摘要
随着透析患者的持续增加及透析时间增长，慢性肾脏病（CKD）相关的继发性甲状旁腺功能亢进（SHPT）发病率持续增加，需要外科干预的患者人数也随之增加。美国内分泌外科医师协会（AAES）于2022年发布了首版《继发性及三发性甲状旁腺功能亢进确定性外科治疗指南》。指南基于大量循证医学研究，规范了SHPT及三发性甲状旁腺功能亢进（THPT）的外科治疗指征，系统对比了不同手术方式的优缺点，特别是对术后复发患者的再次手术治疗做出了介绍。但由于缺乏足够的RCT研究结论，该指南的部分推荐循证医学等级较低。笔者重点针对指南中肾衰性SHPT的相关外科部分进行解读，旨在帮助临床医生更深入地掌握SHPT的临床管理，促使诊疗进一步规范化。
2022年9月，美国内分泌外科医师协会发布了首版《继发性及三发性甲状旁腺功能亢进确定性外科治疗指南
《指南》指出目前并没有一个绝对标准的甲状腺旁腺激素（parathyroid hormone，PTH）值可以作为甲状旁腺切除术（parathyroidectomy，PTX）的指标。2003年的K/DOQI指
甲状旁腺显像在SHPT中的准确性不如PHPT。超声对异位甲状旁腺组织的定位能力有限，但可以用来在术前排除伴随的甲状腺疾病。有研
由于人群中甲状腺结节和甲状腺癌发病率较高，有研
《指南》指出患者知情同意书应该包括5个要点：自愿性、能力、信息披露、理解和最终决定。在术前需与患者详细沟通手术风险、获益和替代方案的信息。这有助于管理患者对手术成功和康复的期望，并提高他们对任何可能发生并发症的理解。鉴于医护人员之间沟通缺失是对患者安全影响的最常见原因之一，鼓励对患者进行多学科交流。
至今为止没有专门针对晚期CKD患者术前评估的指南。因CKD患者伴动脉粥样硬化、钙化性冠状动脉疾病、钙化性瓣膜疾病、外周动脉疾病和心力衰竭等疾病比例较高，这些疾病会增加术中和术后心脏事件并发症的风
SHPT进行PTX的目的是减少过量的PTH来源，需要在术后永久性甲状旁腺功能减退症以及复发或持续性HPT之间达到平衡。对于有计划进行肾脏移植的患者，必须将肾移植的情况纳入考虑，对于该类患者，甲状旁腺次全切术（subtotal parathyroidectomy，SPTX）是比较好的选择，不建议对等待肾移植的患者进行甲状旁腺全切（total parathyroidectomy，TPTX）而不采取自体移植术（autotransplantation，AT）。《指南》认为在术前进行手术规划时需要考虑到患者术后肾移植可能，并根据患者情况考虑手术方式（强推荐，低质量证据）。遗憾的是指南在该篇中未提及术后iPTH目标值。近年来有项多中心回顾性队列研
手术必须权衡术后低钙血症和甲状旁腺功能低下的风险与持续性或复发性HPT的风险，尤其是在持续的终末期肾病（end-stage kidney disease，ESKD）的情况下，其会持续刺激PTH产生。对于肾脏相关HPT，没有统一推荐的手术方式，目前有3种手术方式可供选择。手术方式的选择取决于外科医生。因接受肾脏移植可以恢复正常肾功能，这类患者可能更合适保留部分残余甲状旁腺的手术；相对地，对于不计划接受肾移植的患者，可能从TPTX中获益更
SPTX是由Stanbury
识别并切除所有甲状旁腺组织，不留下腺体残留物，也不进行甲状旁腺移植，该手术最先由Og
切除颈部所有甲状旁腺组织，并提供PTH的替代源，一般合并经颈部胸腺切除术。手术操作开始和甲状旁腺全切一致：先明确所有旁腺组织并切除,建议可以通过冷冻切片来确认甲状旁腺组织以防移植淋巴、脂肪或甲状腺组织。选择弥漫性增生组织进行移植，一般选择外观最正常或最小的腺体。移植最常见的方法是前臂自体移植，其优势是能够从移植侧和非移植侧采集血液通过了解其PTH情况来定义移植物依赖性复发。其次可选择胸锁乳突肌作为移植部位，其优势是仅需一个手术切口即可完成。移植可以用甲状旁腺组织制作成5~30片1 mm×1 mm×1 mm到1 mm×1 mm×3 mm的“碎片”，然后移植到所需要的部位，在移植部位用不可吸收材料进行标记。行AT后，因需重建血液供应，移植物可能出现旁腺功能延迟，并可能由于疤痕成熟导致局部缺血而导致晚期移植物衰竭。相反地，移植物可能随着时间的增加而增生并渗透到周围的结构和血管中。此外，由于移植物中结节性组织持续存在，因此可在肾移植后的自发移植物部位发生THPT。考虑到每个患者的具体情况，术中应由外科医生决定自体移植的最佳部位，并在该部位用不可吸收材料缝合标记（强推荐，低质量证据）。在国内的临床实践中，该手术方式被很多外科医生所偏爱，多项研
