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PubMed1981

Total parathyroidectomy and parathyroid autotransplantation in patients with chronic renal failure.

Sixteen patients with chronic renal failure underwent total parathyroidectomy and parathyroid autotransplantation into the muscle of the forearm. Pertinent preoperative medical history of these patients included renal osteodystrophy, metastatic vascular calcifications, intractable itching and uncontrollable hyperphosphatemia. Efforts to control preoperative serum calcium and elevated serum parathormone levels were unsuccessful. The mass of parathyroid tissue implanted, in most instances, was approximately half that used in other series. Postoperatively, all patients received vitamin D and calcium orally, which were gradually decreased. Fourteen of the 16 patients had relief of symptoms, and all had restoration of parathormone levels to normal or slightly above normal, although in two patients, partial excision of hyperfunctioning tissue from the forearm was subsequently required because of recurring symptoms of secondary hyperparathyroidism. All patients had evidence of functioning grafts six to 40 months postoperatively or until death, attributable to intercurrent causes. The success of total parathyroidectomy and parathyroid autotransplantation in patients with chronic renal failure and symptomatic secondary hyperparathyroidism makes this a viable approach to the disease in such patients.

Female↗
PubMed1981

[Total parathyroidectomy with reimplantation: treatment of choice of hyperparathyroidism secondary to renal insufficiency : report on 24 cases (author's transl)].

Results in a series of 24 total parathyroidectomies with immediate reimplantation in patients with chronic renal insufficiency are described, and the advantages of this method discussed. This technique avoids the complications of sub-total parathyroidectomy, and the very rare failures can be easily treated by local excision if it is velated to recurrence of hyperparathyroidism, or by further reimplantations in cases of hypoparathyroidism. Grafts are possible during a second stage, after several months of freezing, but a limit of 9 months should be suspected. This method is proposed as a routine measure in all cases of parathyroid hyperplasia.

Forearm↗
PubMed1980

Persistent hypophosphatemia following parathyroidectomy in end-stage renal disease: report of three patients.

Immediate and persistent hypophosphatemia following subtotal parathyroidectomy, despite discontinuation of phosphate binders, developed in three chronic hemodialysis patients. Although the serum phosphorous level is regularly reduced by parathyroidectomy in such patients, prolonged hypophosphatemia has not previously been reported. This observation supports the concept that parathyroid overactivity in end-stage renal disease is a major determinant of hyperphosphatemia.

Adult↗
PubMed1978

Total parathyroidectomy with autograft of parathyroid tissue in treatment of secondary hyperparathyroidism.

In 16 patients with severe symptomatic hyperparathyroidism reduction of hyperplastic parathyroid mass was performed by total parathyroidectomy with autotransplantation of parathyroid tissue. In all patients except one serum parathormone (PTH) levels returned to normal and postoperative difficulties in calcium homeostasis were rarely observed. Fifteen patients had normal PTH levels after surgery. Graft function was proven in 10 cases, but in 5 cases graft function could not be definitely established with the methods applied. One graft failure was observed. Total parathyroidectomy with autotransplanation of parathyroid tissue is recommended as the treatment of choice when surgical correction of secondary hyperparathyroidism is necessary.

Adult↗
PubMed1980

Accelerated progression of chronic renal insufficiency after parathyroidectomy.

Three patients with chronic renal failure developed secondary hyperparathyroidism, complicated by severe bone disease in two patients and by acral skin necrosis in the third. Following subtotal parathyroidectomy, the bone disease and the necrotic lesions rapidly improved, but the rate of loss of renal function accelerated concomitant with administration of calcium and vitamin D, although no hypercalcemia developed. Avoiding postoperative administration of calcium and/or vitamin D, unless indicated for symptomatic hypocalcemia, may prevent accelerated loss of renal function in patients requiring subtotal parathyroidectomy.

Adolescent↗
PubMed2001

Minimally invasive open parathyroidectomy in an endemic goiter area: a prospective study.

