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PubMed2001

[Results and complications of parathyroidectomy in secondary hyperparathyroidism].

Retrospective study was performed to measure the results of parathyroidectomy in patients with secondary hyperparathyroidism. From 1987 to 2000, 48 patients underwent surgery for secondary hyperparathyroidism. There were 30 of 48 patients on haemodialysis treatment, and 11 patients were in pre-dialysis stage. Parathyroidectomy was performed after successful kidney transplantation in 4 cases. Indication of the surgery was extremely elevated serum level of parathyroid hormone (at least 10 fold elevation), which was resistant for the conservative medical therapy. Subtotal parathyroidectomy (3 1/2) was performed in 30 patients. Five patients underwent total parathyroidectomy and autotransplantation. Only 2 or 3 parathyroid glands have been removed in 13 patients. Haematoma occurred in 3 cases after parathyroidectomy. Recurrent nerve injury or septic complication did not occur. Two patients died in the early postoperative period due to cardiac failure. Tetania was noted in 2 patients after surgery. Permanent postoperative hypocalcaemia (over 6 months) occurred in 3 cases. Persistent hyperparathyroidism was diagnosed in 5 patients. In these patients 2 parathyroid glands were removed during the primary operation. Recurrent hyperparathyroidism was detected in 2 patients. Subtotal parathyroidectomy was carried out in these cases previously. At the reoperation for persistent and recurrent hyperparathyroidism, total parathyroidectomy and autotransplantation was performed. Serum alkaline phosphatase level and serum parathyroid hormone value decreased after surgery, except those patients with persistent hyperparathyroidism. Bone pain decreased in 96% of the cases and pruritus decreased in 92% of the patients after parathyroidectomy. Soft tissue calcification showed improvement in 45% of cases. In conclusion, the subtotal parathyroidectomy or total parathyroidectomy with autotransplantation cause a rapid decrease of PTH level and the improvement of the clinical symptoms in patients with medical treatment resistant secondary hyperparathyroidism. Persistent hyperparathyroidism occurs in those cases when inadequate parathyroidectomy was performed.

Adolescent↗
PubMed2001

Secondary and tertiary hyperparathyroidism: causes of recurrent disease after 446 parathyroidectomies.

OBJECTIVE: To determine, in a series of patients with secondary and tertiary parathyroid hyperplasia, whether the type of parathyroidectomy (subtotal, total with autotransplantation, or total), the histologic pattern of the parathyroid tissue, or the proliferative index, as determined by Ki-67 analysis, could predispose patients to recurrent hyperparathyroidism. SUMMARY BACKGROUND DATA: Recurrent hyperparathyroidism appears in 10--70% of the patients undergoing surgery for secondary or tertiary hyperparathyroidism. The incidence could be related to the type of operation (Rothmund) but also depends on the histologic pattern of the glands removed (Niederle). METHODS: The retrospective investigation was performed on 446 patients undergoing parathyroid surgery. They were also studied in relation to the possibility of renal transplantation. In this population, two homogeneous groups were subsequently identified (23 patients with clear signs of recurrence and 27 patients apparently cured); they were studied from the histologic and immunohistochemical point of view using antibody to Ki-67 antigen. RESULTS: Subtotal parathyroidectomy, total parathyroidectomy with autotransplantation, and total parathyroidectomy produced similar results when considering the regression of osteodystrophy, pruritus, and ectopic calcification. As one could anticipate, total parathyroidectomy increased the incidence of hypoparathyroidism. The percentage of recurrence was 5% to 8% after subtotal parathyroidectomy, total parathyroidectomy with autotransplantation, and total parathyroidectomy, and only after incomplete parathyroidectomy did this percentage climb to 34.7%. In the recurrence group, the nodular form was more common and the proliferative fraction detected by Ki-67 was 1.9%; it was 0.81% in the control group. CONCLUSIONS: Because more radical procedures were not more effective, the authors favor a less radical procedure such as subtotal parathyroidectomy. Histologic patterns and proliferative fraction could be useful indices of a recurrence, and these patients should be watched closely after surgery.

Adult↗
PubMed1985

Parathyroidectomy in chronic renal failure.

