中国普外基础与临床杂志

中国普外基础与临床杂志

甲状旁腺解剖的再认识及其在临床应用中价值的研究进展

查看全文

目的 对甲状旁腺解剖再认识并探讨其在甲状腺手术中对保护甲状旁腺功能的应用价值。 方法 以甲状旁腺、解剖、甲状腺手术和功能减低为检索词检索文献对甲状旁腺的起源、功能、解剖位置、数目、血供、淋巴系统及与甲状腺等周围组织器官关系以及其在甲状腺切除术中临床意义的相关研究文献进行综述。 结果 上甲状旁腺位置多较固定,下甲状旁腺异位较多。甲状旁腺的数目不确定,约半数以上的患者有 4 枚甲状旁腺,极少数(13%~25.5%)患者为多于 4 枚。主流的观点是甲状旁腺主要由甲状腺下动脉供血,少部分由甲状腺上下动脉的吻合支或甲状腺上动脉供血,但也有观点提出甲状旁腺的血液供应并不主要来源于甲状腺下动脉。甲状旁腺与脂肪组织和淋巴结不易辨别。甲状旁腺是否存在独立的淋巴系统尚存争议。在甲状腺手术中,通过甲状旁腺与 Zuckerkanl 结节、喉返神经及甲状旁腺周围特异性附着脂肪的关系以及采用纳米炭、手术放大镜技术等对甲状旁腺及其血供进行识别后予以保留或保护,在甲状腺术中尤其是行中央区淋巴结清扫时,应仔细解剖并保留甲状腺下动脉主干及其重要分支,术中精细化被膜内解剖,正确使用能量器械,可根据甲状旁腺分型判断原位保留甲状旁腺的难易程度,若无法保留者可采用自体甲状旁腺的移植。 结论 通过了解甲状旁腺的起源及其位置,使得在行甲状腺手术时对甲状旁腺的寻找有了方向;熟悉甲状旁腺的血流供应,就知道如何去保护血管并使甲状旁腺得以存活;被膜内解剖、精细化解剖技术、合理选择能量器械及吲哚氰绿造影术的应用在其中突显其重要性;甲状旁腺数目的确立,让我们把每一枚甲状旁腺当作最后一枚甲状旁腺珍惜;若无法原位保留,需要行甲状旁腺自体移植,避免甲状旁腺功能低下的发生。

Objective To understand anatomy of parathyroid glands and explore its application value in protection of parathyroid gland function during thyroidectomy. Method The literatures, which were associated with the parathyroid anatomy and hypoparathyroidism were collected. The origin, function, anatomical location, number, blood supply, lymphatic system of the parathyroid gland and its relationship with surrounding tissues of parathyroid gland and its clinical significance in the thyroidectomy, were reviewed. Results The position of the superior parathyroid gland was relatively constant, and the inferior parathyroid gland was more likely to be ectopic. The number of the parathyroid gland was uncertain. The mainstream view was that the arterial supply of the superior and inferior parathyroid glands was ensured by the branches of the inferior thyroid artery. However, the alternative view was that the blood supply of the parathyroid gland was not mainly derived from the inferior thyroid artery. The parathyroid gland was not easily distinguishable from the adipose tissue and lymph node. Whether there was an independent lymphatic system in the parathyroid glands was still controversial. In the thyroidectomy, the parathyroid gland and its blood supply were reserved or protected by distinguishing from the Zuckerkanl tubercle, recurrent laryngeal nerve, and parathyroid specific attachment fat, which were identified by utilization of the nanocarbon, loupe magnification, etc.. Especially in the central lymph neck dissection, the main thyroid artery trunk and its important branches should be carefully dissected or retained through the gentle capsular dissection and the correct use of energy devices for vessel sealing. The parathyroid gland in situ was reserved according to the parathyroid type. If it was not possible to be preserved, the parathyroid autotransplantation was necessary during the thyroidectomy. Conclusions Understanding origin and location of parathyroid gland, it could provide a direction for searching parathyroid gland during tthyroidectomy. Being familiar with blood supply of parathyroid gland makes it is possible to protect blood vessel and preserve parathyroid gland. Gentle capsular dissection, rational use of energy device, and indocyanine green angiography seem to be more important. Number of parathyroid gland allows us to treat each parathyroid gland as the last one, if it is not preserved in situ, parathyroid gland need to be autografted to avoid hypoparathyroidism.

