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PubMed1998

Parathyroidectomy in patients with chronic renal failure.

BACKGROUND: Hyperparathyroidism is common in patients with renal disease. These patients may require operation for this disease if it cannot be controlled by medical therapy. Because these patients continue to have renal failure, the risk of recurrence and reoperation is high. METHODS: Sixty-nine patients with renal failure underwent operation for hyperparathyroidism. These patients were followed up on dialysis or after transplantation. RESULTS: Sixty-nine patients, aged 2 to 71 years old, with end-stage renal disease required parathyroidectomy for hyperparathyroidism 6.2 +/- 4.2 (standard deviation) years after beginning dialysis. Thirty-six patients had undergone renal transplantation (creatinine = 1.6 +/- 0.4 mg/dL). All patients had elevated parathyroid hormone (PTH) levels. Sixty-eight patients had hyperplasia; 1 patient had adenoma. Six patients required reoperation for recurrent hyperparathyroidism 30 to 123 months after their initial parathyroidectomy. CONCLUSION: Patients with end-stage renal disease are prone to abnormalities of calcium metabolism. They frequently develop parathyroid hyperplasia. Recurrence can occur following operation because of continuing renal failure.

Adolescent↗
PubMed1999

Effects of a parathyroidectomy on the immune system and nutritional condition in chronic dialysis patients with secondary hyperparathyroidism.

BACKGROUND: Parathyroid hormone (PTH) has an adverse effect on the immune system and may cause immunologic disorders in patients with chronic renal failure. The in vivo effects of a parathyroidectomy on the immunologic parameters was examined. METHODS: Thirty-four patients under dialysis therapy received a parathyroidectomy (PTx) for secondary hyperparathyroidism (HPT). They were prospectively studied regarding serum immunoglobulins, complements, CD markers, and serum soluble IL-2 receptor (sIL-2R) until 12 months after PTx. RESULTS: The serum levels of IgG, IgA and IgM showed significant increase until 12 months after PTx (P<0.001, respectively). C3, C4, and CH50 also indicated significant increase at 12 months after PTx. In cellular immunity, only serum sIL-2R showed significant increase 2 weeks after PTx (P = 0.028). The hematocrit and serum albumin also improved significantly at 12 months. CONCLUSIONS: PTx showed beneficial effects on humoral immunological markers. The effects are probably due to the remarkable PTH reduction and partly improved nutritional state after PTx.

Adult↗
PubMed2000

Impaired flow-mediated vasodilation of the brachial artery in patients with primary hyperparathyroidism improves after parathyroidectomy.

OBJECTIVE: The endothelium is a newly recognised target tissue of parathyroid hormone (PTH). It is not clear whether hyperparathyroidism affects endothelial function and whether parathyroidectomy (Ptx) has an influence on arterial vessel wall properties. We studied brachial flow-mediated vasodilation (FMD) and brachial and carotid intima-media thickness (IMT) in patients with primary hyperparathyroidism (pHPT) before and after Ptx and in healthy controls. METHODS: 19 patients with pHPT (mean+SEM, age 45+/-4.7 years, PTH 238+/-52 ng/l) were studied. Diabetes, hypertension and vascular disease were excluded. Twenty healthy volunteers matched for age, sex and blood pressure served as controls. Enddiastolic diameter, FMD and nitroglycerine-induced (NMD) dilation of the brachial artery were measured by a multigate pulsed doppler system (echo-tracking), IMT was determined using automatic analysis of the M-line signal. Healthy volunteers where studied on one occasion, patients were studied at baseline and 6 months after Ptx. RESULTS: Six months after Ptx PTH had decreased to normal, blood pressure levels remained unchanged. Endothelium dependent FMD at baseline was impaired in patients compared to controls (4.7+/-1.2 vs. 18.2+/-3.7%, P<0.01), however, FMD improved significantly after Ptx (16.7+/-3.0%, P<0.01). Nitroglycerine-induced dilation, IMT and artery diameter were not different between groups and did not change after Ptx. CONCLUSIONS: Impaired endothelium dependent vasodilation in patients with primary hyperparathyroidism improves after successful parathyroidectomy. Endothelial dysfunction associated with primary hyperparathyroidism occurs without detectable structural wall alterations of the brachial artery and appears therefore to be an early and reversible arterial alteration.

Adult↗
PubMed1997

Concise parathyroidectomy: the impact of preoperative SPECT 99mTc sestamibi scanning and intraoperative quick parathormone assay.

