Laboratory and instrumental criteria for assessing the persistence of primary hyperparathyroidism within the first day after surgery. Retrospective assessment of risk
Background. The variability of laboratory results leads to an indepth study of the past medical history and clinical picture, as well as diagnostic procedures to detect parathyroid glands with altered functional activity. The purpose of the study was to determine the most effective methods for assessing the persistence of primary hyperparathyroidism (PHPT) in the early postoperative period and ways to prevent such a condition. Materials and methods. A retrospective review of a prospectively collected database of patients operated for PHPT has been conducted. At the preoperative stage, an ultrasound examination of the neck, along with the evaluation of ionized calcium, parathyroid hormone and blood creatinine, was performed in all patients to visualize parathyroid adenomas. Results. Between January 1, 2014 and December 31, 2018, 436 patients underwent surgery for PHPT, 408 women (93.6 %) and 28 men (6.4 %). Seven patients (1.6 %) required repeated surgery for the persistence of hyperparathyroidism, which correlates with data from foreign scientific papers. Each case is considered separately. Three patients underwent 99mTcMIBI scan at the preoperative stage. The persistence criteria were parathyroid hormone and ionized calcium levels on the first day of the postoperative period. The average level of parathyroid hormone before surgery in these patients was 182.15 ± 31.25 pg/ml, the average level of Ca2+ — 1.44 ± 0.05 mmol/l. After performing first surgery, the level of parathyroid hormone decreased on average to 117.55 ± 20.55 pg/ml, Ca2+ — to 1.34 ± 0.05 mmol/l. It should be noted that all these patients underwent a unilateral revision of the parathyroid glands. Considering the presence of obvious laboratory signs of hyperparathyroidism persistence, additional instrumental study (contrastenhanced computed tomography of the chest) and repeated surgery were performed in 4 patients. After repeated surgical treatment, the level of parathyroid hormone decreased on average to 40.19 ± 13.21 pg/ml, the level of Ca2+ — to 1.25 ± 0.03 mmol/l. For the control group, 80 patients were selected, they underwent successful surgical treatment for PHPT. The average level of parathyroid hormone before surgery was 206.3 ± 16.0 pg/ml, the average level of Ca2+ — 1.48 ± 0.02 mmol/l. After first operation, parathyroid hormone decreased on average to 16.67 ± 1.28 pg/ml and Ca2+ — to 1.19 ± 0.01 mmol/l. The main cause of PHPT persistence is a combination of parathyroid hyperplasia and parathyroid adenoma (4 patients (57.14 %)). Rarely, the cause of disease persistence was double parathyroid adenoma — in 2 patients (28.57 %) and true parathyroid hyperplasia — in 1 patient (14.29 %). Conclusions. Determining the level of parathyroid hormone on the first postoperative day is of critical importance after intervention for PHРT in terms of hypocalcemia or disease persistence detection, followed by determination of ionized calcium in the blood, which characterizes the effectiveness of surgical treatment. The combination of parathyroid adenoma and true parathyroid hyperplasia that was not verified at the preoperative stage by additional instrumental methods (contrastenhanced multislice computed tomography of the neck and chest with) is the main cause of persistence of primary hyperparathyroidism. Rarely, the cause of disease persistence is double parathyroid adenoma and true parathyroid hyperplasia. 99mTcMIBI scan is an important method of preoperative diagnosis, but only in combination with other radiological methods in case of the defeat of 2 or more parathyroid glands.
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