关键词: 甲状旁腺; 解剖位置; 血供; 甲状旁腺功能低下; 甲状腺手术

Key words: parathyroid; anatomy location; blood supply; hypoparathyroidism; thyroidectomy

登录后 ,请手动点击刷新查看全文内容。 没有账号,
登录后 ,请手动点击刷新查看图表内容。 没有账号,
1. Shan CX, Zhang W, Jiang DZ, et al. Routine central neck dissection in differentiated thyroid carcinoma: a systematic review and meta-analysis. Laryngoscope, 2012, 122(4): 797-804.
2. Giordano D, Valcavi R, Thompson GB, et al. Complications of central neck dissection in patients with papillary thyroid carcinoma: results of a study on 1 087 patients and review of the literature. Thyroid, 2012, 22(9): 911-917.
3. Su A, Gong Y, Wu W, et al. Effect of autotransplantation of a parathyroid gland on hypoparathyroidism after total thyroidectomy. Endocr Connect, 2018, 7(2): 286-294.
4. Mansberger AR Jr, Wei JP. Surgical embryology and anatomy of the thyroid and parathyroid glands. Surg Clin North Am, 1993, 73(4): 727-746.
5. Bliss RD, Gauger PG, Delbridge LW. Surgeon’s approach to the thyroid gland: surgical anatomy and the importance of technique. World J Surg, 2000, 24(8): 891-897.
6. Mohebati A, Shaha AR. Anatomy of thyroid and parathyroid glands and neurovascular relations. Clin Anat, 2012, 25(1): 19-31.
7. 李振东, 刘宏伟, 董慧蕾, 等. 甲状腺全切除术中甲状旁腺及其功能的保护. 中华耳鼻咽喉头颈外科杂志, 2010, 45(11): 899-903.
8. Akerström G, Malmaeus J, Bergström R. Surgical anatomy of human parathyroid glands. Surgery, 1984, 95(1): 14-21.
9. Wang C. The anatomic basis of parathyroid surgery. Ann Surg, 1976, 183(3): 271-275.
10. Bahar G, Feinmesser R, Joshua BZ, et al. Hyperfunctioning intrathyroid parathyroid gland: a potential cause of failure in parathyroidectomy. Surgery, 2006, 139(6): 821-826.
11. Goodman A, Politz D, Lopez J, et al. Intrathyroid parathyroid adenoma: incidence and location—the case against thyroid lobectomy. Otolaryngol Head Neck Surg, 2011, 144(6): 867-871.
12. McIntyre RC Jr, Eisenach JH, Pearlman NW, et al. Intrathyroidal parathyroid glands can be a cause of failed cervical exploration for hyperparathyroidism. Am J Surg, 1997, 174(6): 750-754.
13. Kaplan EL, Yashiro T, Salti G. Primary hyperparathyroidism in the 1990s. Choice of surgical procedures for this disease. Ann Surg, 1992, 215(4): 300-317.
14. Alveryd A. Parathyroid glands in thyroid surgery. Ⅰ. Anatomy of parathyroid glands. Ⅱ. Postoperative hypoparathyroidism—identification and autotransplantation of parathyroid glands. Acta Chir Scand, 1968, 389: 1-120.
15. Fancy T, Gallagher D 3rd, Hornig JD. Surgical anatomy of the thyroid and parathyroid glands. Otolaryngol Clin North Am, 2010, 43(2): 221-227.
16. Gschwandtner E, Seemann R, Bures C, et al. How many parathyroid glands can be identified during thyroidectomy?: Evidence-based data for medical experts. Eur Surg, 2018, 50(1): 14-21.
17. Hunt PS, Poole M, Reeve TS. A reappraisal of the surgical anatomy of the thyroid and parathyroid glands. Br J Surg, 1968, 55(1): 63-66.
18. Halsted WS, Evans HM. Ⅰ. The parathyroid glandules. Their blood supply and their preservation in operation upon the thyroid gland. Ann Surg, 1907, 46(4): 489-506.
