指征的患者应积极手术治疗。

纵隔内异位甲状旁腺功能亢进症的诊治体会：附3例报道

目的分析纵隔内异位甲状旁腺功能亢进症2次手术的原因及防治策略。方法回顾性收集四川大学华西医院（简称“我院”）甲状腺外科2021年11月至2022年3月期间收治的三发性甲状旁腺功能亢进症患者的临床病理资料。结果共收集到3例患者即病例1~3，其中病例1和病例3为女性，病例2为男性，年龄分别为61、48及57岁。3例患者均因肾功能衰竭行维持性血液透析分别达13、10及9年。病例1和2初次均于外院经第1次行甲状旁腺切除+甲状旁腺自体移植术后甲状旁腺激素（parathyroid hormone，PTH）未持续下降而入我院治疗，发现纵隔内异位甲状旁腺，经评估后行机器人或胸腔镜下甲状旁腺瘤切除术，术后PTH显著下降，骨痛症状显著缓解。病例3初次因骨痛就诊于外院（具体不详）给予口服药物对症治疗后PTH仍持续偏高而入我院治疗，发现颈部及纵隔内异位甲状旁腺，经综合评估后行经颈甲状旁腺切除联合胸腔镜纵隔内甲状旁腺肿物切除，术后PTH下降显著，骨痛症状显著缓解。结论对于纵隔内异位甲状旁腺功能亢进症患者，术前联合多途径检查充分评估，选择合适的手术方式，若条件许可行微创治疗，必要时联合术中PTH检测，以减少再次手术风险。

围手术期多学科协作诊治流程在继发性甲状旁腺功能亢进症中的临床应用

目的总结多学科协作诊治（multidisciplinary team，MDT）模式运用于继发性甲状旁腺功能亢进症（secondary hyperparathyroidism，SHPT）的效果。方法回顾性收集 2017 年 3 月至 2019 年 5 月期间在成都市第三人民医院按照 MDT 流程完成手术的 45 例 SHPT 患者的临床资料。结果本组 45 例患者的手术均顺利，无术中死亡和围手术期死亡患者。手术时间 56～220 min、（125±40）min；术中出血量 2～30 mL、（12±7）mL；住院时间 7～12 d、（9.07±0.86）d；术前准备时间 2～5 d、（3.26±0.72）d；术后拔管时间 2～5 d、（3.20±0.69）d。与术前的 iPTH 水平相比，术后 1 h、术后 1 周和术后 1 个月的 iPTH 水平均降低（P<0.05）。患者术后的血钙和血磷水平均较术前降低（P<0.01），但手术前后的血钾水平比较差异无统计学意义（P=0.55）。术后 32 例患者的骨及关节疼痛症状均不同程度缓解，其中 3 例无法行走患者可以下地自行行走；9 例瘙痒患者的症状也有明显缓解；4 例不宁腿患者中有 3 例明显缓解；40 例乏力患者中有 15 例自述术后 1 周后乏力症状缓解，19 例自诉术后 1～2 个月一定程度缓解。术后 2 例出现重度低钙血症，1 例出现出血，1 例出现声音轻度嘶哑，6 例出现肺部感染，1 例出现脂肪液化，2 例出现 SHPT 复发。术后有 3 例患者于半年后失访；有 19 例患者于当地医院完成随访，随访时间为8 个月～2.5 年，中位数为 14.5 个月，未出现复发；其余患者于成都市第三人民医院随访 6 个月～2.5 年，中位数为 13.5个月，也未出现复发。结论MDT 的诊疗流程是保障围手术期安全的前提，该流程可以让内外科医生各司其职，紧密配合，更好地监测患者内环境，以减少术后并发症，降低手术风险，缩短术前准备时间，提高治疗效果，最大限度地保障患者安全。

全部甲状旁腺切除加胸锁乳突肌内自体移植术治疗继发性甲状旁腺功能亢进症（附 45 例报道）

目的 探讨全部甲状旁腺切除加胸锁乳突肌内自体移植术治疗继发性甲状旁腺功能亢进症（SHPT）的疗效及技巧。 方法 总结空军总医院普通外科 2008 年 1 月至 2016 年 5 月期间 45 例 SHPT 行全部甲状旁腺切除加胸锁乳突肌内自体移植术患者的临床资料和随访结果，对其手术前后血磷、血钙和全段甲状旁腺素（iPTH）水平以及手术并发症和远期疗效进行分析。 结果 45 例患者手术均顺利完成，平均手术时间 116 min。45 例患者共切除甲状旁腺 173 枚，其中 40 例患者各切除 4 枚甲状旁腺，3 例各切除 3 枚，2 例各切除 2 枚。术后无喉返神经损伤、出血等严重并发症发生。术后病理结果显示 173 枚甲状旁腺良性增生或腺瘤样增生，其中 1 例合并甲状旁腺癌。术后1 周、6 个月及 1 年血磷、血钙及 iPTH 水平均明显低于术前（P<0.05）。在术后 1～2 周，全部患者的骨痛、皮肤瘙痒等症状均明显好转，食欲改善。术后 1 年复发 1 例（2.22%），口服药物治疗后症状控制，未行手术治疗。 结论 全部甲状旁腺切除加胸锁乳突肌内自体移植术治疗 SHPT 在临床上是安全、有效的。

