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Kuo YC, Wang SY, Hung YL, Hsu CC, Kou HW, Chen MY, Tsai CY, Chang CH, Wang YC, Hsu JT, Yeh TS, Lee WC, Yeh CN. Risk factors of recurrent secondary hyperparathyroidism after adequate primary surgical treatment. Front Endocrinol (Lausanne) 2023; 14:1063837. [PMID: 36817581 PMCID: PMC9936184 DOI: 10.3389/fendo.2023.1063837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Secondary hyperparathyroidism (SHPT) is a common condition in patients with end-stage renal disease (ESRD) who are on dialysis. Parathyroidectomy is a treatment for patients when medical therapy has failed. Recurrence may occur and is indicated for further surgery in the era of improved quality of care for ESRD patients. METHODS We identified, 1060 patients undergoing parathyroidectomy from January, 2011 to June, 2020. After excluding patients without regular check-up at our institute, primary hyperparathyroidism, or malignancy, 504 patients were enrolled. Sixty-two patients (12.3%, 62/504) were then excluded due to persistent SHPT even after the first parathyroidectomy. We aimed to identify risk factors for recurrent SHPT after the first surgery. RESULTS During the study period, 20% of patients who underwent parathyroidectomy at our institute (in, 2019) was due to recurrence after a previous parathyroidectomy. There were 442 patients eligible for analysis of recurrence after excluding patients with the persistent disease (n = 62). While 44 patients (9.95%) had recurrence, 398 patients did not. Significant risk factors for recurrent SHPT within 5 years after the first parathyroidectomy, including dialysis start time to first operation time < 3 years (p = 0.046), postoperative PTH >106.5 pg/mL (p < 0.001), and postoperative phosphorus> 5.9 mg/dL (p = 0.016), were identified by multivariate analysis. CONCLUSIONS The starting time of dialysis to first operation time < 3 years in the patients with dialysis, postoperative PTH> 106.5 pg/mL, and postoperative phosphorus> 5.9 mg/dL tended to have a higher risk for recurrent SHPT within 5 years after primary treatment.
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Affiliation(s)
- Yu-Chi Kuo
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Shang-Yu Wang
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Yu-Liang Hung
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Chih-Chieh Hsu
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Hao-Wei Kou
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Ming-Yang Chen
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Chun-Yi Tsai
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Chih-Hsiang Chang
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- Kidney Research Center, Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yu-Chao Wang
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Jun-Te Hsu
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Ta-Sen Yeh
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Wei-Chen Lee
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chun-Nan Yeh
- Division of General Surgery, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan
- *Correspondence: Chun-Nan Yeh,
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg 2022; 276:e141-e176. [PMID: 35848728 DOI: 10.1097/sla.0000000000005522] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.
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Zhong A, Billa V, Rotstein LE, Wong PY, Bargman JM, Vas SI, Oreopoulos DG. Recurrence of Hyperparathyroidism after Total Parathyroidectomy and Autotransplantation in Peritoneal Dialysis Patients. Perit Dial Int 2020. [DOI: 10.1177/089686080002000207] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective To evaluate the effectiveness of total parathyroidectomy (PTX) with autotransplantation in the treatment of secondary hyperparathyroidism (HPT), and to assess recurrence rate of HPT in this peritoneal dialysis (PD) population. Design A retrospective study in a single home PD unit. Patients Between 1994 and 1998, 19 of 574 patients on PD underwent PTX for treatment of secondary HPT. Main Outcome Measures Clinical and biochemical improvement, recurrence of HPT, improvement in anemia post-PTX. Results Nineteen (3.3%) patients required PTX between 1994 and 1998. These 5 men and 14 women ranged in age from 22 to 66 years; they had been on maintenance PD pre-PTX for 47.5 ± 38.1 months, and were followed for 26.1 ± 15.5 months post-PTX. Sixteen patients had temporary hypocalcemia that was managed by oral (n = 10) or intravenous (n = 6) calcium supplements and calcitriol, while 3 patients had severe “hungry bone” syndrome postoperatively. One patient had recurrent laryngeal nerve palsy post-PTX. Bone pain disappeared in all 12 patients. Pruritus improved in 12/13 patients; fatigue improved in 15/16 patients. Comparison showed significant differences between hemoglobin and hematocrit values 1 month pre-PTX and 12 months post-PTX ( p < 0.05). Parathyroid hormone (PTH) level in 15 (79%) patients returned to normal (≤€7.6 pmol/L) during the first month post-PTX. In 5/12 (42%) patients, PTH level was ≤ 7.6 pmol/L 2 years post-PTX, while in 2/12 (17%), PTH was > 22.8 pmol/L (three times normal) 2 years post-PTX, and 3/5 (60%) patients had a PTH > 22.8 pmol/L 3 years post-PTX. Conclusions Total PTX with autotransplantation is associated with a tendency for recurrence of HPT. Our findings suggest that total PTX with autotransplantation may be an ineffective procedure in controlling HPT over the long term.