在进行甲状旁腺手术同时是否附加胸腺切除术一直存在争议。在SHPT患者中，胸腺内甲状旁腺组织将受到引起增生的病理生理过程影响，是潜在的持续性或复发性疾病的来源，在肾脏相关HPT群体中胸腺内甲状旁腺的概率为14.8%~45.3%。因此，部分外科医生在进行SPTX或TPTX+AT时将双侧经颈胸腺切除术作为标准疗
SPTX对比TPTX+AT：SPTX和TPTX+AT是目前SHPT最常用的两种手术方式。有Meta分
TPTX对比TPTX+AT：一项多中心随机对照试
一项纳入26项研究共计5 063例患者的Meta分
基于上述证据，《指南》建议当术中能确认所有旁腺位置并旁腺都增大的时候，SPTX可能是首选的手术方式。但基于对持续疾病、复发疾病及术后低血钙风险的考虑，手术的选择方式应该由外科医生根据每例患者的情况进行选择（弱推荐，中等质量证据）。
因肾衰患者肾脏和肝脏对PTH及其片段的清除能力受损，故这一患者群体中PTH的衰减是不可预测的。目前有多项国内外研
骨饥饿（hungry bone syndrome，HBS）为术后PTH降低后成骨细胞对钙的摄取导致的持续性严重低钙血症，其定义为血清钙低于8.4 mg/dL或术后低钙持续时间>4 d。因术后低钙血症发生率高，《指南》推荐术后即刻开始常规监测血钙并口服和/或静脉补充骨化三醇和钙剂（强推荐，低质量证据）。
需要指出的，目前暂无统一标准的术后复发或持续性HPT的定义。目前被广泛接受的标准如下：⑴ 持续性HPT：在TPTX+AT术后PTH值>正常值上限；其他术式则为术后即刻PTH值>300 pg/mL，术后6个月内3次PTH>200 ng/L或PTH>240 pg/mL。⑵ HPT复发：术后PTH达到正常（或目标值），6个月后增加至正常值上限3倍以上伴有碱性磷酸酶增加或3次PTH>200 ng/L或PTH>300 pg/mL或PTH持续>600 pg/mL。《指南》特别指出的是，仅血清PTH水平不足以诊断持续性或复发性HPT，需合并高血钙的存在方能做出准确诊断。
与初次手术相比，再次手术的并发症更多，失败率更高，手术需要综合考虑PTH、钙、磷值。有研究认为PTH值应设定在500 pg/m
与首次手术不同，因亢进的甲状旁腺组织可能出现的位置很多，术前定位是必须的。在甲旁亢持续的这类患者中，术前定位可以帮助外科医生明确额外的和异位的旁腺组织在颈部或纵隔的位置。在复发的这类患者中，外科医生则需要识别可能的增生残余腺体、额外腺体以及甲状旁腺病。而在接受过自体移植的这类患者中，外科医生还需要评估自体移植物是否功能亢进。在需要再次手术的这类患者中，Sestamibi扫描的敏感度为71%~95.2%，阳性预测值为100%。与Sestamibi的高敏感度不同，可能由于再次手术异位旁腺尤其是纵隔旁腺的比例较高，故超声的敏感度较低，为50%~71.4%。有Meta分
患者进行全身麻醉，建议使用喉返神经监测仪，切口可选择原切口或侧方入路；如果确定腺体在纵隔内，可进行开胸手术。进入颈部后，应先进行双侧探查，确定包括残余腺体、异位或多余腺体在内的所有剩余甲状旁腺组织。手术目的在不使患者出现甲状旁腺功能低下的情况下尽可能切除甲状旁腺组织。如果术中存在残留腺体血供问题，应立刻进行AT。因SPTX术后复发主要由初次手术后残留腺体所引起，有研
如果亢进的旁腺组织同时来源于自体移植物和颈部/纵隔，建议先进行移植物切除，从而可能避免在颈部疤痕区再次手术。因旁腺组织可能嵌入周围的肌肉，故需要对周围的筋膜、肌肉和软组织进行整块切除。可应用冷冻切片证明甲状旁腺组织，并进行冷冻保存。由于自体移植物通常难以完全切除，约50%以上患者需要多次手术切
利益冲突
所有作者均声明不存在利益冲突。
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