核素扫描为假阴性原发性甲状旁腺功能亢进症手术时机及治疗策略的把握

目的结合临床病例分析原发性甲状旁腺功能亢进症（PHPT）患者行 99锝m-甲氧基异丁基异腈（99Tcm-MIBI）SPECT/CT 核素扫描结果为假阴性的原因，为在临床工作中核素扫描结果为假阴性或与其他影像学定位结果不一致的 PHPT 患者提供把握手术时机及治疗策略的思路。方法回顾性分析吉林大学第一医院甲状腺外科收治的 4 例核素扫描结果为假阴性的 PHPT 患者的临床病理资料。结果PHPT 患者甲状旁腺病灶的大小、是否伴有出血、坏死、囊性变以及是否为恶性肿瘤伴发广泛转移都可导致 99Tcm-MIBI SPECT/CT 呈现假阴性结果。结论99Tcm-MIBI SPECT/CT 扫描结果不能作为 PHPT 是否行手术治疗的判定标准，在临床工作中当 99Tcm-MIBI SPECT/CT 结果呈现假阴性或与其他影像学定位结果不一致时，应结合患者实验室检查及其他影像学检查结果综合考虑，定位病灶，避免临床误诊，把握好手术时机以避免遗漏多发甲状旁腺病灶，减少不必要的双侧颈部探查，提高手术成功率。

The Analysis of Diagnosis and Managements for Primary Hyperparathyroidism in 73 Cases

Objective　To summary the experience in diagnosis and managements for primary hyperparathyroidism（PHPT）. Methods　The clinical data of 73 patients with PHPT who underwent parathyroidectomy in our hospital from Jan. 2003 to Dec. 2010 were analyzed retrospectively. Results　There were 1 case of hyperplasia （1.4%）， 67 cases of adenoma （91.8%）， and 5 cases of adenocarcinoma （6.8%） among the 73 cases of PHPT. The common presentations involved with pain in bones and joints in 63 cases （86.3%）， pathologic fractures in 17 cases （23.3%）， osteoporosis in 59 cases （80.8%）， fatigue in 28 cases （38.4%）， abdominal pain in 4 cases （5.5%）， urolithiasis in 17 cases （23.3%）， malignant hypertension in 1 case （1.4%） who suffered multi-endocrine neoplasm （MEN）Ⅱa， and so on. The preoperativeserum parathyroid hormone （PTH） abnormally elevated in all 73 patients， and serum calcium abnormally elevated in 59 patients （80.8%）， and alkaline phosphatase abnormally elevated in 62 patients （84.9%） before operation. The positive rate of lesion locations by ultrasonography， CT， 99Tcm-sestamibi （MIBI） scan， and the combination of 3 kinds of tests were 82.8% （53/64）， 83.3% （20/24）， 90.2% （46/51）， and 91.8% （67/73） respectively， but 6 cases were not traced preop-eratively. Parathyroidectomy was conducted to all the cases， besides， regional neck lymphadenectomy was performed for those 5 adenocarcinoma cases. Tetany in 16 cases， hoarseness in 2 cases， acute pancreatitis in 1 case， acute left heart failure in 1 case were observed after operation. Sixty nine cases were follow-up for 3-72 months （average 17.3 months）. During the followed-up period， most of them were alleviated from bone pain （43 cases） and fatigue （18 cases）within 1 month. However， the recovery of PTH and serum calcium back to normality were relatively slow. One case ofadenoma recurred， 1 case of adenocarcinoma suffered lung metastasis， 1 case of adenocarcinoma survived for 37 monthsprior to death for postoperative lung and bone metastasis， the other cases （including 1 case of adenocarcinoma developed from adenoma） were still alive and had no metastasis or recurrence by the end of follow-up. Conclusions　The symptoms of PHPT vary and lack of specificity， hence， the enhancement of knowledge to this disease and screenings conducted for parathyroid function and serum calcium will increase the rate of diagnosis. Parathyroidectomy is the effective management for PHPT， and preoperatively accurate position contribute to minimal exploration.

Comparative Study and False Negative Cases Analysis of Preoperative Ultrasonography， 99Tcm-Sestamibi Scinti-graphy， and CT in Primary Hyperparathyroidism

Objective　To evaluate the diagnostic significance and to analyze reasons of false negative cases forpreoperative ultrasonography， 99Tcm-sestamibi scintigraphy （MIBI scintigraphy）， and CT in primary hyperparathyroidism（PHPT）. Methods　Clinical data of 69 patients with PHPT， who underwent operation in Affiliated Shengjing Hospital of China Medical University between Jan. 2003 and Aug. 2012 were retrospectively analyzed. Results　There were 76 parathyroid lesions in 69 PHPT patients proved by operation and pathology， including 58 cases of parathyroid adenoma with 60 lesions， 7 cases of parathyroid hyperplasia with 11 lesions， and 4 cases of parathyroid carcinoma with 5 lesions. The sensitivity of ultrasonography， CT， and 99Tcm-MIBI scintigraphy were 81.94% （59/72）， 61.76% （21/34）， and 69.57% （16/23）， the accuracy of 3 kinds of tests were 78.67% （59/75）， 61.76% （21/34）， and 66.67% （16/24）， the positive predictive value were 95.16% （59/62）， 100% （21/21）， and 94.12% （16/17） respectively. There was significant differ-ence only between ultrasonography and CT in sensitivity （P=0.03）， no other significant difference was found （P＞0.05）.Conclusions　Ultrasonography is complementary to 99Tcm-MIBI scintigraphy， but CT has little significance in diagnosis of PHPT. Both of ultrasonography and 99Tcm-MIBI scintigraphy should be used before operation routinely to localize parathyroid lesions.

合并甲状腺癌的持续复发性原发性甲状旁腺功能亢进症1例报道