In order to establish whether parathyroidectomy altered the natural history of ectopic calcification in patients with renal failure we undertook a detailed analysis of 62 patients with hyperparathyroidism secondary to chronic renal failure who were submitted to parathyroidectomy. Biochemical data (61 patients) and radiological skeletal surveys (42 patients) were studied before and after parathyroidectomy. Transiliac bone biopsies were obtained at (or some time in the previous six months before) parathyroidectomy in 30 and in 36 patients after surgery. Paired bone biopsies were available from 17 of these patients. In the majority of patients secondary hyperparathyroidism was controlled after parathyroidectomy although in seven patients (11 per cent), who underwent subtotal parathyroidectomy, it relapsed after initial improvement. Non-visceral soft tissue calcification disappeared or decreased in 60 per cent of the patients after parathyroidectomy. However, despite marked improvement in subperiosteal erosions and histological osteitis fibrosa, with significant reductions in iPTH and Ca X P product after parathyroidectomy, small peripheral arterial calcification developed or progressed in 56 per cent of the patients. Histological osteomalacia after parathyroidectomy developed after operation in two patients. Both had positive aluminium stains for excess aluminium in their bone. Numbers of osteoclasts and the amount of marrow fibrosis declined in parallel following parathyroidectomy, but woven bone persisted for months or years.

Adult↗
PubMed2006

The effect of parathyroidectomy on bone fracture risk in patients with primary hyperparathyroidism.

BACKGROUND: Parathyroidectomy may increase bone density in primary hyperparathyroidism (PHPT), but it is unclear whether fracture risk is decreased. HYPOTHESIS: Parathyroidectomy decreases fracture risk. DESIGN: Retrospective cohort study with median follow-up of 6.5 years. SETTING: Twelve regional hospitals in California. PATIENTS: One thousand five hundred sixty-nine patients with PHPT. INTERVENTIONS: Parathyroidectomy or observation. Main Outcome Measure Fracture-free survival. RESULTS: Mean initial calcium, parathyroid hormone, and creatinine levels were 11.2 mg/dL (2.8 mmol/L), 123.0 pg/mL, and 0.9 mg/dL (79.6 micromol/L), respectively. Parathyroidectomy was performed in 452 (28.8%) patients, and 1117 (71.2%) were observed. The 10-year fracture-free survival after PHPT diagnosis was 73% in patients treated with parathyroidectomy compared with 59% in those observed (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.38-0.73; P < .001). Parathyroidectomy decreased the 10-year hip fracture rate by 8% (P = .001) and the upper extremity fracture rate by 3% (P = .02). Parathyroidectomy was independently associated with a decreased fracture risk (HR, 0.68; 95% CI, 0.47-0.98), whereas female sex (HR, 1.82; 95% CI, 1.19-2.80) and increased creatinine level (HR per 1-mg/dL [88.4-micromol/L] increment, 2.05; 95% CI, 1.22-3.46) remained independently associated with an increased fracture risk. Age of 50 years or older (HR, 1.62; 95% CI, 0.99-2.66), initial parathyroid hormone level (HR, 1.00; 95% CI, 0.99-1.02), and calcium level (HR, 1.02; 95% CI, 0.75-1.37) were not independently associated with fracture risk after adjusting for all other variables. CONCLUSIONS: Parathyroidectomy is associated with a decreased risk of fracture in PHPT. The largest decrease was in hip fractures. Parathyroidectomy should be considered for all patients with PHPT to reduce fracture risk, regardless of age or calcium or parathyroid hormone levels.

Bone Density↗
PubMed2006

Inadvertent parathyroidectomy during thyroid surgery: the incidence of a complication of thyroidectomy.

