Muss der intraoperative Quick-Parathormonwert beim lokalisierten, sporadischen Hyperparathyreoidismus abgewartet werden?

Zusammenfassung

Hintergrund Die fokussierte Parathyreoidektomie hat sich in den letzten Jahren zum Eingriff der Wahl beim lokalisierten sporadischen primären Hyperparathyreoidismus (pHPT) entwickelt. Als Voraussetzung für eine erfolgreiche Operation wird die intraoperative Quick-Parathormonbestimmung (qPTH) angesehen. Allerdings verursacht die qPTH-Bestimmung eine Verlängerung der Operations- und Narkosezeit. Ziel der Studie war zu prüfen, welche Nachteile für den Patienten entstehen, wenn der intraoperative qPTH-Wert nicht generell abgewartet wird.

Methoden Zwischen März 2009 und September 2017 wurde bei 202 Patienten mit pHPT und konkordanter Lokalisationsdiagnostik (^99mTc-Sestamibi-Szintigrafie, Halssonografie) eine fokussierte Parathyreoidektomie angeboten. Bei allen Patienten wurde eine Schnellschnittuntersuchung und ein qPTH-Test (Basalwert und 15-Minuten-post-Exzisions-Wert) durchgeführt. Im Falle eines für den Operateur makroskopisch überzeugenden Adenoms wurde der 15-Minuten-qPTH-Wert nicht abgewartet, sondern der Eingriff nach Vorliegen des bestätigenden Schnellschnittergebnisses beendet. Die Patienten waren informiert, dass für den Fall eines inadäquaten PTH-Abfalls ggf. am Folgetag eine Reexploration erfolgen würde.

Ergebnisse Insgesamt wurden 176 (87,1%) der 202 fokussierten Eingriffe beendet, ohne den qPTH-Wert abzuwarten. Die durchschnittliche Operationszeit bei diesen Eingriffen betrug 60,4 ± 32,9 min. Bei all diesen Patienten wurde der 15-Minuten-qPTH erst nach Extubation durchgegeben und war adäquat um über 50% in den Normbereich abgefallen. Bei 26 (12,9%) Patienten wurde der qPTH-Wert abgewartet. Die durchschnittliche Operationszeit war mit 112,0 ± 43,1 min signifikant länger (p = 0,0095) als bei den 176 Eingriffen ohne Abwarten des qPTH-Werts. Bei 8 der 26 Patienten wurde der Eingriff aufgrund eines inadäquaten PTH-Abfalls ausgeweitet. Bei 2 dieser Patienten, somit 2 von 202 (0,99%) Patienten, persistierte postoperativ der pHPT.

Zusammenfassung Bei Patienten mit sporadischem pHPT und einem präoperativ konkordant lokalisierten, singulären Adenom muss der intraoperative qPTH-Wert nicht generell abgewartet werden, wenn ein makroskopisch überzeugendes Adenom entfernt und im Schnellschnitt bestätigt wurde. Dieses Vorgehen ist für die Patienten sicher und reduziert Operationszeit und Kosten.

Abstract

Background In the recent years, targeted surgery, especially minimally invasive parathyroidectomy, has become the procedure of choice to treat sporadic primary hyperparathyroidism (pHPT) and is performed after preoperative standardised, accurate and reliable localisation. The intraoperative quick parathyroid hormone (qPTH) test is considered as a condition for successful resection of the parathyroid adenoma. The intraoperative qPTH test prolongs surgery and anaesthesia. The aim of this study was to evaluate whether there are disadvantages if patients do not wait for the qPTH result before terminating the procedure.

Methods Between March 2009 and September 2017, 202 patients with solitary parathyroid adenoma – diagnosed on the basis of concordant positive results in ^99mTc-sestamibi scintigraphy and neck ultrasound – were scheduled for a focused procedure. In all patients, frozen section and qPTH test (baseline and 15 minutes after adenoma resection) were performed, but in patients with parathyroid adenoma that was evident to the responsible surgeon after macroscopic resection, surgery was not finished before the results of the qPTH test were available. The result of frozen section was awaited in all cases. Patients were informed that re-exploration has to be performed on the following day if there were persistently high levels of PTH after adenoma excision.

Results Overall, 176 (87.1%) of the 202 targeted procedures were finished without waiting for the qPTH test result. The mean operation time was 60.4 min (SD 32.9). In all patients, the result of the qPTH test was received after extubation. Successful excision of the adenoma was confirmed by a PTH drop of at least 50% into the standard range. In 26 (12.9%) patients the qPTH result was waited for. The mean operation time in these cases was significantly longer with 112.0 min (SD 43.1). In 8 of these 26 patients, the operation was extended with unilateral or bilateral exploration, due to the inadequate decrease in qPTH. Overall, 2 of 202 (0.99%) patients suffered persistent disease after the focussed approach.

Conclusion In patients with sporadic pHPT and preoperative and consistently solitary parathyroid adenoma – localised by neck ultrasound and ^99mTc-sestamibi scintigraphy –, the result of the qPTH test must not generally be awaited. The prerequisite is an adenoma that is convincing for the surgeon and which can be confirmed in frozen section analyses. This approach is safe and spares operative time and money.

Schlüsselwörter

pHPT - minimalinvasive Parathyreoidektomie - intraoperative Parathormonbestimmung

Key words

primary hyperparathyroidism - intraoperative parathyroid hormone measurement - focused parathyroidectomy

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