HYPOTHESIS: Single-gland disease identified by preoperative localization studies in combination with rapid intraoperative parathyroid hormone monitoring seems to allow a limited exploration of the neck in sporadic primary hyperparathyroidism. Minimally invasive open parathyroidectomy by lateral approach (oMIP) in sporadic primary hyperparathyroidism seems feasible in an endemic goiter region. DESIGN: One hundred consecutive patients with sporadic primary hyperparathyroidism underwent preoperative double-phase technetium Tc 99m sestamibi scanning with single-photon emission computed tomography and high-resolution ultrasonography with color Doppler imaging of the cervical region. All patients were operated on with the use of quick parathyroid hormone assay to confirm the surgical success "on-line." Patients with localized single-gland disease, irrespective of additional ipsilateral thyroid disease requiring surgery, were selected for oMIP. Success of the preoperative localization studies, postoperative (at least 6 months) serum calcium levels, and operating time were analyzed. SETTING: University hospital, section of endocrine surgery. RESULTS: Of 100 patients, 83 (83%) were considered suitable for oMIP. In 69 patients, oMIP was finished successfully. Nine of these had had previous neck surgery, and another 24 underwent additional ipsilateral thyroid resection. Permanent normocalcemia was achieved in 67 (97.1%) of 69 patients and 98 (98%) of 100 patients. CONCLUSION: The oMIP in combination with quick parathyroid hormone assay may become the treatment of choice for sporadic primary hyperparathyroidism in an endemic goiter region in centers with high experience in thyroid and parathyroid surgery. It allows treatment of concomitant ipsilateral thyroid disease and is feasible in reoperations.

Adolescent↗
PubMed2004

Early, postinjection MIBI-SPECT as the only preoperative localizing study for minimally invasive parathyroidectomy.

HYPOTHESIS: Early, postinjection technetium Tc 99m sestamibi scintigraphy-single-photon emission computed tomography (MIBI-SPECT) can be used as the only localizing study for focused parathyroidectomy in patients with primary hyperparathyroidism. DESIGN: During a 26-month period, 82 consecutive patients with primary hyperparathyroidism underwent a standard planar scan using a double-tracer subtraction technique for localization. On the morning of surgery, each patient received radiolabeled technetium Tc 99m sestamibi for intraoperative detection and validation. We performed an early, postinjection SPECT study for comparison with the planar study. RESULTS: The SPECT study revealed a sensitivity of 96% vs 78% for the planar study. The SPECT study was helpful in locating adenomas in 10 patients with multinodular goiter disease, of whom 3 patients had ectopic adenomas and 2 patients had 2 adenomas each. A significant correlation was noted between uptake ratio and preoperative parathyroid hormone levels (r = 0.41; P =.04). No recurrent or persistent hyperparathyroidism was reported during a follow-up period of at least 6 months. CONCLUSIONS: Our results encourage the use of preoperative SPECT as the only localizing study on the morning of the operation, both to select patients for minimally invasive radioguided surgery and to provide accurate 3-dimensional information on deeply seated or ectopic adenomas. This approach lowers the costs of preoperative localization and intraoperative validation to a single study. The intraoperative gamma probe technique enables the surgeon to focus the search, provides instant feedback regarding the progress of the operation, reduces surgical trauma and complications, and yields better cosmetic results.

Adenoma↗
PubMed2004

An algorithm to maximize use of minimally invasive parathyroidectomy.

HYPOTHESIS: Minimally invasive parathyroidectomy (MIP) depends on accurate preoperative localization of abnormal parathyroid glands. If the findings of a technetium Tc 99m sestamibi-labeled single-photon emission computed tomography (SPECT) (hereafter referred to as sestamibi SPECT or scan) are negative or ambiguous, cervical ultrasonography (CUS) may increase the success of preoperative gland localization and MIP, avoiding bilateral neck exploration. DESIGN: We collected data regarding preoperative sestamibi SPECT and CUS for parathyroid gland localization and intraoperative findings. SETTING: Tertiary care university hospital. PATIENTS: From August 1, 2000, through January 31, 2003, 71 patients (12 men and 59 women; mean age, 59 years) with primary hyperparathyroidism underwent preoperative sestamibi SPECT and CUS. Patients with prior or concurrent thyroid surgery, reoperative parathyroid disease, secondary/tertiary hyperparathyroidism, or studies performed at outside hospitals, were excluded. The MIP was performed by 1 surgeon with a 2- to 3-cm incision made on the side of the neck where the abnormal gland was preoperatively located. MAIN OUTCOME MEASUREMENTS: Operative findings were compared with results of preoperative studies to determine the accuracy of sestamibi SPECT and CUS for successful MIP. RESULTS: All 71 patients underwent preoperative sestamibi SPECT and CUS. Sestamibi scanning was accurate in 53 (75%) of 71 patients, whereas CUS was accurate in 40 (56%) in determining the side where the glands were located. Sestamibi scan and CUS findings were negative in 5 patients. These patients underwent planned bilateral neck exploration. Of the remaining 66 patients, MIP was successfully performed in 60 (91%). The CUS was complementary to sestamibi scanning in 9 (15%) of these 60 patients, allowing them to avoid bilateral neck exploration. CONCLUSIONS: A positive sestamibi scan finding is the only preoperative requirement for most patients with primary hyperparathyroidism for MIP. If the sestamibi scan findings are negative or ambiguous, preoperative CUS can localize an additional 14% of enlarged parathyroid glands, further facilitating an MIP in these patients.