BACKGROUND AND AIMS: Incidental parathyroidectomy is a complication of thyroid surgery. The aim of this report is to explore the incidence, risk factors, and clinical relevance of inadvertent parathyroidectomy during thyroidectomy. MATERIALS AND METHODS: Patients who underwent thyroidectomy between January 1998 and June 2005 were evaluated. Pathology reports were reviewed for the presence of parathyroid tissue in the thyroidectomy specimens. Information regarding diagnosis, operative details, and postoperative hypocalcemia were collected. RESULTS: Three hundred and fifteen thyroid procedures were performed: 163 total thyroidectomies, 124 near-total thyroidectomies, and 28 lobectomies. The findings were benign in 240 and malignant in 75 cases. Incidental parathyroidectomy was found in 68 (21.6%) cases: 58 were benign and 10 were malignant. One and two parathyroids were accidentally removed in 46 and 22 patients, respectively. Parathyroid tissue was found in intrathyroidal (33%) and extracapsular (27%) sites. Total/near-total thyroidectomy was not associated with increased risk of incidental parathyroidectomy (P=0.646), and there was no association of inadvertent parathyroidectomy with postoperative hypocalcemia (P=0.859). Thyroid malignancy was associated with decreased incidence of incidental parathyroidectomy (P=0.047). CONCLUSION: Inadvertent parathyroidectomy, although not uncommon, is not associated with postoperative hypocalcemia. The type of surgical procedure does not increase the risk of incidental parathyroidectomy, while thyroid malignancy may reduce the incidence of inadvertent parathyroidectomy.

Adult↗
PubMed2005

Maintained normalization of cardiovascular dysfunction 5 years after parathyroidectomy in primary hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism (pHPT) has been associated with premature death in cardiovascular diseases. Short-term prospects for normalization of cardiovascular derangements have been described after parathyroidectomy. This study explores long-term effects of parathyroidectomy on cardiovascular functions in pHPT. METHODS: Thirty consecutive patients with pHPT were reexamined 1 and 5 years after parathyroidectomy, together with 30 matched controls, with echocardiography and a bicycle exercise test. RESULTS: Serum calcium was normal in all patients and control subjects at follow-up. The maximal blood pressure during the exercise was higher before parathyroidectomy (median 223 [range, 200-268] mm Hg vs 202 [165-277] mm Hg, P < .05) but not 5 years after (230 [155-270] mm Hg vs 219 [165-252] mm Hg. The ST-segment depression diminished from -1.4 (-8.3-0) to -0.8 (-3.3-0) mm 1 year after parathyroidectomy and further to -0.1 (-3.3-0.0) mm after 5 years but was unchanged in the control group. The number of ventricular extrasystolic beats at exercise testing in the pHPT group before parathyroidectomy was higher than in the control group (1 [0-340] vs 0 [0-3]). The isovolemic relaxation time at rest was prolonged before parathyroidectomy (mean 100 +/- 17 ms [SD] vs 89 +/- 14 ms, P < .05). CONCLUSION: Parathyroidectomy can induce long-lasting improvement in regulation of blood pressure, left ventricular diastolic function, cardiac irritability (ventricular extrasystolic beats), and other signs of myocardial ischemia, with potential implications for the postoperative life expectancy of patients with pHPT who have undergone parathyroidectomy.

Adult↗
PubMed1997

Intraoperative parathyroid hormone monitoring during parathyroidectomy for secondary hyperparathyroidism.

BACKGROUND: The surgical management of secondary hyperparathyroidism by experienced surgeons is associated with excellent results. The presence of supernumerary glands and inadequate initial parathyroidectomy can lead to reoperations for recurrence. Intraoperative parathyroid hormone monitoring (qPTH), which has been described during parathyroidectomy for primary hyperparathyroidism, may be helpful in preventing or predicting the need for reoperation. This report describes the use of qPTH assays during parathyroidectomy in patients with secondary hyperparathyroidism. METHODS: Intraoperative parathyroid hormone (PTH) levels were determined in 13 patients with secondary hyperparathyroidism undergoing total parathyroidectomy with autotransplantation (n = 3) or subtotal parathyroidectomy (n = 10). Levels were determined using a modified immunochemiluminometric assay (qPTH). RESULTS: The average PTH levels before and after parathyroidectomy were 1599 pg/ml (620 to 2486 pg/ml) and 230.3 pg/ml (129 to 345 pg/ml), respectively. All patients had significant decreases in PTH levels after parathyroidectomy (mean, 84.6%). Symptoms were improved in all patients after operation. PTH levels at early follow-up were consistently below intraoperative levels. CONCLUSIONS: Intraoperative PTH monitoring reproducibly demonstrates the clinically relevant decrease in PTH levels after parathyroidectomy for secondary hyperparathyroidism similar to those previously documented in patients with primary hyperparathyroidism. Long-term follow-up and increasing numbers of patients are crucial in defining the role of qPTH monitoring during parathyroidectomy for secondary hyperparathyroidism.

