Algirdas Šlepavičius, Laura Keinaitė
Introduction: The utility of intraoperative intact parathormone (hereinafter – iPTH) measurement in surgical treatment of secondary hyperparathyroidism is not precised by scientists. The aim of this study is to demonstrate the efficiency of iPTH monitoring, assessing the success of surgery in patients with secondary hyperparathyroidism. Methods: The retrospective measurement efficacy study of the intraoperative diagnostic monitoring of PTH in a cohort of surgical patients with secondary hyperparathyroidism has been applied. The group of investigation consisted of 23 patients: 13 women and 10 men. The average of their age was 33±18 years. All patients had secondary hyperparathyroidism for a long time and dialisis for 6±4,1 years because of the chronic renal failure. From April, 2004, till January, 2013, all 23 patients underwent total parathyroidectomy with resection of thymus gland and autotransplantation surgery of parathyroid glands at the Department of Abdominal and Endocrine system surgery in Klaipeda University Hospital. The levels of iPTH were measured for all patients during the operation. The aliquots were taken at these stages of the operation: the first measurement – after anesthesia induction, the second one – after 15 minutes from all parathyroid tissue removal and as an additional measurement, if the latter level of iPTH didn‘ t decrease acceptably. Then the operation was extended. After 15 minutes from the removal of ectopic parathyroid glands, iPTH level was measured additionally. The third aliquot for all 23 patients was taken after 23 hours from the surgical treatment. Results: Intraoperative PTH was measured for all 23 patients. The average of iPTH before the incision was 1655±343 pg/ml. For 19 patients, after 15 minutes from the removal of all parathyroid glands (18 patients had 4 glands and 1 patient had 3 glands), iPTH levels decreased more than 84% from the baseline (the statistical average of the descent of their iPTH was 91%). After 15 minutes from the removal of all parathyroid tissue (3 parathyroid glands), the descent of iPTH wasn‘t adequate for 3 persons (the statistical average of the descent of their iPTH was 46%). For this reason operations were extended. 2 patients of 3 had fourth parathyroid gland in their necks and after 15 minutes from it‘s removal, iPTH levels were measured additionally – the average of the descent was 96%. However for 1 patient surgeons couldn‘t find the fourth gland, even when the surgical treatment was prolonged. For this reason, the operation was finished and 4 months later the sestamibi scintigram of parathyroid glands was made. The fourth gland was found in the mediastinum. Due to this, the patient underwent surgical treatment repeatedly: sternotomy and total parathyroidectomy were made. After 15 minutes from all parathyroid tissue removal, iPTH levels decreased 96% from the baseline. For that reason autotransplantation was made. For 1 patient of 23 patients, the descent of iPTH after 15 minutes from the removal of 4 parathyroid glands wasn‘t still adequate – only 50%, the operation was continued and finished after the fifth gland had been found. Consequently, iPTH decreased more than 95%. Conclusions: The descent of iPTH for more than 84%, after 15 minutes from all parathyroid tissue removal, indicated the success of surgical treatment in patients with secondary hyperparathyroidism. If the descent of iPTH is less than 84%, the operation has to be extended, because of necessity to find the additional parathyroid glands.
Keyword(s): secondary hyperparathyroidism, total parathyroidectomy, intraoperative monitoring of parathormone
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