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Affiliation(s)
- Aimin Zhong
- Division of Nephrology, The Toronto Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Viswanath Billa
- Division of Nephrology, The Toronto Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Lorne E. Rotstein
- Division of Nephrology, Division of Surgery of the Head and Neck, The Toronto Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Pui Y. Wong
- Laboratory Medicine & Pathobiology, The Toronto Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Joanne M. Bargman
- Division of Nephrology, The Toronto Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Stephen I. Vas
- Division of Nephrology, The Toronto Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Dimitrios G. Oreopoulos
- Division of Nephrology, The Toronto Hospital and University of Toronto, Toronto, Ontario, Canada
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Caglar O, Otgun I, Yalcin Comert H, Gencoglu A, Baskin E. Effectiveness of the Gamma Probe in Childhood Parathyroidectomy: Retrospective Study. Cureus 2020; 12:e6629. [PMID: 31966944 PMCID: PMC6957029 DOI: 10.7759/cureus.6629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background There are few reports about parathyroidectomy due to secondary hyperparathyroidism in patients with end-stage renal failure in the literature. We aimed to evaluate the surgical treatment methods and the results of patients who were operated for secondary hyperparathyroidism with end-stage renal disease in our center. Method Sixteen patients with the diagnosis of secondary hyperparathyroidism were treated surgically in our center. Demographical data, laboratory findings, and imagining methods were all examined. The effect of the Technetium 99m methoxyisobutylisonitrile (Tc-99m-MIBI) probe sensitive to gamma rays detection was also evaluated to locate and identify all the parathyroid glands during the operation. Results Eleven of the patients underwent intravenous (IV) Tc-99m MIBI preoperatively and a gamma probe was detected during surgery. The gamma probe was not used in five patients. Four parathyroid glands were removed in eight (72.7%) out of 11 patients with gamma probes and three parathyroid glands were found in three patients. Total parathyroidectomy and parathyroid autoimplantation were made to eight patients who had removed four glands, subtotal parathyroidectomy was done for the other patients. On a comparison of laboratory findings before and after the surgery, there was a significant relationship between the decrease of serum parathyroid hormone and calcium levels (p<0.05). Conclusion Total parathyroidectomy and parathyroid autoimplantation is the most efficient and safe mode of management for secondary parathyroidism patients. During the surgery, using a probe sensitive to gamma rays detection may also help the surgeon. Thus, unnecessary dissections to prevent the presence of atypical parathyroid glands are prevented.