Adult↗
PubMed1990

[Effect of parathyroidectomy on enamel formation of incisors in rats].

A chronological study on the enamel formation of the incisors in male Wistar rats was undertaken following parathyroidectomy by using glyoxalbis (2-hydroxyanil) stain, ground sections, and scanning and transmission electron micrographs. In addition, the effect of activated vitamin D3 administration on the enamel formation in parathyroidectomized rats was investigated using the same procedures. The following results were obtained. 1) Effects of parathyroidectomy (1) Macroscopic observation and the changes in body weight. The tetany after parathyroidectomy was not observed in this study. However, the reduction of behavior, loss of glistening of body hair, and standing of body hair became evident with time. There was a tendency for loss of the increased body weight as compared with that in normal rats. In the incisors, there were no macroscopic abnormal findings in shape and color. (2) Chronological alterations in serum Ca and P concentration. Serum Ca concentration decreased abruptly until 1 week after parathyroidectomy and the condition of lower concentration of serum Ca remained unchanged after 2 weeks of parathyroidectomy. Serum P concentration increased until 2 weeks after parathyroidectomy, but thereafter it decreased slightly and additionally the condition of higher concentration of serum P remained unchanged. (3) Morphological alterations in ameloblast layer and enamel matrix. No evident changes were observed at the stage of division and proliferation of ameloblasts after parathyroidectomy. But in the morphology of ameloblasts and intercellular organelle at the stage of formation and maturation, various changes were observed: namely atropy, deformities and degeneration of ameloblasts, irregular swelling, disruption and liberation of rough endoplasmic reticulum, disappearance of attached ribosomes, indistinctness of Golgi apparatus, expansion of perinuclear space, reduction in number of mitochondria and loss of crista. In the ameloblasts at the stage of matrix formation and maturation, vacuoles of various sizes were observed, and increases in number and growth in size were seen chronologically. Furthermore, after 4 weeks of parathyroidectomy, cyst formation was observed and enamel hypoplasia was limited only to the superficial layer of enamel. Calcium value at the site of enamel tubules was one fiftieth as much as that of normal rats on the ameloblastic side after 5 weeks of parathyroidectomy and was reduced to one-half at intermediate site. Similarly, P value was reduced.(ABSTRACT TRUNCATED AT 400 WORDS)

Ameloblasts↗
PubMed1996

Parathyroidectomy in chronic renal failure: comparison of three operative strategies.

The efficacy of subtotal parathyroidectomy (n = 11), total parathyroidectomy+autotransplantation (n = 13) and total parathyroidectomy alone (n = 24) were compared in a series of renal patients with hyperparathyroidism. The principal indication for surgery was severe bone disease but other indications were uncontrolled hypercalcaemia, soft tissue calcification and grossly elevated parathyroid hormone (PTH) levels. The clinical success rates at 24 months follow-up for subtotal, total plus autograft, and total parathyroidectomy were 100, 89 and 97% respectively. Similar improvements in radiological changes and alkaline phosphatase levels were seen in all three groups. Recurrent hyperparathyroidism was recorded in three (27%) members of the subtotal parathyroidectomy group and two (16%) of the patients undergoing total parathyroidectomy and autotransplantation. Two patients required re-exploration of their forearm parathyroid autograft. No patients undergoing total parathyroidectomy only suffered persistent or recurrent hypercalcaemia. Vitamin D analogue requirements rates in patients undergoing subtotal, total plus autotransplant, and total parathyroidectomy at 24 months were 44, 70 and 81% respectively. An important finding is the demonstration of residual parathyroid function in 14/16 patients (87.5%) undergoing total parathyroidectomy without autotransplantation and followed-up for 2 years.

Bone Diseases↗
PubMed2004

Minimally invasive parathyroidectomy by unilateral neck dissection--experience in a regional hospital in Hong Kong.

