當洗腎患者副甲狀腺機能亢進時,身體會發生什麼事情?
副甲狀腺會不斷的把骨頭裡面的鈣與磷往外搬,一直搬的結果就是骨質不斷流失,骨折的機會升高,血中鈣與磷過高,會導致血管鈣化、軟組織鈣化,進一步造成心臟血管疾病等等問題。(不知道為甚麼嗎?用之前的文章,再複習一次副甲狀腺的功能吧)
為了避免這些最糟糕的情況,當我們用了各種藥物都無法控制副甲狀腺時,手術摘除,是最後的辦法。說精準一點,經過藥物治療之後,副甲狀腺素仍然 >1000 pg/ml且合併高血鈣,或者副甲狀腺本身的體積 >500 m3等等,這些都是該去手術的時機。
先來複習一下副甲狀腺在哪裡吧?
綠色的四個點點,就是藏在甲狀腺後面的副甲狀腺,這圖是要告訴你:大多數的人有四個腺體喔。
手術的方式有許多種,請注意,目前醫界並沒有共識哪一種手術方式是最好的,因此,我只就手術方式做介紹,介紹的順序並不表示優劣順序。
1. 部分副甲狀腺切除 (Subtotal parathyroidectomy)
把4個腺體摘除 3.5個,剩下半個腺體放在原處。
優點:有留部分的腺體,將來還需要用到它的時候(如:接受腎臟移植,暫時不再需要洗腎了),才不會完全沒有功能(討論一)。
缺點:當副甲狀腺機能亢進復發時,還要再開一次脖子,而開脖子的手術,永遠伴隨著傷害喉返神經的風險(討論二)。因此,有了下一個手術方式。
2. 副甲狀腺全切除,加上部份腺體自體移植 (Total parathyroidectomy with autotransplantation)
把四個腺體全部摘除,而把摘掉的腺體中,選一個看起來比較正常的,切一小塊下來,將這一小部分的腺體種在手臂上。
優點:當復發時,直接去找之前種的地方就好,不用再冒著傷害喉返神經的風險而再開一次脖子。
缺點:由於全部摘除之後,到一小部分腺體能發揮作用的這段時間,身體可說是完全沒有副甲狀腺素的作用,因此術後常伴隨著比較厲害的低血鈣(討論三)。另外,因為大多都是種在手臂上,所以當血液透析的患者的手臂動靜脈廔管壞掉,需要做新的位置時,會因此而受影響。
3. 副甲狀腺全切除 (Total parathyroidectomy)
把四個腺體全部摘除,一個不留。
優點:復發的機會大大減少。
缺點:開完後,除了有較厲害的低血鈣之外,還有變成“終身”副甲狀腺功能低下的疑慮(討論四)。
4. 副甲狀腺酒精注射(Percutaneous ethanol injection therapy)
使用超音波定位,選擇最大顆的副甲狀腺,注射酒精進這一顆腺體,以破壞這顆最大顆的副甲狀腺。
這項技術,需要非常熟練的技術來執行,而且一樣有傷害喉返神經的機會。在日本,這種局部注射的經驗比較多,他們甚至訂定了治療準則,也不只是施打酒精,還有施打維他命D、醋酸等等藥劑選擇。
這項治療,一樣能有效降低副甲狀腺素數值,外科醫師接受過訓練、有把握就可以用這個方式治療。
討論:
一、副甲狀腺完全被摘除之後,就沒有辦法製造副甲狀腺素了,如此一來,反而會變成“副甲狀腺機能低下”,其實,副甲狀腺素最主要的功能,是叫骨頭動起來,當副甲狀腺功能低下的時候,骨頭會變成完全不想動的懶骨頭(Adynamic bone disease,無動力性骨病變),鈣與磷既不會從骨頭中放出來,也不會再進到骨頭裡面,多餘的鈣和磷無處可去的情況下,就會積在我們不想要的地方,如血管、軟組織,造成更糟糕的結果。
還記得之前講洗腎患者的副甲狀腺素建議數值範圍嗎?是正常人範圍上限的二到九倍!你看,洗腎患者的建議值的下限,居然是正常人上限的兩倍耶!這代表在洗腎患者,副甲狀腺素不能低!如果被控制在正常人的範圍內時,那就太低了,因為這時候,骨頭不再幫你吸收鈣與磷,身體的其他部位得承擔鈣化了。
所以,和功能亢進相比,我們反而更害怕功能低下而造成懶骨頭症(Adynamic bone disease,無動力性骨病變),因此,前兩種手術方式,都是保留部分的副甲狀腺組織,以避免這種情形發生。
二、開脖子時,不管是甲狀腺的手術、還是副甲狀腺的手術,外科醫師都會很小心不要傷害到喉返神經,如果傷害到這條神經,會導致聲音沙啞,依傷害程度的不同,可能為暫時性、也可能為永久性的傷害。
三、摘除副甲狀腺後,不管是部分切除還是全切除,副甲狀腺素數值從一千多,一下子掉下來剩下一兩百,骨頭們發現,原本一直叫骨頭把鈣和磷吐出來的副甲狀腺素,忽然幾乎消失了,骨頭們樂的把血中的鈣和磷,通通吃回去骨頭裡面,這種情況,叫做“骨頭好餓”症候群(Hunger bone syndrome,餓骨症候群),因為他們之前吐太久了,餓壞了,所以副甲狀腺手術後的這幾天,骨頭反而是很用力的把血中的鈣和磷吃乾抹淨,造成低血鈣以及低血磷,低血鈣會造成肌肉抽筋、肌肉收縮無法放鬆、心電圖的變化等等,處理方式是:給予患者大量的鈣片和維他命D,讓骨頭吃夠夠,血鈣才會升回到正常值。
骨頭好餓症候群(Hunger bone syndrome,餓骨症候群),每個人術後的程度不一,持續的時間也不一樣,從幾周到幾個月都有可能,所以術後需要小心追蹤鈣離子濃度,並且補充足夠的鈣。
四、既然全切除很有可能會造成副甲狀腺機能低下,而且副甲狀腺機能低下的結果還蠻慘的,懶惰的骨頭都不幫忙處理鈣與磷,這些多餘的鈣與磷會到處沉積鈣化,那怎麼還會有人去做全切除啊!?
這是因為研究發現,就算做全部切除,還是會有殘留的一點點副甲狀腺組織,在經年累月的刺激之下,這些沒切乾淨的組織,就足以增生而恢復一些副甲狀腺功能,不至於產生功能低下。
還有一種建議,就是在全切除之後,用冷凍保存患者自身的副甲狀腺,以便日後假設真的有需要,再種回去身體裡,然而,這種冷凍過後的組織,是否還能正常的運作,還是很令人擔心的呢…
雖然能夠大大降低復發的機會,關於全切除的報告裡還是建議,這種手術方式應該是用在“之後不打算換腎”的患者上,如果想要保留換腎機會的腎友,還是不要做這樣的手術,以保全部分副甲狀腺功能。除此之外,外科醫師對於全切除還是蠻樂觀的,畢竟,日後復發還是得處理,多了一次手術的風險…
結語:
沒有哪一項手術是最好的。
那哪一項手術是比較多人做的呢?我沒有台灣的數據,但美國的數據是:所有接受手術的美國人當中,三分之二的人是接受第一種。而第一種與第二種比較起來,兩者的復發機會、骨頭好餓症候群發生率、手術風險等等,全部都一樣。所以還是那句話,選擇手術的方式,只取決於外科醫師的習慣偏好。
更重要的是,不要開完刀還不控制磷,遲早會再復發,再開一次刀!
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