Influencia de los valores preoperatorios de hormona paratiroidea en el desarrollo de hipoparatiroidismo postquirúrgico
- Autores: José Alberto Vilar
- Directores de la Tesis: Julio Jesús Acero Sanz (dir. tes.), Joaquín Gómez Ramírez (codir. tes.)
- Lectura: En la Universidad de Alcalá ( España ) en 2022
- Idioma: español
- Tribunal Calificador de la Tesis: Francisco Javier Burgos Revilla (presid.), Augusto García Villanueva (secret.), Leyre Lorente Poch (voc.)
- Programa de doctorado: Programa de Doctorado en Ciencias de la Salud por la Universidad de Alcalá
- Materias:
- Enlaces
- Resumen
- español
Introducción: El hipoparatiroidismo postquirúrgico es la complicación más frecuente de la tiroidectomía total. El objetivo principal de este estudio es analizar si los valores de hormona paratiroidea previos a la tiroidectomía total pueden tener un papel en el desarrollo de hipoparatiroidismo postquirúrgico inmediato, prolongado o permanente. Los objetivos secundarios del estudio son: Analizar si el PGRIS (Parathyroid glands remaining in situ) o la escala PDS (Parathyroid damage score) de manipulación intraoperatoria de las glándulas paratiroideas pueden predecir el riesgo de hipoparatiroidismo.
Materiales y métodos: Estudio observacional longitudinal y prospectivo en una serie de 100 pacientes consecutivos en los que se realiza una tiroidectomía total.
Resultados: La tasa de hipoparatiroidismo inmediato fue del 42%, prolongado 11% y permanente 5%. La mediana de PTH preoperatoria entre los pacientes que no padecieron hipoparatiroidismo inmediato y los que lo padecieron fue semejante (65,4 pg/mL [RIQ 49,3-89,6] vs. 62,6 pg/mL [RIQ 49,8-86,1]; p=0,815). Los pacientes con un PGRIS menor presentaron mayor riesgo de hipoparatiroidismo postquirúrgico inmediato (PGRIS 2; 83,3% vs. PGRIS 3; 54,3% vs. PGRIS 4; 30,5%; p=0,008). La mediana de PDS en los pacientes con hipoparatiroidismo fue más alta que en el resto de pacientes (8 (RIQ 6-9,3) vs. 6 (RIQ 4-7); p=0,000). No encontramos esa asociación entre el PGRIS y el PDS con el desarrollo de hipoparatiroidismo prolongado ni permanente. Los pacientes que padecieron hipoparatiroidismo inmediato tuvieron una media de descenso de la PTH mayor a las 24 horas (81,7 ± 17,2% vs. 33,4 ± 26,3; p=0,000). Los pacientes con hipoparatiroidismo prolongado y permanente tuvieron un porcentaje de descenso de PTH mayor (93,7 ± 2,4% vs. 48,4 ± 31,7%; p=0,000) y (94,1 ± 2,3% vs. 51,2 ± 32.6%; p=0,000) respectivamente.
Conclusiones: No encontramos diferencias estadísticamente significativas en la mediana de PTH preoperatoria en los pacientes con hipoparatiroidismo inmediato, prolongado ni permanente. El PDS score puede ser una herramienta útil para predecir el desarrollo de hipoparatiroidismo inmediato. Los pacientes con un PGRIS menor presentaron mayor riesgo de hipoparatiroidismo inmediato. Los pacientes que padecieron hipoparatiroidismo inmediato, prolongado y permanente tuvieron mayor porcentaje de descenso de la PTH.
- English
Background: Postoperative hypoparathyroidism is the most frequent complication after total thyroidectomy. Being the main cause of increased hospital stay and healthcare costs. The identification of possible preoperative predictors of hypoparathyroidism could be helpful to identify patients at risk of postoperative hypoparathyroidism. This study aimed to evaluate the potential influence of preoperative PTH levels on instant, protracted and permanent hypoparathyroidism. The secondary objectives are the analysis of an association between PGRIS (“Parathyroid glands remaining in situ”) and postoperative hypoparathyroidism, and if PDS (Parathyroid damage score) of parathyroid gland manipulation could predict the risk of hypoparathyroidism. The determination of a PTH cut-off point at 24 hours and an analysis of the percentage of decrease in PTH at 24 hours can predict the development of instant, prolonged and permanent hypoparathyroidism.
Method: A prospective, observational study that includes 100 consecutive patients who underwent total thyroidectomy between September 2018 and December 2020. Demographic, surgical and biochemical variables were analysed using the statistical data program SPSS® 20th ed.
Results: 84% of the sample are women and 16% men. The mean age is 54,88 years old (SD 14,78). The main surgical indication was multinodular goiter (57%), followed by papillary carcinoma (30%), Graves’ disease (16%) and medullary carcinoma (1%). The mean hospital stay was 1.78 days (SD 1.368). 6-9.3) vs. 6 (IQR 4-7); p = 0,000). We did not find such association between PGRIS and PDS, and the development of protracted nor permanent hypoparathyroidism. The median PTH at 24 hours in patients with protracted and permanent hypoparathyroidism was significantly lower than the rest (4.7 pg / mL [IQR 3.3- 6.5] vs. 29.4 pg / mL [IQR 13, 4-46.7]; p= 0, 000) and (4.7 pg / mL [IQR 3.7-6] vs. 26.7 pg / mL [IQR 11.3-46.4]; p = 0.000). The rate of protracted and permanent hypoparathyroidism was significantly higher in patients with PTH at 24 hours lower than 6.6 pg/mL (64.5% vs. 2.3%; p = 0.000 and 35.7% vs. 0 %; p = 0.000, respectively). Patients with postoperative hypoparathyroidism had a greater mean PTH decrease (81.7 ± 17.2% vs. 33.4 ± 26.3; p = 0.000). The prevalence of hypoparathyroidism was higher among patients who suffered a PTH decrease rate above 60% compared to those with a lower decrease (83% vs. 5.7%; p = 0.000). Patients with protracted and permanent hypoparathyroidism had a greater PTH decrease (93.7 ± 2.4% vs. 48.4 ± 31.7%; p = 0.000 and 94.1 ± 2.3% vs. 51.2 ± 32.6%; p = 0.000, respectively).
Conclusions: No statistically significant differences were found between preoperative mean PTH in patients with instant, protracted or permanent hypoparathyroidism. We found that groups with higher preoperative PTH had significantly higher rates of protracted and permanent hypoparathyroidism. We did not find a statistically significant association between sex, age, initial diagnosis and extent of surgery, and hypoparathyroidism. Patients that suffer transient hypoparathyroidism had lower preoperative vitamin D. Patients with lower PGRIS had a higher risk of instant hypoparathyroidism; on the other hand, we did not find a statistically significant association in regards to the incidence of protracted or permanent hypoparathyroidism. The PDS score could be a useful tool to predict the development of instant hypoparathyroidism; patients with a PDS of more than 7 had a 4.6-fold increased risk. We did not find a statistically significant association with protracted nor permanent hypoparathyroidism. Median PTH at 24 hours was significantly higher in patients without hypoparathyroidism. The cut-off point for instant hypoparathyroidism was 13.8 pg / mL and 6.6 pg / mL for protracted and permanent hypoparathyroidism. Patients with instant, protracted and permanent hypoparathyroidism had a higher percentage of PTH decrease. The incidence of instant hypoparathyroidism was higher among patients who suffered a PTH decrease rate above 60%. The incidence of protracted and permanent hypoparathyroidism was higher in patients with a decrease greater than 90%.
- español