OBJECTIVE: To compare the efficacy and safety of minimally invasive open parathyroidectomy with localised unilateral neck dissection to the conventional method of bilateral neck exploration and parathyroidectomy as a surgical treatment for primary hyperparathyroidism. PATIENTS AND METHODS: Eleven patients diagnosed with primary hyperparathyroidism at Queen Elizabeth Hospital from 1 January 2002 to 31 December 2002 were treated surgically with minimally invasive open parathyroidectomy. Their results were compared to a retrospective series of 15 patients treated by conventional bilateral neck exploration and parathyroidectomy between 1 January 2001 and 31 December 2001. Demographic data; cure, recurrence, and complication rates; operating time; and hospital stay were analysed. RESULTS: The cure rate was 100% in both groups. There was no recurrence in either group. Minor complication rates were 9% and 20% in the minimally invasive open parathyroidectomy and the control groups, respectively. Mean operating time was 63 minutes in the minimally invasive open parathyroidectomy group, and 92 minutes in the control group. The mean postoperative hospital stay for the minimally invasive open parathyroidectomy group was 1.36 days. Three of these procedures were performed as day surgery. The mean hospital stay for the control group was 2.93 days. The operating time and hospital stay were significantly shorter in the minimally invasive open parathyroidectomy group. CONCLUSION: Minimally invasive open parathyroidectomy is a viable alternative treatment method for primary hyperparathyroidism. It has comparable cure and recurrence rates to the conventional approach. It is safe, with a lower complication rate, and has the benefits of being a shorter procedure and allowing a shorter hospital stay. It can be performed as day surgery, further reducing hospital costs.

Adult↗
PubMed1999

Osteoporosis in multiple endocrine neoplasia type 1: severity, clinical significance, relationship to primary hyperparathyroidism, and response to parathyroidectomy.

BACKGROUND: Sporadic primary hyperparathyroidism (PHPT) occurs most frequently in postmenopausal women. Multiple endocrine neoplasia type 1 (MEN 1) is an autosomal-dominant disease in which mild to moderate PHPT develops in most gene carriers by 20 years of age. Primary hyperparathyroidism associated with MEN 1 is typically recurrent, despite initially successful subtotal parathyroidectomy. Osteoporosis is considered a complication of sporadic PHPT and an indication for parathyroidectomy. In the setting of MEN 1, however, the relationship of bone mass to PHPT, fracture risk, and parathyroidectomy is unknown. HYPOTHESIS: Parathyroidectomy improves bone mineral density for patients with primary hyperparathyroidism in the setting of MEN 1. DESIGN: Case series. SETTING: Tertiary referral center. PATIENTS: Twenty-nine women with MEN 1 belonging to a single family with a history of MEN 1. INTERVENTIONS: Parathyroidectomy. MAIN OUTCOME MEASURES: Bone mineral density (BMD) and history of skeletal fracture. RESULTS: Osteopenia and osteoporosis were diagnosed in 41% and 45% of patients, respectively. Forty-four percent of patients with uncontrolled PHPT had severe osteopenia (T score, <-2.0) by 35 years of age. Reduction in BMD was greatest at the femoral neck. Reduced BMD was associated with an increased likelihood of skeletal fracture (P = .05). Patients with uncontrolled PHPT had lower femoral neck and lumbar spine BMDs than those in whom PHPT was controlled by parathyroidectomy (P = .005 and .02, respectively). Successful parathyroidectomy improved femoral neck and lumbar spine BMDs by a mean +/- SEM of 5.2% +/- 2.5% and 3.2% +/- 2.9%, respectively. CONCLUSIONS: Osteoporosis is a frequent and early complication of PHPT in MEN 1. Despite difficulty in achieving a cure of PHPT in MEN 1, parathyroidectomy has an important role in the optimization of BMD for patients with MEN 1.

Adult↗
PubMed1995

Uremic small-artery disease with medial calcification and intimal hyperplasia (so-called calciphylaxis): a complication of chronic renal failure and benefit from parathyroidectomy.

