Surgical Treatment of Primary Hyperparathyroidism: Which Therapy to Whom?
Nurcihan Aygun, Mehmet UludagDepartment of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, TurkeyPrimary hyperparathyroidism (pHPT) is characterized by an increase in the levels of PTH and Ca, or one of these (Ca, PTH) as a result of a dysregulation of calcium (Ca) metabolism due to inappropriate excess parathyroid hormone (PTH) autonomously produced from one or more than one parathyroid glands. Ninety to 95% of pHPT is a sporadic type, which is not associated with the familial history and other endocrine organ tumors, and 5-10% of it is hereditary. While 80-85% of pHPT arises from a single parathyroid adenoma, 4-5% is caused by a double adenoma, 10-15% by multigland hyperplasia and less than 1% by parathyroid cancer. The diagnosis of pHPT is reached biochemically. The only curative treatment of pHPT is surgery. The choice of surgery in pHPT may vary depending on whether the patient has hereditary HPT or thyroid disease requiring surgical treatment, preoperative localization studies and the findings in these studies, the possibilities of using intraoperative PTH and the preference of the surgeon.
The preoperatively determined surgical strategy can be revised according to intraoperative findings in case of need to achieve excellent results. The two main approaches in the surgical treatment of pHPT are BNE (bilateral neck exploration) and MIP (minimal invasive parathyroidectomy). Although BNE is a consistently valid option that has excellent results in the surgical treatment of pHPT and is considered the gold standard, MIP is the ideal approach in selected patients with clinically and radiologically considered a single-gland disease. Negative imaging is not a contraindication for parathyroid surgery and is not a criterion for the presence or absence of surgical indication. Although both methods are safe and effective in the surgical treatment of sporadic pHPT, there is still controversy regarding the effectiveness of both methods.
Surgical intervention should establish the risk-benefit balance well, minimize the risk of persistent and recurrent disease and provide the highest cure rate without increasing the risk of complications. Complication rates are higher in the secondary surgery, thus in secondary procedures, selective surgery should be performed under guidance of an imaging modality.
The surgical strategy should be determined to achieve maximum cure with minimum dissection and minimal morbidity. In this study, we aimed to determine the type of surgical treatment and pHPT patients suitable for the surgical treatment.
Primer Hiperparatiroidizmde Cerrahi Tedavi: Kime Hangi Tedavi?
Nurcihan Aygun, Mehmet UludagDepartment of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, TurkeyPrimer hiperparatiroidizm (pHPT) bir veya birden fazla paratiroid bezinden uygunsuz olarak otonom fazla paratiroid hormon (PTH) uretimine bagli olarak kalsiyum (Ca) metabolizmasinin regulasyonunda bozukluk sonucunda PTH ve Ca duzeylerinde artis veya bunlardan birinin (Ca, PTH) uygunsuz olarak normal olmasi ile karakterizedir. pHPT'nin %90-95'i ailesel oyku ve diger endokrin organ tumorleri ile iliskisi olmayan sporadik tip olup, %5-10'u herediterdir. pHPT'nin % 80-85'ine tek paratiroid adenomu, % 4-5'ine cift adenom, % 10- 15'ine coklu bez hiperplazisi ve % 1'den azina paratiroid kanseri neden olmaktadir. pHPT'nin tanisi biyokimyasal olarak koyulur. pHPT'nin tek kuratif tedavisi cerrahidir. pHPT'de ameliyat tercihi hastada herediter HPT olup olmamasina, cerrahi tedavi gerektirecek tiroid hastaligi olup olmamasina, yapilan preoperatif lokalizasyon calismalarina ve bu calismalardaki bulgulara gore, intraoperatif PTH kullanilma olanaklarina, cerrahin tercihine bagli olarak degisebilir. Mukemmel sonucu alabilmek icin preoperatif belirlenen cerrahi strateji, gerektiginde intraoperatif bulgulara gore revize edilebilir. pHPT'nin cerrahi tedavisinde 2 temel yaklasim, BBE ve MIP yontemleridir. BBE, pHPT'nin cerrahi tedavisinde mukemmel sonuclara sahip, altin standart olarak kabul edilen ve surekli gecerli bir opsiyon olmasina ragmen, gunumuzde MIP klinik ve radyolojik olarak tek bez hastaligi dusunulen secilmis hastalarda ideal yaklasimdir. Goruntulemenin negatif olmasi cerrahi endikasyonun olup olmadigini belirleyen kriter olmayip paratiroid cerrahisi icin kontrendikasyon degildir. Sporadik pHPT'nin cerrahi tedavisinde her iki yontem de guvenli ve etkili yontemler olmasina ragmen, her iki yontemin etkinligi ile ilgili tartismalar halen devam etmektedir. Temel olarak yapilan cerrahi girisim risk yarar dengesini iyi kurmali, persistan ve rekuren hastalik riskini minimalize ederek en yuksek kur oranini saglamali, komplikasyon riskini de arttirmamalidir. Kur oranini azaltan herhangi bir yontem persistan ve rekuren hastaliga bagli olarak ikincil paratiroidektomi riskini arttirmaktadir. Deneyimli cerrahlar tarafindan yapilan ikincil paratiroidektomilerde basari orani %90'in uzerinde olmasina ragmen, hastanin en dusuk komplikasyonla en yuksek kur orani ilk cerrahide elde edilebilir. Ayrica ikincil cerrahide komplikasyon oranlari daha yuksektir. Ikincil girisimlerde mumkun oldugunca goruntuleme klavuzlugunda selektif cerrahi uygulanmalidir. En az diseksiyonla ve en az morbidite ile en yuksek kurun saglanabilecegi cerrahi strateji belirlenmelidir. Bu calismada pHPT tanili hastalarda kime hangi cerrahi tedavinin uygulanabilecegini degerlendirmeyi amacladik.
Anahtar Kelimeler: primer hiperparatiroidizm, bilateral boyun eksplorasyonu, tek tarafli boyun eksplorasyonu, minimal invaziv paratiroidektomiManuscript Language: Turkish