BACKGROUND: Results of initial operation for sporadic primary hyperparathyroidism are generally excellent, yet today there is pressure to improve outcome and resource utilization. METHODS: We designed a prospective longitudinal cohort study comparing two approaches to concise parathyroidectomy. Strategy A was defined as the palpation method for selective unilateral exploration. Strategy B was defined as the routine use of both preoperative 99mTc sestamibi single photon emission computed tomography (SPECT) imaging and intraoperative quick parathormone assay. With either strategy the study period was 19 months and patients explored unilaterally were candidates for same-day discharge. We compared surgical outcome for 128 consecutive consenting patients each with 6 months or more of follow-up (mean 12 +/- 7.6 months). RESULTS: Demographic, biochemical and pathologic findings did not differ between groups. SPECT imaging precisely localized hyperfunctioning parathyroid tissue. Compared with Strategy A (n = 61), the 67 patients treated by use of Strategy B experienced a higher rate of unilateral exploration (41.0% versus 62.7%, p < 0.00001) and a shorter length of stay (1.07 versus 1.90 days, p < 0.00001) and tended to have shorter operative times, fewer operative failures, and less morbidity. Total perioperative costs did not differ between groups. CONCLUSIONS: Routine use of intraoperative quick parathormone measurement and preoperative 99mTc sestamibi SPECT is as safe, effective, and cost-effective as conventional approaches to parathyroidectomy. Use of this strategy is associated with significant reductions in extent of surgery and length of hospital stay.

Adult↗
PubMed2005

[Modification of nephritic colic and 24-hour calcium excretion in urine in primary hyperthyroidism after parathyroidectomy].

We documented the frequency of nephritic colic in patients with primary hyperparathyroidism, and determined its modification after the parathyroidectomy; we also studied laboratory parameters such as calcium, phosphorus and parathyroid hormone in serum, and the excretion of Cao 24h, previous and later to the intervention. At sight of the results it is possible to be concluded that the parathyroidectomy is useful in the treatment of the kidney stone disease produced by the primary hyperparathyroidism.

Calcium↗
PubMed1998

[End-stage renal failure following parathyroidectomy for advanced primary hyperparathyroidism].

PURPOSE: We report two cases of long-standing, advanced primary hyperparathyroidism with renal failure. After surgery the two patients presented with marked hypocalcemia and deterioration of renal function which required dialysis 2 and 3 months after parathyroidectomy. These two cases lead us to consider that renal function should be studied before and after surgery in patients operated on for primary hyperparathyroidism. METHODS: In 19 patients operated on for hyperparathyroidism with few symptoms and without renal failure or with very moderate renal failure, blood creatinine and creatinine clearance were measured before (T1) and 1 year (T12) parathyroidectomy. RESULTS: No significant overall changes in the following parameters were observed: blood creatinine T1 71 +/- 19 mumol/L, T12 82 +/- 20 mumol/L, CrCl T1 72 +/- 13 mL/min, CrCl T12 70 +/- 19 mL/min. However, in the patient with greatest deterioration of renal function, CrCl decreased from 45 mL/min at T0 to 33 mL/min at T12. CONCLUSION: A review of the literature shows that in certain cases, renal insufficiency present before cervicotomy may worsen after surgery even if hypercalcemia is corrected. The mechanism is still unclear. A sharp decrease in parathormonemia and parathyroid hypertensive factor may play a role via intrarenal hemodynamic changes.

Aged↗
PubMed1992

Calciphylaxis in a hemodialysis patient: appearance after parathyroidectomy during a psoriatic flare.

Chronic renal failure patients are prone to soft tissue calcifications. A phenomenon of acute ischemic skin necrosis and dermohypodermic arteriolar medial calcification has been described recently in patients with chronic renal failure and secondary hyperparathyroidism (HPT). This phenomenon, termed calciphylaxis, occurs in response to certain factors, the most important of which appears to be an elevated blood calcium-phosphate product. Accordingly, parathyroidectomy in addition to normalization of calcium-phosphate product has been proposed as the only effective therapeutic approach for this condition. We describe a case of chronic renal failure with severe secondary HPT in which the patient developed calciphylaxis 4 days after the appearance of a psoriatic flare. Four months before, a subtotal parathyroidectomy was performed for severe HPT and at the time the ulcerations appeared, blood calcium-phosphate product was correct. Etiological and physiopathological aspects of calciphylaxis are discussed.

Calciphylaxis↗
PubMed1997

Biochemical aberrations in a dialysis patient following parathyroidectomy.