BACKGROUND: Uremic small-artery disease with medial calcification and intimal hyperplasia can lead to life-threatening skin necrosis or acral gangrene. It is a distinct complication of chronic renal failure that must be differentiated from soft-tissue calcification. An increased calcium-phosphate product and secondary hyperparathyroidism are the main underlying conditions. The benefit of parathyroidectomy is controversial. OBJECTIVE: This article is based on a literature search to determine prognostic factors and, in particular, the benefit of parathyroidectomy. METHODS: The literature on uremic small-artery disease (so-called calciphylaxis) was reviewed (full data set: 104 cases, including five of our own). The therapeutic benefit of parathyroidectomy and the relation between prognostic predictors (localization, dialysis, and transplant) and outcome were analyzed. The relation between diabetes and acral gangrene was also examined. Further epidemiologic data on the reviewed group of patients were established. RESULTS: Thirty-eight of 58 patients who underwent parathyroidectomy survived compared with 13 of 37 patients who did not undergo parathyroidectomy (p = 0.007, n = 95). Forty of 53 patients with distal localization of necrosis survived compared with 11 of 42 patients with proximal pattern (p < 0.00001; n = 95). Dialysis and kidney transplantation followed by immunosuppression showed no relation to disease outcome. No association was found between diabetes and acral gangrene (p = 0.50). CONCLUSION: Uremic small-artery disease is a distinct complication of chronic renal failure. Its recognition and early diagnosis should allow more effective treatment. In our retrospective study parathyroidectomy was significantly related to survival. Only a randomized, controlled, prospective trial (parathyroidectomy vs conservative treatment of secondary hyperparathyroidism) can establish the value of parathyroidectomy in uremic small-artery disease.

Adult↗
PubMed1998

Assessment of ultrasound guided percutaneous ethanol injection and parathyroidectomy in patients with tertiary hyperparathyroidism.

BACKGROUND: Tertiary hyperparathyroidism continues to cause significant morbidity in patients with chronic renal failure. This is frequently resistant to medical management and may ultimately require a surgical parathyroidectomy. Recent studies have reported upon the technique of percutaneous ethanol ablation for both primary and tertiary hyperparathyroidism. In this study we report on a 5 year experience using ethanol injection and compare the results with surgical parathyroidectomy. METHODS: A prospective study in 39 patients with tertiary hyperparathyroidism, 25 were dialysis dependent and 14 had a functioning renal allograft. Twenty-two patients underwent percutaneous fine needle ethanol injection (PFNEI) and 17 underwent surgical parathyroidectomy. RESULTS: A > 30% reduction in intact parathyroid hormone (iPTH) was achieved in 11 of 22 patients undergoing PFNEI after a mean of 1.8 +/- 1.4 injections per gland. In four patients, symptomatic hyperparathyroidism recurred and they required further PFNEI or surgical parathyroidectomy at 17, 28, 46, and 48 months later. There was no significant reduction in iPTH in 11 patients following PFNEI after a mean of 2.5 +/- 1.3 injections per gland. They all required a subsequent surgical parathyroidectomy for symptomatic hyperparathyroidism. Four patients developed a laryngeal nerve palsy following PFNEI, two of which were permanent. Seventeen patients underwent successful surgical parathyroidectomy as a primary procedure. CONCLUSION: Whilst PFNEI is successful in primary hyperparathyroidism, when typically only one adenoma is present, the effectiveness of PFNEI is unpredictable and the long term results are poor compared with those of surgical parathyroidectomy in tertiary hyperparathyroidism. The procedure is not without complications and makes subsequent surgery more difficult. Therefore it can only be recommended for patients with a known single parathyroid gland such as patients in whom hyperparathyroidism has recurred following a previous surgical subtotal parathyroidectomy and who are unsuitable for further surgery.

Administration, Cutaneous↗
PubMed2005

Ten years' experience in subtotal parathyroidectomy of hemodialysis patients.