19. Park I, Rhu J, Woo JW, et al. Preserving parathyroid gland vasculature to reduce post-thyroidectomy hypocalcemia. World J Surg, 2016, 40(6): 1382-1389.
20. Attie JN, Khafif RA. Preservation of parathyroid glands during total thyroidectomy. Improved technic utilizing microsurgery. Am J Surg, 1975, 130(4): 399-404.
21. Johansson K, Ander S, Lennquist S, et al. Human parathyroid blood supply determined by laser-Doppler flowmetry. World J Surg, 1994, 18(3): 417-421.
22. Nobori M, Saiki S, Tanaka N, et al. Blood supply of the parathyroid gland from the superior thyroid artery. Surgery, 1994, 115(4): 417-423.
23. 王飞亮, 缪刚, 韦军民, 等. 甲状腺全切除术中对甲状旁腺特异性附着脂肪进行保护的临床和解剖研究. 中华外科杂志, 2016, 54(11): 859-863.
24. Bruneton JN, Livraghi T, Lecesne R, et al. Parathyroid glands. Springer Berlin Heidelberg, 2002: 67-89.
25. Suh YJ, Choi JY, Chai YJ, et al. Indocyanine green as a near-infrared fluorescent agent for identifying parathyroid glands during thyroid surgery in dogs. Surg Endosc, 2015, 29(9): 2811-2817.
26. Hyun H, Park MH, Owens EA, et al. Structure-inherent targeting of near-infrared fluorophores for parathyroid and thyroid gland imaging. Nat Med, 2015, 21(2): 192-197.
27. Vidal Fortuny J, Belfontali V, Sadowski SM, et al. Parathyroid gland angiography with indocyanine green fluorescence to predict parathyroid function after thyroid surgery. Br J Surg, 2016, 103(5): 537-543.
28. Vidal Fortuny J, Sadowski SM, Belfontali V, et al. Indocyanine green angiography in subtotal parathyroidectomy: technique for the function of the parathyroid remnant. J Am Coll Surg, 2016, 223(5): e43-e49.
29. Zaidi N, Bucak E, Okoh A, et al. The utility of indocyanine green near infrared fluorescent imaging in the identification of parathyroid glands during surgery for primary hyperparathyroidism. J Surg Oncol, 2016, 113(7): 771-774.
30. Sadowski SM, Vidal Fortuny J, Triponez F. A reappraisal of vascular anatomy of the parathyroid gland based on fluorescence techniques. Gland Surg, 2017, 6(Suppl 1): S30-S37.
31. 张筱骅, 郝儒田, 尤捷, 等. 甲状腺淋巴管造影在鉴别甲状旁腺中的意义. 温州医学院学报, 2010, 40(1): 31, 35.
32. Yang F, Jin C, Yang D, Jiang Y, et al. Magnetic functionalised carbon nanotubes as drug vehicles for cancer lymph node metastasis treatment. Eur J Cancer, 2011, 47(12): 1873-1882.
33. 朱精强, 汪洵理, 魏涛, 等. 纳米碳甲状旁腺负显影辨认保护技术在甲状腺癌手术中的应用. 中国普外基础与临床杂志, 2013, 20(9): 992-994.
34. Gu J, Wang J, Nie X, et al. Potential role for carbon nanoparticles identification and preservation in situ of parathyroid glands during total thyroidectomy and central compartment node dissection. Int J Clin Exp Med, 2015, 8(6): 9640-9648.
35. 中国医师协会外科医师分会甲状腺外科医师委员会. 甲状腺手术中甲状旁腺保护专家共识. 中国实用外科杂志, 2015, 35(7): 731-736.
36. 李文杰, 徐海倩, 翟立斌. 甲状旁腺微血管解剖与甲状腺囊内切除技术. 中国普外基础与临床杂志, 2013, 20(1): 104-107.
37. Gilmour JR. The gross anatomy of the parathyroid glands. J Pathol Bacteriol, 1938, 46(1): 133.
38. Yun JS, Lee YS, Jung JJ, et al. The Zuckerkandl’s tubercle: a useful anatomical landmark for detecting both the recurrent laryngeal nerve and the superior parathyroid during thyroid surgery. Endocr J, 2008, 55(5): 925-930.
