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PubMed1993

[A case of an infant on continuous ambulatory peritoneal dialysis who markedly improved in subjective symptoms after total parathyroidectomy and autotransplantation].

Total parathyroidectomy and autotransplantation to treat secondary hyperparathyroidism (SHP) have been often performed on adult patients with a favorable result, but have rarely been reported in the pediatric literature. We performed the above operations on a 4-year-7-month girl who was treated by continuous ambulatory peritoneal dialysis (CAPD). The postoperative levels of serum calcium remained low in spite of oral calcium and Vitamin D3 medication, and intravenous calcium administration. But an administration of calcium into CAPF fluid has been maintained the normal level of serum calcium. A calcium balance study conducted for 3 days starting the 24th postoperative day showed 391 mg/day of calcium absorption. The girl obtained a relief from the bone pain approximately 2 weeks after the operation and was able to run easily one and a half month after the operation. Total parathyroidectomy and autotransplantation were considered to be an effective treatment for severe symptoms of osteodystrophy in infantile patients with chronic renal failure.

Child, Preschool↗
PubMed1999

Parathyroidectomy: new criteria for evaluating outcome.

Following successful parathyroidectomy, subjective improvement in recognized symptoms and in the overall "well being" of asymptomatic primary hyperparathyroid patients has been well documented. Because quantitative methods for measuring parathyroid hormone (PTH) and normal reference ranges of serum calcium have changed in recent years, a revised biochemical criteria for evaluating postoperative outcome has become necessary. Two hundred seventy-one selected patients were followed for an average of 6.3 years after parathyroidectomy. Although 257 patients had serum calcium levels <10.6 mg/dL during the entire follow-up period, 15 per cent of them had elevated intact PTH (iPTH) levels. Fourteen patients had calcium levels > or =10.6 mg/dL at some point during follow-up, with nine patients (64%) showing high iPTH levels and eight (57%) of them developing recurrent hyperparathyroidism (calcium > or =11 mg/dL and iPTH > or =68 pg/mL). Of the 14 remaining patients, 5 had hypercalcemia with normal iPTH levels. In patients with successfully treated primary hyperparathyroidism, the recommended annual follow-up is: 1) monitor total serum calcium only if serum calcium level is <10.6 mg/dL, or if serum calcium level is > or =10.6 mg/dL; and 2) monitor serum calcium and PTH levels, because these patients have an increased incidence of hyperfunctioning parathyroid glands, which may point to late recurrence.

Calcium↗
PubMed1999

The evolution of parathyroidectomy failures.

BACKGROUND: Reported operative failure rates for primary hyperparathyroidism range from 5% to 10%. Failure has been due to multiglandular disease, ectopic parathyroid glands, errors in frozen section, and missed diagnoses. Recently, our operative approach has changed from bilateral cervical exploration to direction by preoperative localization and intraoperative quick parathyroid hormone assay. The purpose of this study is to examine the causes and rates of failure in this evolving approach to parathyroidectomy. METHODS: Among 447 consecutive cases of primary hyperparathyroidectomy, 20 operative failures were examined. Three different operative approaches were compared with respect to causes and rates of failure. RESULTS: From 1969 to 1989, with bilateral neck exploration, failure was due to missed diagnoses, ectopic glands, multiglandular disease, and unknown causes, with a failure rate of 5%. From 1990 to 1993, with bilateral neck exploration and quick parathyroid hormone assay, failure was due to ectopic mediastinal glands, misinterpretation of frozen section, and operative judgment, with a failure rate of 10%. From 1993 to 1998, with preoperative localization and quick parathyroid hormone assay, the two operative failures (1.5%) were due to operative judgment and misinterpretation of the quick parathyroid hormone assay. CONCLUSIONS: The new surgical approach combining preoperative localization studies and intraoperative parathyroid hormone monitoring has eliminated the most common causes of parathyroidectomy failure and has significantly decreased the operative failure rate.