Renal osteodystrophy is a common problem in patients with end-stage renal disease. Severe secondary hyperparathyroidism unresponsive to an intensive regimen of diet, phosphate binders, and calcitriol therapy is an indication for surgical parathyroidectomy. Certain unique postoperative electrolyte aberrations are seen after parathyroidectomy, including severe hypocalcemia and hypophosphatemia (hungry bone syndrome), as well as hyperkalemia. Identifying the patient at high risk for developing these electrolyte abnormalities will facilitate perioperative and postoperative management.

Adult↗
PubMed2002

Prognosis of parathyroid function after minimally invasive radioguided parathyroidectomy (MIRP) and percutaneous ethanol injection therapy (PEIT) for primary hyperparathyroidism.

During parathyroidectomy (PTx) for primary hyperparathyroidism (PHP), we surgically explored the contralateral parathyroid glands as well as those whose localization was clarified by ultrasonography and parathyroid scintigraphy. Although it is important to explore the contralateral side and other glands, we frequently treat only the gland whose localization is confirmed. Recently, we have performed minimally invasive radioguided parathyroidectomy (MIRP) that resects only one gland observed on the imaging under technetium 99m-labeled sestamibi (MIBI) scanning guidance after obtaining prior informed consent. In this surgery, even if recurrence is observed contralaterally, it is possible to apply a similar procedure to the contralateral side again. We examined six PHP patients who underwent MIRP and two PHP patients treated with percutaneous ethanol injection therapy (PEIT). The follow-up period was 2 years. PEIT was selected as a treatment method for two patients based on the patients' characteristics. When only one gland is treated, the efficacy of PEIT was considered to be similar to that of MIRP.

Administration, Cutaneous↗
PubMed2002

Minimally invasive parathyroidectomy under local anesthesia.

Primary hyperparathyroidism is commonly associated with uniglandular swelling, and thus the lesion has been localized before surgical reduction. Since March 1997, we have performed uniglandular parathyroidectomy under local anesthesia with combined scintigram and ultrasound tomography in patients with primary hyperparathyroidism preoperatively identified for uniglandular swelling. We had seen consecutive 18 patients with primary hyperparathyroidism until April 2001; 15 of those underwent surgical reduction. Postoperative intact PTH value was normalized in 14 patients. The remaining patient, diagnosed with thyroid adenoma, required re-surgery due to proved intake on scintigram a year later. Mean follow-up period is 33 months, and the disease does not relapse. In addition, we removed the swollen gland in two patients with renal hyperparathyroidism under local anesthesia; the disease involved two glands in a patient and one gland in another patient. After surgery, their subjective symptoms including itching and arthralgia were eliminated, and did not relapse at 30 and 14 months, respectively. Minimally invasive parathyroidectomy under local anesthesia might be performed as a same-day surgery, and improve QOL of patients.

Aged↗
PubMed2002

Direct mini-incision parathyroidectomy.

We describe our technique for performing a mini-incision parathyroidectomy in patients with hyperparathyroidism. Since our procedure differs from conventional parathyroidectomy in requiring a 2- or 3-cm skin incision and no raising of skin flap, this technique resulted in a good cosmetic status and less invasiveness. Hypesthesia or paresthesia in the neck and discomfort while swallowing related to a large skin incision and raising of skin flap are minimized. Although the cosmetic results of endoscopic techniques are better than those of our procedures, endoscopic instruments remain traumatic, can easily inflict iatrogenic lesions to parathyroid adenomas and enhance the risk of tumor cell exfoliation, especially if the parathyroid adenoma is manipulated by the instruments. Our surgical procedure can be less technically demanding and time-consuming. Although the number of patients whom we have treated in this manner is still small, we believe that our new procedure constitutes a useful surgical treatment for hyperparathyroidism.

Humans↗
PubMed2003

Minimally invasive parathyroidectomy.

Efforts to minimize the incision, extent of exploration, length of hospital stay, and cost associated with parathyroidectomy have resulted in the development of a number of new surgical techniques, including minimally invasive, "concise," radio-guided, and endoscopic parathyroid exploration. With minimally invasive parathyroidectomy, a small incision is used in combination with a cervical block and sedation to perform a unilateral neck exploration. In so doing, risks of bilateral neck exploration are avoided, and the procedure can be done on an outpatient basis. This minimally invasive strategy has been shown to maintain the outstanding success of conventional bilateral neck exploration. All of the new surgical techniques necessitate pre-operative localization, which allows for unilateral neck exploration, and are facilitated by use of the intra-operative parathyroid hormone assay, which provides surgeons with feedback in the operating room regarding whether the patient has undergone adequate resection.

