原发性甲状旁腺功能亢进

技术问题可导致血肿的发生，如手术钳或缝线意外脱落，或原来已结扎的血管破裂。术后，应在监测环境中观察患者，以评估是否有颈部血肿。[1]Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. 2016;151:959-968.http://jamanetwork.com/journals/jamasurgery/fullarticle/2542667http://www.ncbi.nlm.nih.gov/pubmed/27532368?tool=bestpractice.com 纠正措施是及时进行紧急血肿清除和结扎术。通常在纠正措施实施后该问题可立刻缓解。[94]Burkey SH, van Heerden JA, Thompson GB, et al. Reexploration for symptomatic hematomas after cervical exploration. Surgery. 2001 Dec;130(6):914-20.http://www.ncbi.nlm.nih.gov/pubmed/11742317?tool=bestpractice.com

喉返神经和喉上神经损伤可能会在外科手术期间发生。喉上神经的损伤可能导致声调改变。喉返神经损伤会导致声嘶。喉上和喉返神经的损伤可能是暂时的，永久损伤不常见。如果在 6 个月内症状没有消退，声带内移术是有效的治疗。手术方法为经甲状软骨放置异质材料，将受累声带推移到中线。[95]Chester MW, Stewart MG. Arytenoid adduction combined with medialization thyroplasty: an evidence-based review. Otolaryngol Head Neck Surg. 2003 Oct;129(4):305-10.http://www.ncbi.nlm.nih.gov/pubmed/14574281?tool=bestpractice.com 声音治疗也可能有帮助。

低钙血症可能会因为骨饥饿综合征而出现，该症状出现的原因是既往钙耗竭的骨骼因为破骨细胞活动的逆转和成骨细胞的激活而获益。低钙血症也可能因术中其他被抑制的甲状旁腺的血供阻断或损伤引起。另外，低钙血症也可能是由于血肿压迫伤口引起的甲状旁腺淤血所致。这种情况在维生素 D 缺乏的患者和接受全面双侧颈部探查的患者中更为常见。[1]Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. 2016;151:959-968.http://jamanetwork.com/journals/jamasurgery/fullarticle/2542667http://www.ncbi.nlm.nih.gov/pubmed/27532368?tool=bestpractice.com 在发生低钙血症的患者中，症状最常发生在术后第 2 天或第 3 天；术后第 1 天，只有术前钙水平极度升高的患者才偶尔出现症状。患者在手术当天几乎从来不会出现症状。[96]Vasher M, Goodman A, Politz D, et al. Postoperative calcium requirements in 6,000 patients undergoing outpatient parathyroidectomy: easily avoiding symptomatic hypocalcemia. J Am Coll Surg. 2010 Jul;211(1):49-54.http://www.ncbi.nlm.nih.gov/pubmed/20610248?tool=bestpractice.com 口服补钙通常可在数小时内缓解低钙血症，静脉补钙可在一小时内实现缓解。暂时性低钙血症时，可通过口服补充钙剂进行纠正。如果患者缺乏维生素 D，则应该补充。[1]Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. 2016;151:959-968.http://jamanetwork.com/journals/jamasurgery/fullarticle/2542667http://www.ncbi.nlm.nih.gov/pubmed/27532368?tool=bestpractice.com 一些指南推荐考虑在甲状旁腺切除术后用补充钙和/或维生素 D 的方法短期预防低钙血症，但相关支持证据较弱。[1]Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. 2016;151:959-968.http://jamanetwork.com/journals/jamasurgery/fullarticle/2542667http://www.ncbi.nlm.nih.gov/pubmed/27532368?tool=bestpractice.com

Hypoparathyroidism

如果在剥离的过程中肺尖部胸膜有拉伤或撕裂，可出现气胸。[102]Guerrero MA, Wray CJ, Kee SS, et al. Minimally invasive parathyroidectomy complicated by pneumothoraces: a report of 4 cases. J Surg Educ. 2007 Mar-Apr;64(2):101-7.http://www.ncbi.nlm.nih.gov/pubmed/17462211?tool=bestpractice.com 气胸的发生似乎与下方的甲状旁腺手术或者颈部手术部位存在因既往放疗或手术导致的疤痕有关。通过连续胸部 X 线检查进行观察是常用方法。如果其很严重或者有症状，需留置导管或插入胸腔引流管进行排气以解决胸膜泄漏问题。

Pneumothorax

如果存在持续的、不能治愈的、无法手术治疗的甲旁亢，在咨询骨代谢专家后，可考虑使用阿仑膦酸、雌二醇或者雷洛昔芬以保护骨骼，尽管目前并没有骨折发生几率的数据。[67]Khan AA, Bilezikian JP, Kung AW, et al. Alendronate in primary hyperparathyroidism: a double-blind, randomized, placebo-controlled trial. J Clin Endocrinol Metab. 2004 Jul;89(7):3319-25.http://press.endocrine.org/doi/full/10.1210/jc.2003-030908http://www.ncbi.nlm.nih.gov/pubmed/15240609?tool=bestpractice.com[97]Marcus R. The role of estrogens and related compounds in the management of primary hyperparathyroidism. J Bone Miner Res. 2002 Nov;17(suppl 2):N146-9.http://www.ncbi.nlm.nih.gov/pubmed/12412792?tool=bestpractice.com[98]Zanchetta JR, Bogado CE. Raloxifene reverses bone loss in postmenopausal women with mild asymptomatic primary hyperparathyroidism. J Bone Miner Res. 2001 Jan;16(1):189-90.http://www.ncbi.nlm.nih.gov/pubmed/11149484?tool=bestpractice.com[99]Pallan S, Khan A. Primary hyperparathyroidism: update on presentation, diagnosis, and management in primary care. Can Fam Physician. 2011 Feb;57(2):184-9.http://www.cfp.ca/content/57/2/184.longhttp://www.ncbi.nlm.nih.gov/pubmed/21321169?tool=bestpractice.com 手术治疗和骨吸收抑制剂疗法在增加轻度 PHPT 患者的骨密度 (BMD) 方面疗效相似；在未治疗的轻度 PHPT 患者中，骨损失速率较慢。[100]Sankaran S, Gamble G, Bolland M, et al. Skeletal effects of interventions in mild primary hyperparathyroidism: a meta-analysis. J Clin Endocrinol Metab. 2010 Apr;95(4):1653-62.http://press.endocrine.org/doi/full/10.1210/jc.2009-2384http://www.ncbi.nlm.nih.gov/pubmed/20130069?tool=bestpractice.com

Osteoporosis

持续高 PTH 引起的骨钙释放的增多可导致骨量减少和骨质疏松症，进而引发骨折，特别是长骨骨折。治疗包括请骨科医生会诊，使用合适的石膏固定和夹板。

由于血钙和尿钙水平升高，钙可能会沉积，形成草酸盐结晶，进而形成结石。治疗选择包括紧随甲旁亢治疗方案的高钙血症的治疗，其余可考虑碎石术或外科手术。[101]Marcocci C, Brandi ML, Scillitani A, et al. Italian Society of Endocrinology consensus statement: definition, evaluation and management of patients with mild primary hyperparathyroidism. J Endocrinol Invest. 2015 May;38(5):577-93.http://www.ncbi.nlm.nih.gov/pubmed/25820553?tool=bestpractice.com 应该请泌尿科医生进行会诊。

Nephrolithiasis