Humans↗
PubMed2000

[Focal proliferation in reactive hyperplastic parathyroid tissue in end-stage renal failure--implication for autotransplantation after total parathyroidectomy].

Total parathyroidectomy with simultaneous autotransplantation may be associated with recurrence of graft-dependent hyperfunction due to excessive proliferation. We performed macroscopic tissue selection with a stereomicroscope prior to autotransplantation, which resulted in very low recurrence rates. As this technique greatly depends on experience, we investigated the possibility of additionally using proliferation staining (PCNA, MIB-1) for the detection of dysfunctional tissue. Selected tissue from 26 patients was investigated. Serial sections of freshly removed parathyroid tissue were correlated with their macroscopic appearance, HE and immunohistochemically stained paraffin sections, and with semithin Epon sections. The asymptotic growth mode of clonal proliferating regions was reflected by highest staining intensity (1-5%) in small to medium sized foci (diffuse, up to 3 mm in diameter) and very low staining in large areas (diffuse or nodular, 5-15 mm in diameter, from 0.03 to 0.003% positive cells). Thus, very large dysfunctional regions with (almost) no proliferation could not be detected by this method. However, they were very evident on macroscopic investigation. In conclusion, multiple fulminant recurrence after parathyroidectomy can be prevented by selecting tissue after proliferation staining. This may allow a delayed autotransplantation after total parathyoidectomy for those surgeons lacking experience in macroscopic tissue classification.

Adult↗
PubMed2000

[Preliminary experiences with endoscopic parathyroidectomy].

Since the advent of extraperitoneal approaches for laparoscopic surgery, the creation of extraperitoneal virtual spaces has spread rapidly. We describe our preliminary experience with selective neck exploration and endoscopic parathyroidectomy in 4 women, aged 57-74, with primary hyperparathyroidism. Preoperative localization of parathyroid adenoma was assessed by technetium-sestamibi scanning and cervical ultrasonography. A cervical work space was created by the introduction of a trocar with an inflatable balloon-tip and maintained with low-pressure CO2 insufflation. All procedures were completed endoscopically. There were no intraoperative complications. Mean operative time was 40 minutes and cosmetic results were very satisfactory. We found endoscopic parathyroidectomy a feasible and safe option and particularly appropriate for the surgical treatment of primary hyperparathyroidism. Further refinements in technique will enhance its practicability in exploring the mediastinum for ectopic parathyroid glands and in those with secondary hyperparathyroidism.

Aged↗
PubMed2001

Evaluation of the performance and clinical impact of a rapid intraoperative parathyroid hormone assay in conjunction with preoperative imaging and concise parathyroidectomy.

BACKGROUND: (99m)Tc-sestamibi scans and rapid, intraoperative intact parathyroid hormone (PTH) assays allow preoperative identification of diseased glands and intraoperative confirmation of diseased gland removal, respectively. Use of these two new technologies may facilitate simpler, more concise surgery, shorter hospital stays, and decreased costs for frozen-section analysis. One major drawback to this new strategy has been the high cost of rapid point-of-care PTH assays. METHODS: We performed rapid PTH assays with the DPC Turbo PTH assay on the DPC IMMULITE automated analyzer. The number of intraoperative frozen sections, type of anesthesia, surgical approach, length of hospital stay, and pre- and postoperative calcium values were compared between a group of 49 patients undergoing parathyroidectomy where the intraoperative PTH assay was used in conjunction with preoperative imaging, and a historical control group of 55 patients before the use of these two technologies in our institution. RESULTS: Comparison of the Turbo PTH assay to the standard IMMULITE PTH assay gave the following: y = 1.08 x - 4.36 (r = 0.97; n = 48). For the 49 patients, the median turnaround time for each intraoperative PTH determination was 19 min (range, 14-40 min). The median decrease in PTH values from baseline was 88% (range, 33-99%). Thirty-seven patients required two PTH determinations, 7 required three, 4 had four, and 1 required five determinations. The average laboratory cost for the rapid intraoperative PTH assays was < $100 per patient (range, $55 to $113). Compared with the control group, the experimental group had significantly fewer frozen sections (1.4 vs 2.5; P < 0.0001), shorter hospital stays (17 discharged on the day of surgery vs none discharged on the day of surgery; P < 0.0001), greater use of local anesthesia (33% vs 0%; P < 0.001), and more unilateral, rather than bilateral neck explorations (65% vs 0%; P < 0.001). CONCLUSIONS: The combination of intraoperative Turbo PTH assay and preoperative (99m)Tc-sestamibi scans can lead to significant decreases in laboratory and surgical pathology costs, hospital stays, and exposure to general anesthesia by facilitating concise parathyroidectomy surgery.