Humans↗
PubMed2003

Minimally invasive parathyroidectomy: the Australian experience.

Minimally invasive parathyroidectomy (MIP) was introduced into Australia after endocrine surgeons agreed that it should only be undertaken in the context of a feasibility study or controlled trial, and under the auspices of the Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S). Feasibility of endoscopic-assisted parathyroidectomy was studied at Royal North Shore Hospital (RNS) and 49 cases were completed. Subsequently, the technique of a focused lateral approach using a 2-cm incision placed directly over the site of the localized adenoma was developed and has now become the standard technique for the unit. To date, 357 MIPs using the focused lateral approach have been performed with a 1.5% rate of negative neck exploration and a permanent recurrent laryngeal nerve palsy rate of 0.8%. The use of intraoperative rapid measurement of parathyroid hormone (PTH, IO-QPTH) as an assessment of completeness of resection of abnormal parathyroid tissue has been replaced by simply measuring PTH levels 30 minutes postoperatively, a technique that is more cost-effective, and which still allows same-day discharge whilst avoiding false-positive results with IO-QPTH. The introduction of MIP appears to be a factor in the increasing number of referrals for parathyroid surgery.

Adenoma↗
PubMed2002

Muscle force, motor nerve conduction velocity and compound muscle action potentials after parathyroidectomy for secondary hyperparathyroidism.

OBJECTIVE: We studied the motor nerve conduction velocity (MNCV) and the amplitude of compound muscle action potentials (CMAP) in patients with symptomatic secondary hyperparathyroidism at preoperative and 3 months post-operative period, to find the factors affecting muscle force after parathyroidectomy. METHODS: Twenty-six patients with symptomatic secondary hyperparathyroidism with levels of intact parathyroid hormone (iPTH) over 6.8 pmol/l who underwent total parathyroidectomy and autotransplantation of 60 mg of tissue were included in this research. Extension force of the quadriceps muscle was measured at 60 degrees of right knee flexion and expressed as Newtons (N) in peak force and average force. Nerve conduction studies of four limbs were checked and the MNCV and CMAP of right femoral and tibial nerves were analyzed and correlated with the muscle force. RESULTS: Three months after operation, the peak force increased from 272 +/-108 to 315 +/- 123 N (P=0.015) and the average force from 215 +/- 94 to 253 +/- 103 N (P=0.006). MNCV and latencies of femoral and tibial nerves did not show definite change, but the amplitude of CMAP increased significantly from 7.1 +/- 4.1 to 10.7 +/- 3.2 mV (P=0.005) at femoral stimulation and from 9.8 +/- 4.6 to 11.7 +/- 4.3 (P=0.007) and 13.2 +/- 5.9 to 14.9 +/- 6.0 (P=0.011) at proximal and distal tibial stimulation. CONCLUSION: The improvement of muscle force after surgery was found to be parallel to the increment of the amplitude of CMAP but not to nerve conduction velocity or latency. We propose that the weakness of the patients with secondary hyperparathyroidism is probably related to alteration of muscle fiber contraction.

Action Potentials↗
PubMed2002

Normalized dyslipidaemia after parathyroidectomy in mild primary hyperparathyroidism: population-based study over five years.

OBJECTIVE: Postmenopausal women are at increased risk of primary hyperparathyroidism (pHPT). Secondary dyslipidaemia in pHPT has attracted little attention, although morbidity and mortality associated with cardiovascular diseases have been reported to be increased in these patients. DESIGN: A population-based screening programme was used to recruit postmenopausal women with mild, asymptomatic pHPT (mean serum calcium 2.57 +/- 0.12 mmol/l) and matched controls. MEASUREMENTS AND PATIENTS: Serum lipids, lipoprotein fractions and influences of treatment for the parathyroid disease were studied in 87 case-control pairs (mean age 67 years), 69 of whom completed a 5-year follow-up period. RESULTS: pHPT was characterized by decreased serum high-density lipoprotein (HDL)-cholesterol, increased total triglycerides, very-low-density lipoprotein (VLDL)-triglycerides and VLDL-cholesterol levels and an elevated atherogenic index. The differences were more pronounced in the cases with serum parathyroid hormone levels in the normal range and were inversely correlated to the serum parathyroid hormone level. Parathyroidectomy, with or without additive hormone replacement therapy, normalized the dyslipidaemia. Five-year surveillance of pHPT without treatment was associated with a maintained increase in total triglycerides and the atherogenic index and a decrease in HDL-cholesterol levels. CONCLUSION: Proatherosclerotic dyslipidaemia characterizes mild pHPT and is effectively reversed by parathyroidectomy. As dyslipidaemia might contribute to the increased risk of cardiovascular diseases and death observed in pHPT, the findings favour operative intervention rather than conservative surveillance in mild, asymptomatic pHPT in postmenopausal females.

