Unizentrische Ergebnisse der Chirurgie des primären Hyperparathyreoidismus mit postoperativer Langzeitbeobachtung sowie Rolle des intraoperativen Quick-Parathormon-Tests^[*]

 

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Zusammenfassung

Hintergrund: Die Einführung des intraoperativen Quick-Parathormon-Tests (ioPTH) sowie die Verbesserung der präoperativen Lokalisationsdiagnostik hat zur zunehmenden Verbreitung eines fokussierten operativen Vorgehens in der NSD-Chirurgie (NSD: Nebenschilddrüse) geführt. In dieser Studie wurden frühpostoperative und Langzeitergebnisse der Chirurgie des primären Hyperparathyreoidismus (pHPT) sowie der Nutzen des standardisierten ioPTH beurteilt. Methoden: Vom 01. 01. 1996 bis 30. 09. 2011 wurden alle konsekutiven Operationen aufgrund eines pHPT erfasst. Die Daten dieser klinischen Beobachtungsstudie wurden retrospektiv ausgewertet. Die Patienten wurden in 2 Gruppen eingeteilt: A) Anwendung des Quick Intraoperative Intact PTH Assay (n = 142; „ioPTH-Gruppe“) vs. B) Vergleichsgruppe (n = 44; „VG“). Für das klinische Langzeit-Follow-up wurden bei den Patienten der ersten 4 Untersuchungsjahre (n = 43) prä- und postoperative Symptome und Befunde semiquantitativ miteinander verglichen. Ergebnisse: Es wurden 186 Operationen aufgrund eines pHPT durchgeführt (73 alleinige NSD-Resektionen; 113 kombinierte Schilddrüsen- [SD] und NSD-Resektionen). Alleinige NSD-Operationen dauerten durchschnittlich 87 (S_D ± 48) min, kombinierte Operationen 120 (S_D ± 49) min (S_D: Standardabweichung). Eine persistierende Hyperkalzämie fand sich bei 16 Patienten (8,6 %), eine postoperative Erhöhung von Serumkalzium und Parathormon bei 7 (3,8 %). Eine Hypokalzämie bestand bei 35 Patienten (18,8 %). Die Unterschiede zwischen der ioPTH-Gruppe und der VG hinsichtlich postoperativer Hypo- (p = 1,0) oder Hyperkalzämie (p = 0,67), Hyperparathyrinämie (p = 0,12) und Rate der Nachresektion (p = 0,055) waren nicht signifikant. Von den ersten 43 eingeschlossenen Patienten wiesen 39 ein oder mehrere Symptome auf (90,7 %). Am häufigsten traten Nephrolithiasis (41,9 %), Wirbelsäulenbeschwerden (51,2 %), Oberbauchschmerzen (41,9 %), rasche Ermüdbarkeit (41,9 %) und reduziertes Allgemeinbefinden (65,1 %) auf. Im Follow-up (Median: 4,7 [Streubreite: 3,2–6,5] Jahre) überwog eine Besserung bei 65 %, 27 % zeigten keine Veränderung und 8 % eine Verschlechterung des Allgemeinbefindens. Schlussfolgerungen: Das ioPTH gilt aktuell als Standard in der NSD-Chirurgie. Der Nutzen korreliert jedoch direkt mit den individuell oder klinikintern verwendeten Erfolgskriterien. Je strenger das Kriterium, desto zuverlässiger die Voraussage einer Mehrdrüsenerkrankung. Bei insgesamt sehr niedriger Komplikationsrate wiesen ca. 2/3 der Patienten im Langzeit-Follow-up eine klinische Verbesserung auf.

Abstract

Background: The increasing use of focussed parathyroidectomy is attributed to introduction of intraoperative parathyroid hormone measurement (ioPTH) and novel preoperative imaging techniques. This study assesses the early postoperative and long-term outcomes of surgery and the value of standardised ioPTH in patients undergoing surgery for primary hyperparathyroidism (pHPT). Methods: From 01/01/1996 to 09/30/2011, all consecutive patients undergoing surgery for pHPT were documented. Data of this observational study were retrospectively evaluated. Patients were subdivided into 2 groups: A.) use of Quick Intraoperative Intact PTH Assay (n = 142; “ioPTH group”) vs. B.) control group (“CG”, n = 44). For clinical long-term follow-up, also pre- and postoperative signs, symptoms and findings of the initial 43 patients obtained during the first 4 years of the study were semiquantitatively compared. Results: 186 consecutive operations for pHPT were performed – in particular, 73 sole parathyroidectomies; 113 combined thyroid and parathyroid resections. Mean operation time was 87 (S_D ± 48) min for parathyroidectomy and 120 (S_D ± 49) min for combined resections. A persisting hypercalcaemia was found in 16 patients (8.6 %) while postoperative elevation of serum calcium and parathormone occurred in 7 patients (3.8 %). Postoperative hypocalcaemia was present in 35 patients (18.8 %). Differences between both groups regarding hypocalcaemia (p = 1.0), hypercalcaemia (p = 0.67), hyperparathyrinaemia (p = 0.12) and rate of reintervention (p = 0.055) were not significant. Thirty nine of the initial 43 patients reported one or more signs of pHPT (90.7 %). Most frequent symptoms were nephrolithiasis (41.9 %), back pain (51.2 %), discomfort in the upper abdomen (41.9 %), fatigue (41.9 %) and general weakness (61.1 %). Follow-up investigations (mean, 4.7 [range, 3.2–6.5] years) revealed that 65 % of patients reported improvement of general condition, 27 % had no change and 8 % reported deterioration. Conclusions: IoPTH is now standard in parathyroid surgery. Value of ioPTH correlates directly with selected centre-specific intraoperative criteria. The stricter the criteria the more reliable is the exclusion of multiglandular disease. Surgery for pHPT was performed with a very low complication rate. Through the long-term follow-up, nearly two thirds of patients benefited from the operation.

^* Gewidmet Herrn Prof. Dr. med. Dr. h. c. Hans Lippert anlässlich seiner Emeritierung als Ordinarius für Chirurgie der Medizinischen Fakultät der Otto-von-Guericke-Universität Magdeburg

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