Adolescent↗
PubMed2001

Arterial distensibility and pulse wave velocity in patients with primary hyperparathyroidism before and after parathyroidectomy.

AIMS: There is evidence that secondary hyperparathyroidism alters arterial vessel wall properties. However, it is unclear whether effects of parathyroid hormone (PTH) on the vascular wall are direct or permissive and related to hypertension and renal failure. To assess early direct effects of PTH on large artery wall properties isobaric distensibility (DC), pulse wave velocity (PWV) and intima-media thickness (IMT) were studied before and after parathyroidectomy (Ptx) in patients with primary hyperparathyroidism (pHPT). METHODS: DC and IMT of the brachial and carotid artery were measured by echo-tracking and tonometry, PWV by the automatic Complior-device at baseline and 6 months after Ptx in 20 patients with pHPT (data mean +/- SEM, age 45+/-5 years, PTH 240+/-61 ng/l). Cardiovascular risk factors like diabetes, hypertension, renal insufficiency and hypercholesterolemia were excluded. Twenty healthy volunteers matched for age, sex and blood pressure served as controls. RESULTS: Six months after Ptx, PTH decreased to normal; however, blood pressure levels and vessel wall parameter remained unchanged. At baseline, there were no significant differences in brachial and carotid IMT (0.48+/-0.04 and 0.62+/-0.04 mm vs. 0.47+/-0.06 and 0.61+/-0.06 mm), radial and aortic PWV (9.1+/-0.4 and 9.9+/-0.7 m/s vs. 9.2+/-0.5 and 10.0+/-0.6 m/s), brachial and isobaric carotid DC (10.1+/-1.4 and 19.5+/-3.4 10(-3)/kPa vs. 9.1+/-0.9 and 20.4+/-3.2 10(-3)/kPa) or artery diameter between patients and controls. CONCLUSIONS: Structural and viscoelastic properties of large arteries are not disturbed and not influenced by parathyroidectomy in patients with early pHPT devoid of hypertension and renal disease. We conclude that increased PTH levels per se are not associated with alterations of mechanical arteriall wall properties; permissive factors like renal insufficiency may be necessary to mediate vessel wall alterations in patients with hyperparathyroidism.

Blood Flow Velocity↗
PubMedDate not supplied

Video-assisted parathyroidectomy by a skin-lifting method for primary hyperparathyroidism.

OBJECTIVE: The use of endoscopic surgical procedures has rapidly spread to abdominal and thoracic surgeries and subsequently to surgeries of the neck region. Several surgeons initiated endoscopic parathyroidectomy using CO2 insufflation to create the working space; however, they reported various complications. We describe here a skin-lifting method that may have few complications. METHODS: A 65-year-old man was diagnosed with primary hyperparathyroidism due to a solitary adenoma of the left inferior parathyroid gland. A 3-cm oblique incision was made below the left clavicle, and a 5-mm incision was made on the lateral neck. After the skin was lifted up, we performed video-assisted parathyroidectomy. RESULTS: Parathyroid extirpation took 2 hours and blood loss was minimal. The patient had minimal pain and no complications postoperatively. Serum concentrations of calcium and intact parathyroid hormone were normalized on the next day. CONCLUSION: Using the skin-lifting method, we obtained a sufficient operative view and encountered no complications. This procedure is cosmetically desirable, and we consider it a feasible alternative for the treatment of parathyroid adenoma.