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Affiliation(s)
- Ozgur Caglar
- Pediatric Surgery, Ataturk University, Erzurum, TUR
| | | | | | | | - Esra Baskin
- Pediatric Nephrology, Baskent University, Ankara, TUR
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Aiti A, Rossi M, Alviano F, Morara B, Burgio L, Cioccoloni E, Cavicchi O, Pasquinelli G, Bonsi L, Buzzi M. Parathyroid Tissue Cryopreservation: Does the Storage Time Affect Viability and Functionality? Biopreserv Biobank 2019; 17:418-424. [PMID: 31025874 DOI: 10.1089/bio.2018.0140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Parathyroidectomy is a standard practice to treat recurrent or persistent hyperparathyroidism. However, this can lead to the onset of hypoparathyroidism, treatable with the autotransplantation of parathyroid tissue (PT). Tissue can be transplanted immediately after parathyroidectomy or cryopreserved and transplanted only in case of necessity. Since 2011, the Cord Blood Bank and Cardiovascular Tissue Bank of Emilia-Romagna has been storing PT for potential autologous transplantation. To date, there are highly variable data about the viability and function of PT after thawing. However, it is not clear if the PT quality is affected by different cryopreservation protocols and/or by the storage time. The aim of this study was to assess the ex vivo function and viability of the PTs of ten patients stored in the Bank. Tissue morphology was evaluated before and after cryopreservation through histological investigations. PT function was analyzed by assessing the ability of cryopreserved PT to synthesize and secrete parathyroid hormone (PTH) in response to different calcium concentrations. Moreover, viability and function were also investigated on tissue-isolated cells in culture. These data show that tested tissues appear to be viable and able to produce PTH even after 5 years of storage, and the histological architecture is well preserved.
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Affiliation(s)
- Annalisa Aiti
- Emilia Romagna Cord Blood Bank, Immunohaematology and Transfusion Medicine, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Martina Rossi
- Unit of Histology, Embryology and Applied Biology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Francesco Alviano
- Unit of Histology, Embryology and Applied Biology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Barbara Morara
- Emilia Romagna Cord Blood Bank, Immunohaematology and Transfusion Medicine, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Luca Burgio
- Otolaringology Unit, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Eleonora Cioccoloni
- Otolaringology Unit, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Ottavio Cavicchi
- Otolaringology Unit, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Gianandrea Pasquinelli
- Unit of Surgical Pathology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Laura Bonsi
- Unit of Histology, Embryology and Applied Biology, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Marina Buzzi
- Emilia Romagna Cord Blood Bank, Immunohaematology and Transfusion Medicine, St. Orsola-Malpighi University Hospital, Bologna, Italy
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Ribeiro C, Penido MGMG, Guimarães MMM, Tavares MDS, Souza BDN, Leite AF, de Deus LMC, Machado LJDC. Parathyroid ultrasonography and bone metabolic profile of patients on dialysis with hyperparathyroidism. World J Nephrol 2016; 5:437-447. [PMID: 27648407 PMCID: PMC5011250 DOI: 10.5527/wjn.v5.i5.437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 04/12/2016] [Accepted: 06/29/2016] [Indexed: 02/07/2023] Open
Abstract
AIM To evaluate the parathyroid ultrasonography and define parameters that can predict poor response to treatment in patients with secondary hyperparathyroidism due to renal failure.
METHODS This cohort study evaluated 85 patients with chronic kidney disease stage V with parathyroid hormone levels above 800 pg/mL. All patients underwent ultrasonography of the parathyroids and the following parameters were analyzed: Demographic characteristics (etiology of chronic kidney disease, gender, age, dialysis vintage, vascular access, use of vitamin D), laboratory (calcium, phosphorus, parathyroid hormone, alkaline phosphatase, bone alkaline phosphatase), and the occurrence of bone changes, cardiovascular events and death. The χ2 test were used to compare proportions or the Fisher exact test for small sample frequencies. Student t-test was used to detect differences between the two groups regarding continuous variables.
RESULTS Fifty-three patients (66.4%) had parathyroid nodules with higher levels of parathyroid hormone, calcium and phosphorus. Sixteen patients underwent parathyroidectomy and had higher levels of phosphorus and calcium × phosphorus product (P = 0.03 and P = 0.006, respectively). They also had lower mortality (32% vs 68%, P = 0.01) and lower incidence of cardiovascular or cerebrovascular events (27% vs 73%, P = 0.02). Calcium × phosphorus product above 55 mg2/dL2 [RR 1.48 (1.06, 2.08), P = 0.03], presence of vascular calcification [1.33 (1.01, 1.76), P = 0.015] and previous occurrence of vascular events [RR 2.25 (1.27, 3.98), P < 0.001] were risk factors for mortality in this population. There was no association between the occurrence of nodules and mortality.
