矢野 由希子¹, 八代 享², 菊池 博¹

Yukiko YANO¹, Tohru YASHIRO², Hiroshi KIKUCHI¹

¹筑波学園病院, ²筑波大学臨床医学系乳腺甲状腺内分泌外科

¹Department of Surgery Tsukuba Gakuen Hospital, ²Department of Breast, Thyroid, and Endocrine Surgery Tsukuba University Institute of Clinical Medicine

キーワード : color Doppler ultrasonography, intraoperative ultrasonography, recurrent hyperparathyroidism, secondary hyperparathyroidism

腎性上皮小体機能亢進症では上皮小体手術後も慢性腎不全の状態が継続するため, 移植上皮小体腺が原因となり再発を起こすことがある. 再発時には腫大した上皮小体を再度摘出する必要がある. 大きく腫大し, 触知できる移植腺であれば容易に位置を同定できるが, 小さな腫大移植腺については術前に画像診断を用いて大体の位置をマーキングした後, 術中に肉眼で腫大腺を探しながら周囲の剥離を進めていく. 腎不全患者では組織が脆弱で易出血であり, 腫大した移植腺を探す剥離操作で組織損傷が大きくなる可能性がある. 今回我々は腎性上皮小体機能亢進症が再発した57歳の男性の再手術を行った. 肉眼と触診で移植腺を探す従来の方法に代えて, 術中に超音波検査を併用し, 触知される腫大した移植腺の他, 触知できない小さい移植腺を前腕の筋肉内に低エコー腫瘤として確認し摘出した. 摘出の際に周囲血管の損傷を避けることができ, 組織への損傷を最小限にできた. 術前に腫大した移植上皮小体腫大腺をカラードプラ検査で評価したのであわせて報告する. 術中超音波ガイドによる上皮小体移植腺摘出は触知できない小さな移植腺を周囲組織損傷なく確認でき有用である.

Persistence of chronic renal failure in patients with renal hyperparathyroidism occasionally causes graft-dependent recurrence of hyperparathyroidism after total parathyroidectomy with autotransplantation. The graft should be removed, however, when hyperparathyroidism recurs in these patients. The graft is easily located if it swells enough to be palpable. If the graft is small, however, its position can be roughly determined using preoperative imaging, and tissues surrounding the graft can be dissected by determining their location with macroscopy. Because tissues are brittle and tend to bleed in patients with chronic renal failure, exploration of the graft can seriously damage the surrounding tissues. We operated on a man aged 57 years in whom graftdependent hyperparathyroidism had recurred. Intraoperative ultrasonography was used in addition to the conventional method, in which the graft is located using manipulation and the naked eye. Ultrasonography showed small impalpable grafts as hypoechoic masses in the muscle of the forearm. Injury of vessels surrounding the small graft was prevented, and damage to the surrounding tissues was minimized. The results of color Doppler ultrasonography that revealed hypervascularity of the graft before surgery are also reported. We conclude that graft exploration using intraoperative ultrasonography as a guide could prove useful in detecting small impalpable grafts without damaging the surrounding tissues.