Secondary hyperparathyroidism (SHP) is a frequent complication of long-term dialysis patients, and surgical parathyroidectomy remains necessary in patients resistant to medical therapy. The present paper reports single center results in subtotal parathyroidectomy, presenting diagnostic procedure, indications for parathyroidectomy, and postoperative course of metabolic and endocrine disorders. Forty-seven patients (25 males and 22 females), aged 25-60 years, regularly hemodialyzed between 3-23 years, have undergone parathyroidectomy at our Clinical Center during the last 10 years. The patients had plasma iPTH levels 8-45 times higher than the top normal limit, high values of alkaline phosphatase, calcemia on the upper normal level, and hyperphosphatemia. Radiographic changes characteristic for SHP were seen in all patients before parathyroidectomy, and the most common were subperiosteal resorptions (100%), bone cysts and periosteal neostosis (66%), and extraskeletal calcifications (98%). Enlarged parathyroid glands were seen by ultrasound in 62% of patients. All patients manifested pruritus and bone pain, 89% of them had myopathy, while other symptoms and signs were present in lower proportions. After parathyroidectomy, pruritus and myopathy reduced significantly, while pain in bones and joints remained. One patient had brown tumor at the maxillary bone that regressed gradually after parathyroidectomy. Significant decreases of phosphate and calcium levels were recorded in all but two patients on the very first postoperative day. Regular peroral and parenteral supplementations of calcium and vitamin D metabolites were used, but calcemia was not normalized until the end of the third week of the postoperative period. Serum alkaline phosphatase showed an increase after the surgery, thereupon a sudden and then slower decrease up to 1 year from the surgery. Plasma iPTH levels, checked on the 21st postoperative day, were close to the lower normal limit in all but two (4.3%) patients with persistent SHP, who required reoperation. In conclusion, subtotal parathyroidectomy was proved as a successful and safe treatment for patients with SHP resistant to medical therapy, and treatment was followed by improvement of clinical symptoms and metabolic disorders.

Adult↗
PubMed1991

Total parathyroidectomy alone or with autograft for renal hyperparathyroidism?

Seventy-six patients underwent parathyroidectomy for renal hyperparathyroidism. There were 10 subtotal parathyroidectomies, 49 total parathyroidectomies with implantation of part of one gland as an autograft, nine total parathyroidectomies with no autograft, and eight patients in whom only three parathyroid glands were found. In 34 dialysis patients who underwent total parathyroidectomy with an autograft there was a high rate of recurrent hyperparathyroidism after 6 years in those remaining on dialysis. Fifty per cent had asymptomatic recurrent hyperparathyroidism and 30 per cent required partial autograft excision for symptomatic hyperparathyroidism. In contrast, recurrent hyperparathyroidism was rare in renal transplant recipients with good renal function. This favourable outcome did not depend upon whether parathyroid surgery was performed before or after transplantation, or on the type of parathyroidectomy. Total parathyroidectomy without an autograft was performed in nine dialysis patients without any short-term adverse effects, and with clinical and pathological improvement in bone disease. In summary, the results of surgery for renal hyperparathyroidism were excellent in patients who received a successful renal transplant. However, there was a high incidence of recurrent hyperparathyroidism in patients who remained on long-term dialysis. Total parathyroidectomy without an autograft may be the treatment of choice in patients unlikely to receive a renal transplant.

Adult↗
PubMed1990

Parathyroidectomy in chronic renal failure: indications, surgical approach and the use of calcitriol.

The appropriate use of phosphate binders, calcium supplements and especially calcitriol therapy has significantly decreased the incidence of overt secondary hyperparathyroidism in dialysis patients. Nevertheless some patients may still need parathyroidectomy, especially in the event of severe clinical signs and symptoms such as persistent hypercalcemia, pruritus, calcifilaxis, or extensive extra-skeletal calcification. Since aluminum-induced bone disease may resemble hyperparathyroidism in dialysis patients, whenever parathyroidectomy is contemplated the diagnosis of secondary hyperparathyroidism must be firmly established. Thus, a bone biopsy is mandatory prior to parathyroidectomy. It is our experience that once the patient goes to surgery the most important factor in the surgical approach is the presence of a skilled surgeon who has extensive experience in parathyroid gland surgery. The data comparing subtotal parathyroidectomy with total parathyroidectomy and autotransplantation are similar. The most important shortcoming is the lack of long-term follow-up. Recently, new data by several investigators has been advanced reintroducing total parathyroidectomy. Long-term observations in patients who despite total parathyroidectomy still have normal PTH levels are of special interest. In addition, long-term follow-up of these patients has shown that normal plasma calcium and phosphorus levels may be maintained without the use of Vitamin D; this occurred in the presence of active mineralization. However, our major objection to this procedure is the risk of aluminum-induced bone disease. At the present time we feel that the relative high incidence of recurrent hyperparathyroidism following subtotal parathyroidectomy is a reasonable trade off for the risk of aluminum bone disease which may develop in absence of PTH.(ABSTRACT TRUNCATED AT 250 WORDS)