CONCLUSION The identification of nodules at ultrasonography strengthens the indication for parathyroidectomy in patients with secondary hyperparathyroidism due to renal failure.
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Abstract
BACKGROUND The aim of the present study was to evaluate the outcome of different surgical procedures for patients on permanent dialysis who underwent initial parathyroidectomy for renal hyperparathyroidism (rHPT). METHODS Out of a prospective database of patients who underwent parathyroid surgery for rHPT between 1976 and 2009, patients on permanent dialysis who underwent initial parathyroidectomy were further analyzed regarding perioperative biochemical changes and postoperative outcome. RESULTS A total of 606 patients were analyzed. Total parathyroidectomy with autotransplantation (group A) was performed in 504 patients, total parathyroidectomy without autotransplantation in 32 (group B), subtotal parathyroidectomy in 21 (group C), and incomplete parathyroidectomy in 49 (group D). After surgery, mean calcium levels dropped from 2.76 to 1.91 mmol/l in group A, from 2.67 to 2.11 mmol/l in group B, from 2.70 to 2.09 mmol/l in group C, and from 2.65 to 1.94 mmol/l in group D. The parathyroid hormone level dropped from 1,371.4 pg/ml to 28.8 pg/ml in group A, from 1,078.4 pg/ml to 27.0 pg/ml in group B, from 2,377.9 pg/ml to 61.4 pg/ml in group C, and from 1,010.2 pg/ml to 99.5 pg/ml in group D. Persistent rHPT occurred in 2/504 patients from group A (0.4%), 0/32 patients from group B (0%), 1/21 patients from group C (4.8%), and 2/49 patients from group D (4.1%). After a mean follow-up of 57.6 months, recurrent rHPT occurred in 27/504 patients from group A (5.4%), in 0/32 patients from group B (0%), in 2/21 patients from group C (9.5%), and in 3/49 patients from group D (6.1%). CONCLUSIONS Total parathyroidectomy with or without autotransplantation is a feasible and safe surgical procedure for patients on permanent dialysis with otherwise uncontrollable rHPT.
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Ardito G, Revelli L, Giustozzi E, Giordano A. Radioguided parathyroidectomy in forearm graft for recurrent hyperparathyroidism. Br J Radiol 2012; 85:e1-3. [PMID: 22190754 DOI: 10.1259/bjr/64348019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We report a peculiar case of recurrent hyperparathyroidism caused by hyperplasia of a forearm graft implanted following a total parathyroidectomy in a 38-year-old patient with chronic renal failure. The forearm graft hyperplasia was detected using (99)Tc(m)-sestamibi scanning, which identified hyperplastic transplanted parathyroid tissue in the forearm of the patient. During the initial surgery, the surgeon failed to mark the parathyroid tissue with sutures or clips to facilitate locating it. Therefore, we referred the patient for radioguided surgery. This surgical procedure allowed us to locate and completely remove the hyperfunctioning transplanted parathyroid tissue.
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Affiliation(s)
- G Ardito
- Department of Endocrine Surgery, Catholic University of Sacred Heart, Rome, Italy.
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Removal of autografted parathyroid tissue for recurrent renal hyperparathyroidism in hemodialysis patients. World J Surg 2010; 34:1312-7. [PMID: 20130870 DOI: 10.1007/s00268-010-0412-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recurrent renal hyperparathyroidism (HPT) is a serious problem after parathyroidectomy (PTx). We evaluated the frequency of graft-dependent recurrent HPT and the clinical outcomes after removal of the autograft. METHODS Between March 1980 and January 2009, 2660 patients underwent total PTx with forearm autograft. After resection of all parathyroid glands, 30 pieces of 1 x 1 x 3 mm parathyroid tissue from diffuse hyperplasia, if possible, were autografted into brachioradial muscle. Graft-dependent recurrence of HPT was diagnosed by a high PTH gradient and detection of swollen autografts by palpation and/or MRI or US. RESULTS In 248/2660 (9.3%) patients, removal of the graft was required a total of 327 times (53 patients required removal of the autograft several times). The cumulative frequency of graft-dependent recurrent HPT was 17.4% ten years after the initial PTx. Thirty-two patients underwent both resection of missed glands located in the neck or mediastinum and removal of the graft. En-bloc resection of autograft with surrounding muscle was required to avoid reoperation. When the intact PTH level dropped under 300 pg/ml, in the majority of patients renal HPT could be medically managed after the operation. The mean weight of the resected parathyroid tissue was 1583.7 mg. No specimen had histopathologically malignant features. Three patients suffered from hematoma in the wound. CONCLUSIONS Graft-dependent recurrent renal HPT is not negligible. However, in the majority of patients, renal HPT can be controlled by removal of the autograft noninvasively. Total PTx with forearm autograft is preferable for hemodialysis patients, especially when long-term survival is expected.