Aged↗
PubMed2002

Minimally invasive parathyroidectomy using the 'focused' lateral approach. II. Surgical technique.

BACKGROUND: This paper describes the technique of minimally invasive parathyroidectomy. The technique is based on a thorough understanding of the anatomy of the fascial planes in neck, the surgical pathology and embryology of parathyroid glands and precise anatomical interpretation of preoperative localization studies. METHODS: Tissue trauma is minimized by using a 2.0 cm incision placed directly over the abnormal parathyroid gland and by removing the adenoma, without compromising the basic endocrine surgical principles of identification and preservation of recurrent laryngeal nerve, avoidance of any capsular breech, and ligation of the vascular pedicle. RESULTS/CONCLUSIONS: With proper patient selection, this technique results in a failure rate of less than 4% and ensures that the incidence of complications, such as recurrent laryngeal nerve injury, remains comparable with that of standard open parathyroidectomy.

Adenoma↗
PubMed2002

Parathyroidectomy in dialysis patients.

Subtotal parathyroidectomy or total parathyroidectomy (PTx) with autotransplantation are surgical procedures considered while the patient is included on the waiting list for renal transplantation. Total PTx alone is based in the possibility that a fragment of tissue (nodular hyperplasia in particular) left in the same pathophysiological environment of long term dialysis would show the same behavior and reproduce in time the same clinicopathological picture. The persistence of uremia induces a continued growth stimulus developing residual hyperplasia and consequently a very high risk of recurrence. We performed total PTx alone in 15 uremic patients excluded for renal transplantation 10 patients with undetectable iPTH serum concentration and were followed up for 37 to 144 months. There was no evidence of clinical bone disease (bone pain or fractures). Bone mineral lumbar spine and hip density was measured at the end of follow-up. The z score data showed that all patients had a bone mass similar than that expected for their age. Bone biopsies performed in four patients showed a uniform picture of low turnover without aluminium staining. Calcification of small arteries (digital and arcade vessels in hands and feet) were evaluated pre and post total PTx alone in nine out of the 10 patients with undetectable PTH levels. The small vessel calcification was present in five patients at the moment of PTx. At the end of the long term follow-up only one patient showed progression. In conclusion, total PTx without autotransplantation is a very effective and adequate treatment for refractory severe hyperparathyroidism in patients excluded for renal transplantation. Aluminium related osteopathy post PTx is a risk to be controlled with aluminium "free" dialysis water and avoiding aluminium containing phosphate binders.

Calcitriol↗
PubMedDate not supplied

Are parathyroidectomies still appropriate in chronic dialysis patients?

The uremic milieu generates chronic stimulatory input to the parathyroid glands, which is mediated principally by low calcium, high phosphate and low calcitriol, and results in increased parathyroid hormone (PTH) synthesis and release and an increase in parathyroid mitotic activity with the development of monoclonal areas of nodular hyperplasia. Such glands do not fully express the machinery required to mediate the suppressive inputs to the parathyroids; the extracellular calcium receptor (CaR) and the vitamin D receptor (VDR) are both downregulated. In most of these patients ablation, by parathyroidectomy or ethanol injection, provides the only means of correcting the hyperparathyroidism; apoptosis in parathyroid cells is negligible and clinically irrelevant. In practice, surgery is often delayed by a doomed and ultimately futile attempt to effect control by medical means. Better predictors of the likely success or failure of optimal non surgical management are needed. Gland size exceeding 1 cm3 and elevated PTH despite hypercalcemia (implying loss of suppressibility by calcium), in the presence of good phosphate control and adequate calcitriol provision point strongly to eventual failure of medical treatment and the need for parathyroid ablation. Parathyroidectomy, usually subtotal, remains the standard management, with ultrasound guided injection of ethanol or calcitriol showing promise in some centers. The above scenario is unlikely to be changed greatly by the new emerging vitamin D metabolites, but calcimimetic agents may well increase the scope of non surgical management.

Humans↗