Adenoma↗
PubMed1997

Thyroid carcinoma found at parathyroidectomy: association with primary, secondary, and tertiary hyperparathyroidism.

BACKGROUND: Frequent reports of an association between primary hyperparathyroidism (HPT) and well differentiated thyroid carcinoma, compared with the few reports of associated secondary HPT and thyroid carcinoma, may have implications for different etiologic relationships between the conditions. METHODS: A retrospective review was performed of patients who underwent surgery for HPT between 1975 and 1996 in a single institution. The prevalence of well differentiated thyroid carcinoma diagnosed at the time of parathyroidectomy (PTX) was compared for patients with primary, secondary, or tertiary HPT. RESULTS: There were 845 operations for HPT in 824 patients. Twenty-two patients were found to have thyroid carcinoma at the time of PTX. Thyroid carcinoma was found in 2.6% of the patients with primary and 3.2% of the patients with either secondary or tertiary HPT (P = 0.550). Twenty-one of the patients had papillary carcinoma and 1 had a follicular carcinoma. Eighteen of the carcinomas were < 1 cm in size. A prior history of head and neck irradiation was associated with the diagnosis of thyroid carcinoma at the time of PTX (P < 0.001). Neither renal failure, organ transplantation, female gender, lymphocytic infiltration, nor follicular adenoma of the adjacent thyroid were significant in the association between HPT and thyroid carcinoma. CONCLUSIONS: These data suggest that the association between thyroid carcinoma and HPT is coincidental and possibly related to the closer surveillance of the thyroid gland due to PTX and often concomitant removal of thyroid tissue. Patients with HPT and a history of head and neck irradiation are at increased risk of thyroid carcinoma.

Adolescent↗
PubMed1998

Reoperative parathyroidectomy in the era of localization technology.

BACKGROUND: Recurrent and/or persistent hyperparathyroidism (HPT) is an uncommon disease. Relatively few cases are seen by any one center or surgeon. Most of the prior reviews of this problem were done in the era prior to potentially accurate magnetic resonsance imaging (MRI) and sestimibi scan localization and do not reflect current preoperative localization technology. METHODS: All cases of recurrent or persistent parathyroidectomy seen in our institution between 1992 and 1996 were reviewed retrospectively to assess the predictive value of preoperative MRI, selective venous sampling, sestimibi scanning, ultrasound examination, and computerized tomography (CT) scanning. The preoperative localization studies were compared with the findings at operation, the pathology report, and the patient's long-term calcium status. RESULTS: Twenty-eight patients were operated upon at our institution for recurrent or persistent HPT during this time interval. The final pathology turned out to be: adenoma, 24; hyperplasia, 2; carcinoma, 2. The site at which the reoperative pathology was found was in the neck in 22 patients and intrathoracic requiring sternotomy in 6. The long-term outcome, i.e., serum calcium level at > 6 months postoperatively, was normocalcemia in 22 of 28 (85%), persistent hypocalcemia in 2 of 28, and persistent hypercalcemia in 2 of 28. Some combination of MRI, sestimibi, selective venous sampling, ultrasound, and CT scan was performed on all patients preoperatively. Preoperative MRI scans were performed on 26 of 28 patients. They correctly localized the side and site of the pathology in only 12, yielding a sensitivity of 66%. There were, however, no false positives; therefore, the positive predictive value of this test was 100%. Selective venous sampling was carried out on 26 of 28 patients and correctly localized in only 8 (sensitivity, 50%). Again, there were no false positives, yielding a positive predictive value of 100%. Sestimibi scanning was performed in 16 of 28, localizing in 8 (sensitivity, 50%). The positive predictive value of this test was 80%. Ultrasound was performed in 26 of 28 patients and localized in only 3, yielding a sensitivity of 17%, with a positive predictive value of 75%. Computerized tomographic scan was performed preoperatively only when all other investigations turned out to have been nonlocalizing and was therefore done in only four patients, one of whom had a positive CT scan showing an intrathoracic, intrapericardial adenoma. CONCLUSIONS: These data demonstrate that despite the availability of what are putatively accurate preoperative localizing tests for previously unoperated cases, no one localizing test is particularly sensitive in reoperative parathyroid surgery. Magnetic resonance imaging and selective venous sampling, however, are complementary and when positive do accurately predict the site of the persistent/recurrent parathyroid pathology. Use of these preoperative localizing studies resulted in a successful outcome, i.e., normocalcemia or hypocalcemia in 93% of patients operated on.