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Coulston JE, Egan R, Willis E, Morgan JD. Total parathyroidectomy without autotransplantation for renal hyperparathyroidism. Br J Surg 2010; 97:1674-9. [DOI: 10.1002/bjs.7192] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Parathyroidectomy is the standard treatment for renal hyperparathyroidism although controversy exists about the optimal surgical procedure. Total parathyroidectomy without either autotransplantation or thymectomy is one suggested approach. This study reviewed the medium- to long-term results of this procedure.
Methods
A retrospective review was undertaken of patients undergoing total parathyroidectomy between August 2000 and March 2009. The procedure was performed by a single surgeon and median follow-up was 31 (range 1–120) months.
Results
Data were obtained on 115 patients with no re-explorations for bleeding or clinical recurrent laryngeal nerve injuries. The rate of postoperative hypocalcaemia on the day after surgery was 15·7 per cent. Thirty-three patients (28·7 per cent) had an undetectable parathyroid hormone level at the end of follow-up. Fourteen patients (12·2 per cent) developed recurrent hyperparathyroidism with a median parathyroid hormone level of 35·4 (range 5·4–200·0) pmol/l. The reoperation rate was 3·5 per cent. Thymectomy tissue, taken if all four glands could not be identified, revealed no parathyroid glands.
Conclusion
Total parathyroidectomy alone has minimal associated morbidity or mortality, and a good medium- to long-term clinical outcome with a low recurrence rate.
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Affiliation(s)
- J E Coulston
- Department of Endocrine Surgery, North Bristol NHS Trust, Bristol BS10 5NS, UK
| | - R Egan
- Department of Endocrine Surgery, North Bristol NHS Trust, Bristol BS10 5NS, UK
| | - E Willis
- Department of Endocrine Surgery, North Bristol NHS Trust, Bristol BS10 5NS, UK
| | - J D Morgan
- Department of Endocrine Surgery, North Bristol NHS Trust, Bristol BS10 5NS, UK
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Tominaga Y, Matsuoka S, Uno N. Surgical and Medical Treatment of Secondary Hyperparathyroidism in Patients on Continuous Dialysis. World J Surg 2009; 33:2335-42. [DOI: 10.1007/s00268-009-9943-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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12
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Mazzaferro S, Pasquali M, Farcomeni A, Vestri AR, Filippini A, Romani AM, Barresi G, Pugliese F. Parathyroidectomy as a therapeutic tool for targeting the recommended NKF-K/DOQITM ranges for serum calcium, phosphate and parathyroid hormone in dialysis patients. Nephrol Dial Transplant 2008; 23:2319-23. [DOI: 10.1093/ndt/gfm931] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Schlosser K, Veit JA, Witte S, Fernández ED, Victor N, Knaebel HP, Seiler CM, Rothmund M. Comparison of total parathyroidectomy without autotransplantation and without thymectomy versus total parathyroidectomy with autotransplantation and with thymectomy for secondary hyperparathyroidism: TOPAR PILOT-Trial. Trials 2007; 8:22. [PMID: 17877805 PMCID: PMC2075519 DOI: 10.1186/1745-6215-8-22] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2007] [Accepted: 09/18/2007] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Secondary hyperparathyroidism (sHPT) is common in patients with chronic renal failure. Despite the initiation of new therapeutic agents, several patients will require parathyroidectomy (PTX). Total PTX with autotransplantation of parathyroid tissue (TPTX+AT) and subtotal parathyroidectomy (SPTX) are currently considered as standard surgical procedures in the treatment of sHPT. Recurrencerates after TPTX+AT or SPTX are between 10% and 12% (median follow