Adenoma↗
PubMed2001

Persistent hyperparathyroidism after kidney transplantation requiring parathyroidectomy.

INTRODUCTION: Successful kidney transplantation (KT) is believed to cure secondary hyperparathyroidism, but persistent disease has emerged in a significant number of allograft recipients. Parathyroidectomy (PTX) is ultimately required in some of these patients. AIM: To provide an in-depth analysis of 42 patients who required surgical treatment for persistent hyperparathyroidism after successful renal transplantation and to identify risk factors for PTX present at the time of transplantation. DESIGN: Retrospective case controlled study. METHODS: Charts of 1332 kidney allograft recipients, transplanted between 1989 and 2000, were reviewed. Patients requiring a PTX after a first successful kidney transplantation (serum creatinine < 2.5 mg/dl) were identified. Their charts were checked for various demographic, clinical and biochemical variables. The data were compared with data obtained from a control group closely matched for time of transplantation. RESULTS: Persistent hyperparathyroidism after successful KT requiring PTX occurred in 55 (4.1%) patients. Because of insufficient follow-up data only 42 recipients were eligible for further analysis. The age of the patients was 52 +/- 2.1 years (mean +/- SEM). The time between transplantation and PTX was 416 +/- 61 days. The mean serum creatinine at the time of PTX amounted to 1.6 +/- 0.1 mg/dl. Persistent hypercalcemia, albeit asymptomatic in most patients, was the main indication for PTX. Enlarged parathyroid glands were visualised by ultrasonography in 74% of the cases. Subtotal parathyroidectomy was the procedure of choice. The operative morbidity was negligible and the incidence of persistent or recurrent hyperparathyroidism was low, being 15%. In comparison to the control group, the patients with persistent hyperparathyroidism had a significant longer duration of pre-transplantation dialysis treatment (36.3 vs. 23.0 months, p < 0.01) and significant higher values of intact parathyroid hormone (iPTH) (268.1 vs. 96.0 ng/l, p < 0.001), total serum calcium (10.6 vs. 9.4 mg/dl, p < 0.001), and serum alkaline phosphatases (185.5 vs. 132.0 U/L, p < 0.001) at the time of transplantation. No relationship with the mode of dialysis treatment was observed. CONCLUSION: Persistent hyperparathyroidism requiring PTX after successful KT is a common clinical problem. Patients who spent a long time on dialysis and/or patients with a high pre-transplant level of iPTH, serum calcium and alkaline phosphatases are especially at risk.

Alkaline Phosphatase↗
PubMed2001

Recurrent hyperparathyroidism after total parathyroidectomy due to multiple ectopic parathyroid glands in a patient with long-term haemodialysis.

We report the rare case of a recurrent hyperparathyroidism after total parathyreoidectomy due to multiple ectopic glands in a patient on long-term haemodialysis. In a today 47 years old man with membranoproliferative glomerulonephritis intermittent haemodialysis therapy was started in 1975. In 1982 an advanced secondary hyperparathyroidism with a parathormone (PTH) level > 500 pg/l was diagnosed; later on PTH concentration increased to 2,550 pg/ml. In 1987 total parathyroidectomy with parathyroid autograft into the left forearm was performed. After parathyroidectomy the PTH level fell to 150 pg/ml. In 1993 PTH concentration increased again to 1,750 pg/ml. There was no evidence for recurrent parathyroid glands in the neck or forearm. Therefore, we investigated the substernal region by 99mTc-tetrofosmin scintigraphy and magnetic resonance imaging. Both investigations showed evidence for two ectopic parathyroid glands in the anterior mediastinum. In June 1999 in an open thoracic surgical procedure only the greater parathyroid gland in the anterior mediastinum was isolated, but a second gland was detected in the posterior mediastinum. Both parathyroid glands were resected (histologically hyperplastic parathyroid gland tissue). After surgery the PTH level decreased to 340 pg/ml, but later on PTH increased again to > 1,000 pg/ml in January 2001. A control 99mTc-tetrofosmin scan showed evidence for a third ectopic parathyroid gland in the anterior mediastinum. Recurrent secondary hyperparathyroidism can rarely be caused by recurrent ectopic parathyroid glands in the mediastinum.