Calcitriol↗
PubMed1985

Effect of parathyroidectomy on bone aluminum accumulation in chronic renal failure.

In some patients with chronic renal failure, bone mineralization becomes defective after parathyroidectomy for secondary hyperparathyroidism. Because aluminum deposition in bone is associated with impaired bone formation and osteomalacia, we retrospectively studied bone-biopsy specimens from patients on hemodialysis who were not exposed to dialysate contaminated with aluminum, to determine whether aluminum accumulation on bone surfaces was enhanced by parathyroidectomy. Serial biopsy specimens taken before and after parathyroidectomy revealed an increase in the rate of aluminum deposition on the surface of mineralized bone after parathyroidectomy in each of the six patients studied. The accelerated rate of aluminum accumulation could not be explained by changes in the oral aluminum intake. The mean rate of bone formation (+/- S.E.M.) before parathyroidectomy was higher in the six patients than in six control patients who did not undergo parathyroid surgery (586 +/- 147 vs. 237 +/- 85 micron2 per square millimeter per day; P less than 0.05). After parathyroidectomy, the rate of bone formation fell to levels below normal (148 +/- 32 vs. 311 +/- 29 micron2 per square millimeter per day; P less than 0.05) but was not significantly different from the rate in the control group (319 +/- 126 micron2 per square millimeter per day). We conclude that parathyroidectomy in patients with chronic renal failure is associated with enhanced aluminum deposition on the bone surface, possibly as a result of low bone formation. Patients with secondary hyperparathyroidism who may be candidates for parathyroidectomy should be evaluated for aluminum excess before surgery, so that treatment with aluminum chelation may be considered.

Aluminum↗
PubMed1987

Effect of calcitriol in the control of plasma calcium after parathyroidectomy. A placebo-controlled, double-blind study in chronic hemodialysis patients.

Severe, prolonged hypocalcemia in observed in some, but not all, hemodialysis patients after parathyroidectomy performed because of uncontrolled hyperparathyroidism. The aim of the present study was to investigate whether calcitriol and calcium supplementation in the immediate period after parathyroidectomy (days 1-14) was of more help in the control of plasma calcium than calcium supplementation alone. Fourteen hemodialysis patients were enrolled in a prospective, randomized, double-blind and placebo-controlled study. From the day after parathyroidectomy, 7 patients received calcitriol and the remaining 7 a placebo using incremental doses adjusted to the degree of hypocalcemia (up to 4 micrograms/day for calcitriol). Plasma calcium, phosphorus, alkaline phosphatase and immunoreactive parathyroid hormone levels before parathyroidectomy were comparable in both patients groups, as was the lowest plasma calcium achieved after parathyroidectomy. The decrease in plasma calcium after parathyroidectomy was related to plasma alkaline phosphatase and to the number of osteoclasts and osteoblasts on bone biopsy surface before parathyroidectomy. The mean decrement of plasma calcium (days 3-9) as compared to that before parathyroidectomy was less pronounced in calcitriol-treated than in placebo-treated patients (0.25 +/- 0.06 versus 0.45 +/- 0.05 mM, mean +/- SEM, p less than 0.025). Treatment with placebo was interrupted before day 14 because of persistent severe hypocalcemia in 4 of 7 patients, whereas calcitriol treatment was continued in all 7 patients up to 14 days. Patients on calcitriol treatment required less mean calcium supplements (days 1-9) than patients receiving placebo (37.4 +/- 3.2 versus 49.4 +/- 3.7 g, p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Calcitriol↗