up: 36 months). Recent retrospective studies demonstrated a lower rate of recurrent sHPT of 0-4% after PTX without autotransplantation and thymectomy (TPTX) with no higher morbidity when compared to the standard procedures. The observed superiority of TPTX is flawed due to different definitions of outcomes, varying follow up periods and different surgical treatment strategies (with and without thymectomy). METHODS/DESIGN Patients with sHPT (intact parathyroid hormone > 10 times above the upper limit of normal) on long term dialysis (>12 months) will be randomized either to TPTX or TPTX+AT and followed for 36 months. Outcome parameters are recurrence rates of sHPT, frequencies of reoperations due to refractory hypoparathyroidism or recurrent/persistent hyperparathyroidism, postoperative morbidity and mortality and quality of life. 50 patients per group will be randomized in order to obtain relevant frequencies of outcome parameters that will form the basis for a large scale confirmatory multicentred randomized controlled trial. DISCUSSION sHPT is a disease with a high incidence in patients with chronic renal failure. Even a small difference in outcomes will be of clinical relevance. To assess sufficient data about the rate of recurrent sHPT after both methods, a multicentred, randomized controlled trial (MRCT) under standardized conditions is mandatory. Due to the existing uncertainties the calculated number of patients necessary in each treatment arm (n > 4000) makes it impossible to perform this study as a confirmatory trial. Therefore estimates of different outcomes are performed using a pilot MRCT comparing 50 versus 50 randomized patients in order to establish a hypothesis that can be tested thereafter. If TPTX proves to have a lower rate of recurrent sHPT, no relevant disadvantages and no higher morbidity than TPTX+AT, current surgical practice may be changed. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number Registration (ISRCTN86202793).
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Affiliation(s)
- Katja Schlosser
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University, Marburg, Germany
| | - Johannes A Veit
- Study Center of the German Surgical Society (SDGC), University of Heidelberg, Germany
| | - Stefan Witte
- Study Center of the German Surgical Society (SDGC), University of Heidelberg, Germany
- Institute of Medical Biometrics and Informatics (IMBI), University of Heidelberg, Germany
| | | | - Norbert Victor
- Institute of Medical Biometrics and Informatics (IMBI), University of Heidelberg, Germany
| | - Hans-Peter Knaebel
- Study Center of the German Surgical Society (SDGC), University of Heidelberg, Germany
| | - Christoph M Seiler
- Study Center of the German Surgical Society (SDGC), University of Heidelberg, Germany
| | - Matthias Rothmund
- Department of Visceral, Thoracic and Vascular Surgery, Philipps University, Marburg, Germany
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Hamada C, Tanaka Y, Sakamoto T, Kaneko K, Shou I, Fukui M, Fukazawa M, Tomino Y. Transient Thyrotoxicosis After Parathyroidectomy in a Hemodialysis Patient with Secondary Hyperparathyroidism. Int J Organ Transplant Med 2007. [DOI: 10.1016/s1561-5413(07)60009-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Richards ML, Wormuth J, Bingener J, Sirinek K. Parathyroidectomy in secondary hyperparathyroidism: Is there an optimal operative management? Surgery 2006; 139:174-80. [PMID: 16455325 DOI: 10.1016/j.surg.2005.08.036] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2005] [Revised: 08/16/2005] [Accepted: 08/19/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND Subtotal parathyroidectomy (SPTX) and total PTX with autotransplantation (TPTX + AT) are both accepted operations for secondary hyperparathyroidism (2HPT). Studies have shown the 2 procedures to have similar rates of recurrent or persistent HPT (0% to 10%). The majority of these reports are small case series and despite apparently similar outcomes; the optimal operative management for 2HPT remains controversial. The purpose of this study was to determine whether there were any clinical outcome differences between these apparently comparable operations. METHODS A meta-analysis of 53 publications on reoperative operation for 2HPT from 1983 to 2004 identified 501 patients who had undergone an operation for recurrent or persistent 2HPT. The data evaluated included the type of initial operation, the need for reoperative operation as it related to the type of initial operation, and the intraoperative findings. RESULTS The initial operation had been a SPTX in 36% and a TPTX + AT in 64% of patients. Reoperative operation was for persistent 2HPT in 82 of 485 (17%) and for recurrent 2HPT in 403 of 485 (83%) patients. Findings at reoperation included: autograft hyperplasia (49%), supernumerary glands (20%), remnant hyperplasia (17%), a missed in situ gland (7%), and a negative exploration (5%). Supernumerary glands, missed in situ glands, and negative explorations occurred at equal rates for both operations. Reoperation determined that inadequate cervical explorations occurred in 42% of patients who had undergone a SPTX and in 34% of patients who had undergone a TPTX + AT. CONCLUSIONS Operative failures occur because of the limitations in preoperative localization, inadequate exploration, and the natural history of hyperplastic parathyroid tissue. The initial operation should include an attempt to localize supernumerary glands both pre- and intra-operatively.
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Affiliation(s)
- Melanie L Richards
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
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Echenique M, Antonio Amondarain J, Vidaur F. Función paratiroidea en el autotrasplante paratiroideo subcutáneo preesternal en el hiperparatiroidismo secundario. Cir Esp 2004. [DOI: 10.1016/s0009-739x(04)72351-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Falvo L, Catania A, Sorrenti S, D'Andrea V, Santulli M, Antoni ED. Relapsing Secondary Hyperparathyroidism Due to Multiple Nodular Formations after Total Parathyroidectomy with Autograft. Am Surg 2003. [DOI: 10.1177/000313480306901117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Total parathyroidectomy with autograft represents an optimal surgical technique in the treatment of secondary hyperparathyroidism. Relapsing hyperparathyroidism due to miliary-type nodular formations scattered over the autograft site represents a complication that is rarely described in the literature. We examined five case histories of patients relapsing as a result of miliary-type nodular formations in the autograft site; in four cases the relapse was localized in the upper limb and in one case in a pouch of the sternocleidomastoid muscle. The patients underwent removal of the hyperfunctioning parathyroid formations accompanied by demolition of the surrounding muscle tissue. The relapsing hyperparathyroidism caused by multiple miliary-type nodular formations is a rare occurrence, akin to parathyromatosis. The increasingly widespread use of total parathyroidectomy with autograft to treat secondary hyperparathyroidism can lead to an increase in the incidence of this complication. Correct surgical technique and a careful selection of the parathyroid tissue to be autografted can prevent this complication. Furthermore, extensive demolition of the muscle tissue in the autograft site can prevent further relapses. Intraoperative rapid parathormone assay was found to be predictive of the disease's persistence and recurrence.