Adult↗
PubMed2003

Regional cerebral blood flow in patients with primary hyperparathyroidism before and after successful parathyroidectomy.

BACKGROUND: Single-photon emission computed tomography (SPECT) is used to study cerebral blood flow and cerebral metabolism in various neuropsychiatric disorders. Reduced regional cerebral blood flow has been demonstrated in patients with depression and chronic fatigue, symptoms that are common in primary hyperparathyroidism. The aim of this study was to reveal possible changes in regional cerebral blood flow in patients with primary hyperparathyroidism before and after operative treatment. METHODS: This was a prospective study of regional cerebral blood flow in 16 consecutive women of median age 72 (range 50-82) years using SPECT with (99m)Tc-labelled hexamethylpropylenamine-oxime. The measurements were performed before and 2, 4 and 12 months after parathyroidectomy. The Montgomery and Asberg depression rating scale (MADRS) depression score was used as a parallel clinical test. RESULTS: Reduced (pathological) regional cerebral blood flow was seen before operation in 14 patients, 13 with a solitary adenoma and one with double adenoma. After surgery, this improved to normal values in 13, but was further reduced in one. In two patients with preoperative normal regional cerebral blood flow, both of whom were asymptomatic and had diffuse hyperplasia, a slight reduction was demonstrated. Eight patients had a pathological preoperative MADRS score, which normalized in seven after surgical treatment. CONCLUSION: The finding of reduced regional cerebral blood flow in patients with primary hyperparathyroidism followed by significant improvement after operation might influence the case for surgical treatment.

Aged↗
PubMed2005

Conventional bilateral cervical exploration versus open minimally invasive parathyroidectomy under local anaesthesia for primary hyperparathyroidism.

BACKGROUND: Minimally invasive parathyroidectomy (MIP) has been introduced for the treatment of patients with primary hyperparathyroidism (pHPT). Thus far, only one randomized trial has compared video-assisted MIP with conventional bilateral cervical exploration (BCE). The value of open MIP is therefore not known. METHODS: Fifty patients with a solitary parathyroid adenoma localized before surgery by sestamibi scintigraphy were randomized to undergo BCE under general anaesthesia (n = 25) or targeted MIP via a 2-cm incision using local anaesthesia (n = 25). Postoperative hypocalcaemia was the primary endpoint. Secondary outcome measures were operating time, complications, postoperative analgesia and recurrent disease. Follow-up was carried out at 1 and 6 months. RESULTS: All patients who underwent BCE and 24 of those who had MIP were cured by the primary operation. Operating time was 22 min shorter in the MIP group (P = 0.024). Serum levels of calcium were slightly lower during the first 4 days after surgery in the BCE group (P = 0.022). No other no significant differences were found. CONCLUSION: Targeted MIP using local anaesthesia reduces operating time and causes less postoperative biochemical hypocalcaemia compared with bilateral neck exploration.

Adenoma↗
PubMed2005

Randomized clinical trial comparing regional and general anaesthesia in minimally invasive video-assisted parathyroidectomy.

BACKGROUND: This randomized clinical trial was performed in a single institution to compare the results of minimally invasive video-assisted parathyroidectomy (MIVAP) conducted under regional anaesthesia (RA) or general anaesthesia (GA). METHODS: Fifty-one patients undergoing MIVAP for primary hyperparathyroidism were assigned randomly to either RA (26 patients) or GA (25). RA involved a bilateral deep cervical block, and local infiltration of the incision site with a mixture of 0.25 per cent lignocaine and 0.15 per cent bupivacaine. GA was induced by intravenous administration of propofol, remifentanil and rocuronium bromide. RESULTS: The two groups were matched for age, sex, adenoma size, and preoperative serum calcium and parathyroid hormone levels. The interval from skin incision to closure was similar in the two groups (27.6 and 25.8 min for RA and GA respectively), whereas the total operating time (from induction of anaesthesia to return to the ward) was significantly lower with RA (72.1 versus 90.2 min; P = 0.001). The postoperative requirement for pain medication, measured in terms of amount of ketorolac administered at the request of the patient, was significantly lower in the RA group (28.5 versus 80 mg/day; P < 0.001). CONCLUSION: MIVAP performed under RA was associated with a shorter overall operating time and a reduced need for postoperative pain relief.