Choristoma↗
PubMed2002

Total parathyroidectomy with or without autoimplantion in the therapy of secondary hyperparathyroidism.

BACKGROUND: Secondary hyperparathyroidism (HPTs) in patients with chronic renal failure is related to a reduction of absorption of calcium with hyperplasia of main cells and an increase of PTH levels: this often leads to complications in dialysis. METHODS: Data from 10 patients (mean age 55 years) with HPTs who underwent total parathyroidectomy from November 1999 to November 2001 were retrospectively collected. Surgical indications included: persistent hypercalcemia, bone fractures, fatigue, joint pain and itching. Median preoperative PTH level was 800 pg/ml. Presurgical work-up included: serum PTH, calcium and alkaline phospha-tases. Thyroid ultrasound and scintigraphy, 99Tc sestamibi scintigraphy, CBM, FNB were also performed. In 5 patients 2 hours prior to the operation 2 MCu of sestamibi 99Tc had been injected. Patients underwent cervical exploration radioguided in 5 cases under general anesthesia. The operation consisted in the removal of all glands with subcutaneous forearm implant in 4 cases. PTH dosage at starting time of operation (time 0) was performed; it was repeated after the removal of each parathyroid gland and postoperatively on days 1 and 3 and then every month for 6 months. RESULTS: Twenty-four hours postoperatively 9 patients showed a great reduction of PTH levels with improved symptoms already on day 1 postoperative. In the patient with persistent HPT an autoimplant had been performed. CONCLUSIONS: Secondary HPT still shows unclear aspects. Parathyroidectomy determines an immediate improvement in symptoms. In all observed patients PTH was significantly reduced, serum calcium returned to normal and in any case hypoparathyroidism was detected.

Female↗
PubMedDate not supplied

Painful cutaneous lesions, renal failure and urgent parathyroidectomy.

We describe two patients with end stage renal failure who presented with painful skin lesions, which rapidly progressed to become necrotic and gangrenous. The diagnosis was calciphylaxis, a rare disorder due to calcification and luminal fibrosis of small and medium sized cutaneous and systemic vessels. Both patients had tertiary hyperparathyroidism. An urgent parathyroidectomy was performed on one patient, which relieved her symptoms; the other required local surgery but refused parathyroidectomy and died.

Calciphylaxis↗
PubMed2003

Subtotal parathyroidectomy: a possible treatment for calciphylaxis.

Calciphylaxis is a rare disorder in patients with chronic renal failure that is characterized by ischemic necrotic skin lesions. The prognosis is grave and mortality is high (80%). The precise mechanism of calciphylaxis is still unknown, but in addition to chronic renal failure, elevated parathyroid hormone levels appear to play a role. The role of parathyroidectomy in treating affected patients is questionable. In this article, we describe the case of a patient with chronic renal failure who developed rapidly progressive subcutaneous calcifications and ulcerations in the lower extremities. These lesions regressed following subtotal parathyroidectomy. We also review the literature on calciphylaxis, with a focus on treatment options.

Biopsy, Needle↗
PubMed2003

Minimally invasive radioguided parathyroidectomy (MIRP).