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Affiliation(s)
- Laura Falvo
- From the Division of General Surgery, Department of Surgical Sciences, “La Sapienza” University of Rome, Rome, Italy
| | - Antonio Catania
- From the Division of General Surgery, Department of Surgical Sciences, “La Sapienza” University of Rome, Rome, Italy
| | - Salvatore Sorrenti
- From the Division of General Surgery, Department of Surgical Sciences, “La Sapienza” University of Rome, Rome, Italy
| | - Vito D'Andrea
- From the Division of General Surgery, Department of Surgical Sciences, “La Sapienza” University of Rome, Rome, Italy
| | - Maria Santulli
- From the Division of General Surgery, Department of Surgical Sciences, “La Sapienza” University of Rome, Rome, Italy
| | - Enrico De Antoni
- From the Division of General Surgery, Department of Surgical Sciences, “La Sapienza” University of Rome, Rome, Italy
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Sippel RS, Bianco J, Chen H. Radioguided parathyroidectomy for recurrent hyperparathyroidism caused by forearm graft hyperplasia. J Bone Miner Res 2003; 18:939-42. [PMID: 12733736 DOI: 10.1359/jbmr.2003.18.5.939] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
One of the surgical options for symptomatic secondary hyperparathyroidism is a total parathyroidectomy with forearm implantation. Recurrence can occur and is most likely caused by hyperplasia of the small fragments of parathyroid tissue implanted in the forearm muscle. Forearm graft hyperplasia can be detected using Tc-99m sestamibi scanning of the forearm, which can show abnormal enhancement at the former graft site. In this report, we present the case of a 49-year-old gentleman with recurrent hyperparathyroidism caused by hyperplasia of forearm graft fragments. Unfortunately, no sutures or clips were placed at his initial surgery to identify the location of the parathyroid tissue in the forearm. Thus, we describe the first reported use of radioguided techniques using Tc-99m sestamibi injection and intraoperative gamma probe to localize parathyroid fragments in the forearm muscle. During our initial exploration, we found that injection of the tracer in the operative arm leads to prohibitively high levels of background activity. During a second exploration, the tracer was injected in the lower extremity, minimizing the background in the forearm and allowing the gamma probe to clearly identify two areas of abnormal parathyroid tissue. The intraoperative radioprobe allowed quick identification and removal of the abnormal parathyroid tissue in a case that was made particularly challenging by the absence of marking sutures.
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Affiliation(s)
- Rebecca S Sippel
- Department of Surgery, University of Wisconsin Medical School, Madison, Wisconsin 53792, USA
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Affleck BD, Swartz K, Brennan J. Surgical considerations and controversies in thyroid and parathyroid surgery. Otolaryngol Clin North Am 2003; 36:159-87, x. [PMID: 12803015 DOI: 10.1016/s0030-6665(02)00135-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The techniques of thyroid surgery have been fully elucidated in several surgical texts and atlases. This article discuss surgical pearls of thyroid and parathyroid surgery. We discuss preoperative, intraoperative, and postoperative considerations and controversies for both procedures.
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Affiliation(s)
- Brian D Affleck
- Department of Otolaryngology/Head and Neck Surgery, Lakenheath Hospital, 48 MDOS/SGOSL, RAF Lakenheath, APO AE 09464, UK
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21
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Mchenry CR, Wilhelm SM, Icanati E. Refractory Renal Hyperparathyroidism: Clinical Features and Outcome of Surgical Therapy. Am Surg 2001. [DOI: 10.1177/000313480106700403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Despite improvements in medical management parathyroidectomy has an important role in treatment of refractory renal hyperparathyroidism (HPT). The medical records of all patients who underwent parathyroidectomy from 1991 through 2000 were reviewed to determine the clinical and laboratory features and outcomes of treatment in patients with renal versus primary HPT. Twenty-one of 92 patients who underwent parathyroidectomy had renal HPT with a mean age of 47 ± 3 years compared with 56 ± 2 years for patients with primary HPT ( P < 0.05). Clinical manifestations included osteodystrophy (19), pruritus (six), extraosseous calcification (three), and calciphylaxis (one). Parathyroid hormone, phosphorus, and alkaline phosphatase levels and weights of excised glands were higher in renal versus primary HPT ( P < 0.05). Supernumerary glands were found in three patients (14%) with renal HPT and none of nine patients with primary parathyroid hyperplasia. After surgical therapy persistent or recurrent HPT occurred in three (14%) patients with renal and one (1.4%) patient with primary HPT ( P < 0.05). Postoperative hypocalcemia occurred in 20 (95%) patients with renal HPT all of whom required intravenous calcium, compared with 25 (35%) patients with primary HPT ( P < 0.05) of whom only three (4%) required intravenous calcium ( P < 0.05). In contrast to those with primary HPT patients with renal HPT are younger and more likely to have severe osteodystrophy, postoperative hypocalcemia, and persistent or recurrent HPT.
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Affiliation(s)
- Christopher R. Mchenry
- Departments of Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Scott M. Wilhelm
- Departments of Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Edmond Icanati
- Departments of Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
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