Department of Visceral-, Thoracic and Vascular Surgery, Philipps-University Marburg, Baldingerstraße, 35043 Marburg, Germany.
Langenbecks Arch Surg. 2013 Jan;398(1):99-106. doi: 10.1007/s00423-012-1004-y. Epub 2012 Sep 23.
Reoperations (R-PTX) for primary hyperparathyroidism (pHPT) are challenging, since they are associated with increased failure and morbidity rates. The aim was to evaluate the results of reoperations over two decades, the latter considering the implementation of Tc(99m)sestamibi-SPECT (Mibi/SPECT), intraoperative parathormone (IOPTH) measurement, and intraoperative neuromonitoring (IONM).
Data of 1,363 patients who underwent surgery for pHPT were retrospectively analyzed regarding reoperations. Causes of persistent (p) pHPT or recurrent (r) pHPT, preoperative imaging studies, surgical findings, and outcome were analyzed. Data of patients who underwent surgery between 1987 and 1997 (group 1; G1) and between 1998 and 2008 (group 2; G2) with the use of Mibi/SPECT, IOPTH, and IONM were evaluated.
One hundred twenty-five patients with benign ppHPT (n = 108) or rpHPT (n = 17) underwent reoperations (R-PTX). Group 1 included 54, group 2 71 patients. Main cause of ppHPT (G1 = 65 % vs. G2 = 53 %) and rpHPT (G1 = 80 % vs. G2 = 60 %) was the failed detection of a solitary adenoma (p = 0.2). Group 1 patients had significantly less unilateral/focused neck re-explorations (G1 = 23 % vs. G2 = 57 %, p = 0.0001), and more sternotomies (G1 = 35 vs. G2 = 14 %, p = 0.01). After a median follow-up of 4 (range 0.9-23.4) years, reversal of hypercalcemia was achieved in 91 % (G1) and in 98.6 % in group 2 (p = 0.08, OR 7.14 [0.809-63.1]). The rates of permanent recurrent laryngeal nerve palsy (G1 = G2 = 9 %, p = 1) and of postoperative permanent hypoparathyroidism (G1 = 9 % vs. G2 = 6 %, p = 0.5) were not significantly different. Other complications such as wound infection, postoperative bleeding, and pneumonia were significantly lower in group 2 (p < 0.001).
Nowadays, cure rates of R-PTX are nearly the same as in primary operations for pHPT. These results can be achieved in high-volume centers by routine use of well-established preoperative Mibi/SPECT and US in combination with IOPTH. However, morbidity is still considerably high.
甲状旁腺功能亢进症（pHPT）的再次手术（R-PTX）具有挑战性，因为其与手术失败率和发病率的增加有关。本研究旨在评估过去二十年的再次手术结果，后者考虑了 Tc(99m)锝甲氧基异丁基异腈 SPECT（Mibi/SPECT）、术中甲状旁腺激素（IOPTH）测量和术中神经监测（IONM）的应用。
回顾性分析了 1363 名接受 pHPT 手术的患者的再次手术数据，分析了持续性（p）pHPT 或复发性（r）pHPT 的原因、术前影像学研究、手术发现和结果。评估了 1987 年至 1997 年（第 1 组；G1）和 1998 年至 2008 年（第 2 组；G2）之间接受 Mibi/SPECT、IOPTH 和 IONM 检查的患者数据。
125 名患有良性 ppHPT（n=108）或 rpHPT（n=17）的患者接受了再次手术（R-PTX）。G1 组包括 54 名患者，G2 组包括 71 名患者。p pHPT（G1=65% vs. G2=53%）和 rpHPT（G1=80% vs. G2=60%）的主要原因是单发性腺瘤的漏诊（p=0.2）。G1 组单侧/焦点性颈部再次探查的比例明显较低（G1=23% vs. G2=57%，p=0.0001），胸骨切开术的比例较高（G1=35% vs. G2=14%，p=0.01）。中位随访 4 年（范围 0.9-23.4）后，G1 组 91%（G1）和 G2 组 98.6%（G2）的血钙水平恢复正常（p=0.08，OR 7.14 [0.809-63.1]）。永久性喉返神经麻痹的发生率（G1=G2=9%，p=1）和术后永久性甲状旁腺功能减退症的发生率（G1=9% vs. G2=6%，p=0.5）无显著差异。G2 组的其他并发症如伤口感染、术后出血和肺炎明显较低（p<0.001）。
目前，R-PTX 的治愈率与 pHPT 的初次手术几乎相同。在高容量中心，通过常规使用已建立的术前 Mibi/SPECT 和 US 联合 IOPTH，可以实现这些结果。然而，发病率仍然相当高。