The technique of parathyroidectomy has traditionally involved a bilateral exploration of the neck with the intent of visualizing 4 parathyroid glands and resecting pathologically enlarged glands. Parathyroid scanning using technetium-99m sestamibi has evolved and can now localize 80% to 90% of parathyroid adenomas. The technique of minimally invasive radioguided parathyroidectomy (MIRP) is a surgical option for most patients with primary hyperparathyroidism and a positive preoperative parathyroid scan. The technique makes use of a hand-held gamma probe that is used intraoperatively to guide the dissection in a highly directed manner with the procedure often performed under local anesthesia. The technique results in excellent cure rates while allowing most patients to leave the hospital within a few hours after the completion of the procedure. Current data also suggest the procedure can decrease hospital charges by approximately 50%. This technique may significantly change the management of primary hyperparathyroidism.

Equipment Design↗
PubMed1965

CARCINOMA OF LUNG WITH ADRENAL HYPERFUNCTION AND HYPERCALCEMIA TREATED BY PARATHYROIDECTOMY.

A case of severe hypercalcemia secondary to carcinoma of the lung is described in which hypokalemic alkalosis, renal failure and pancreatitis were also present. The relative importance of the few bone metastases found at autopsy is considered, and a probable endocrine-like effect of the tumour in the development of the hypercalcemia is postulated. Treatment of the hypercalcemia included administration of corticosteroids and disodium EDTA, peritoneal dialysis and subtotal parathyroidectomy; the most effective of these was peritoneal dialysis. Subtotal parathyroidectomy failed to produce a further decrease in serum calcium values. The occurrence of hypokalemic alkalosis in the presence of increased adrenocortical function and its relationship to the carcinoma of the lung are discussed. The possibility that this neoplasm produced two factors which caused systemic effects ordinarily associated with the function of endocrine glands must be considered.

Adrenal Cortex Hormones↗
PubMed2003

Relapsing secondary hyperparathyroidism due to multiple nodular formations after total parathyroidectomy with autograft.

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.

Aged↗
PubMedDate not supplied

[Total parathyroidectomy with forearm graft in tertiary hyperparathyroidism].

Autonomic and persistent hypersecretion of PTH is a frequent and tormenting complication of the patients with chronic renal dialysis for end stage renal disease (ESRD). In these cases, surgery remains a therapy option with real effects on clinical status of patients, especially in perspective of a renal transplant. The authors present the case of a patient with tertiary hyperparathyroidism for which a total parathyroidectomy followed by autotransplantation of small glandular fragments in forearm muscles was performed. The postoperative clinical and immunological statuses were favorable with the disappearance of pruritus and osteoartralgia with improvement of psychic behavior and normalization of calcium blood level. Considering the parathyroidectomy as a palliative stage in the treatment of ESRD, the authors discussed a hierarchy system of both indications and surgical alternatives to be considered in this condition. In well selected cases this surgical method represents an attractive and easy possibility to control and later adjustment of the hyperfunction of remained parathyroid tissue, avoiding in this way a very risky intervention.

Forearm↗
PubMed1992

The effect of parathyroidectomy on bone mineral density in primary hyperparathyroidism.

Bone mineral density was studied before, and at one year after successful parathyroidectomy in six postmenopausal, three premenopausal females and one male with primary hyperparathyroidism. Dual photon absorptiometry was used to measure bone mineral density at the lumbar spine in all subjects, and at three areas of the hip in eight of the subjects. There was no significant change in bone mineral density at the lumbar spine after one year. Bone mineral density increased 7.4% at the femoral neck from 0.822 (SEM 0.053) g/cm2 to 0.895 (0.04) g/cm2; p less than 0.01, 8.7% at Wards triangle from 0.681 (0.065) g/cm2 to 0.745 (0.07) g/cm2; p less than 0.02. A 5.6% increase at the trochanteric region from 0.785 (0.053) g/cm2 to 0.803 (0.053) g/cm2 was not significant. These results indicate that significant increases occur in bone mineral density at the hip, but not at the lumbar spine at one year after parathyroidectomy in patients with primary hyperparathyroidism.

Adult↗