39. Chevallier JM, Martelli H, Wind P. Surgical discovery of parathyroid glands and the recurrent laryngeal nerve. Application of well known embryological concepts in the operating room. Ann Chir, 1995, 49(4): 296-304.
40. Pelizzo MR, Toniato A, Gemo G. Zuckerkandl’s tuberculum: an arrow pointing to the recurrent laryngeal nerve (constant anatomical landmark). J Am Coll Surg, 1998, 187(3): 333-336.
41. Persky M, Fang Y, Myssiorek D. Relationship of the recurrent laryngeal nerve to the superior parathyroid gland during thyroidectomy. J Laryngol Otol, 2014: 1-4.
42. Teshima M, Otsuki N, Morita N, et al. Postoperative hypoparathyroidism after total thyroidectomy for thyroid cancer. Auris Nasus Larynx, 2018: pii: S0385-8146(18)30075-0.
43. Yu W, Zhu L, Xu G, et al. Potential role of carbon nanoparticles in protection of parathyroid glands in patients with papillary thyroid cancer. Medicine (Baltimore), 2016, 95(42): e5002.
44. Pata G, Casella C, Mittempergher F, et al. Loupe magnification reduces postoperative hypocalcemia after total thyroidectomy. Am Surg, 2010, 76(12): 1345-1350.
45. Vidal Fortuny J, Sadowski SM, Belfontali V, et al. Randomized clinical trial of intraoperative parathyroid gland angiography with indocyanine green fluorescence predicting parathyroid function after thyroid surgery. Br J Surg, 2018, 105(4): 350-357.
46. Dzodic R, Santrac N. In situ preservation of parathyroid glands: advanced surgical tips for prevention of permanent hypoparathyroidism in thyroid surgery. J BUON, 2017, 22(4): 853-855.
47. Sanabria A, Kowalski LP, Tartaglia F. Inferior thyroid artery ligation increases hypocalcemia after thyroidectomy: A meta-analysis. Laryngoscope, 2018, 128(2): 534-541.
48. Filho EBY, Machry RV, Mesquita R, et al. The timing of parathyroid hormone measurement defines the cut-off values to accurately predict postoperative hypocalcemia: a prospective study. Endocrine, 2018, 61(2): 224-231.
49. Orloff LA, Wiseman SM, Bernet VJ, et al. American Thyroid Association Statement on postoperative hypoparathyroidism: diagnosis, prevention, and management in adults. Thyroid, 2018, 28(7): 830-841.
50. Iorio O, Petrozza V, De Gori A, et al. Parathyroid autotransplantation during thyroid surgery. Where we are? A systematic review on indications and results. J Invest Surg, 2018: 1-8.
51. Roh JL, Park JY, Park CI. Prevention of postoperative hypocalcemia with routine oral calcium and vitamin D supplements in patients with differentiated papillary thyroid carcinoma undergoing total thyroidectomy plus central neck dissection. Cancer, 2009, 115(2): 251-258.
52. Chisholm EJ, Kulinskaya E, Tolley NS. Systematic review and meta-analysis of the adverse effects of thyroidectomy combined with central neck dissection as compared with thyroidectomy alone. Laryngoscope, 2009, 119(6): 1135-1139.
53. 彭喆, 田文, 姚京, 等. 中央区淋巴结清扫术对甲状腺乳头状癌患者甲状旁腺功能的影响. 解放军医学院学报, 2014, 35(7): 684-687.