Adult↗
PubMed2007

Minimally invasive parathyroidectomy without intraoperative parathyroid hormone monitoring in patients with primary hyperparathyroidism.

BACKGROUND: Minimally invasive parathyroidectomy (MIP) is the preferred operation for patients with primary hyperparathyroidism (HPT) and positive preoperative imaging. This non-randomized case series assessed the long-term results of MIP performed without the use of intraoperative parathyroid hormone (ioPTH) monitoring. METHODS: The study involved prospective collection of demographic, biochemical and operative details on a consecutive, unselected cohort of 298 patients who underwent surgery for non-familial primary HPT during a 5-year interval. The mean preoperative serum calcium level was 3.00 mmol/l with a mean parathyroid hormone concentration of 25.8 pmol/l. (99m)Tc-labelled sestamibi scanning and neck ultrasonography were performed in 262 patients. RESULTS: Sestamibi scan showed unilateral uptake in 182 patients and a single parathyroid adenoma was confirmed on ultrasonography in 161 patients. MIP was performed in 150 patients. The mean duration of operation was 25 (range 8-65) min. Four patients needed conversion to conventional neck exploration. There was one postoperative haematoma and three cases of temporary recurrent laryngeal nerve neuropraxia. All but four patients were normocalcaemic after MIP. All the parathyroid tumours removed were adenomas, with a mean weight of 1.3 (range 0.1-17.4) g. No patient developed recurrent HPT after a median follow-up of 16 (range 3-48) months. CONCLUSION: The outcome of MIP without ioPTH monitoring was comparable to that reported in series that used ioPTH monitoring.

Adolescent↗
PubMed2007

Minimally invasive parathyroidectomy using the lateral focused mini-incision technique without intraoperative parathyroid hormone monitoring.

BACKGROUND: Minimally invasive parathyroidectomy (MIP) involves scan-directed removal of a single adenoma through a 2.0-cm mini-incision without intraoperative monitoring. The aim of this study was to analyse the outcomes of MIP using such a simplified technique. METHODS: The study group comprised 500 consecutive patients undergoing MIP via a lateral mini-incision from August 2000 to September 2005. Levels of parathyroid hormone (PTH) were measured after operation solely to aid informed discharge. RESULTS: Some 97.4 per cent of patients were initially cured by MIP. Eight patients remained hypercalcaemic and a further five were normocalcaemic on the day after surgery but became hypercalcaemic again within 3 months of the procedure. Eleven of these patients were cured with subsequent re-exploration. Analysis of postoperative PTH data indicated that, at best, the use of intraoperative PTH measurement during surgery would have increased the cure rate by only a further 1 per cent. Three (0.6 per cent) of 500 patients had permanent recurrent laryngeal nerve palsy after MIP. CONCLUSION: MIP performed by the lateral focused mini-incision technique, without the use of intraoperative PTH monitoring, is a safe and effective procedure that results in outcomes equal to those of bilateral neck exploration.

Adenoma↗
PubMed2001

Re-operation for bleeding after thyroidectomy and parathyroidectomy.

BACKGROUND: This study was undertaken to determine the frequency and timing of re-operation for bleeding following thyroidectomy (THY) and parathyroidectomy (PARA) as well as the implications of this concerning the safety of ambulatory surgery. METHODS: Patients requiring re-operation after THY and PARA were identified from a computerized database of patients undergoing surgery between 3/l/95 and 12/31/99. The medical records of these patients were reviewed in detail. RESULTS: Six of 918 THY (0.7%) and 4 of 350 PARA (1.1%) required re-operation for bleeding. In two cases the wounds were opened emergently at the bedside due to worsening airway obstruction. One patient required an emergency tracheostomy. There were no deaths. Excluding one patient who bled five days post-operatively, the time interval from the completion of surgery to the identification of postoperative hematoma ranged from 2 to 48 hours, the median being 16 hours. CONCLUSIONS: Postoperative bleeding is an uncommon but unavoidable complication of THY and PARA. If treated promptly, serious consequences can be avoided. The relatively long interval between the initial operation and the development of the hematoma needs to be considered when recommending the performance of these procedures on an ambulatory basis.

Hemorrhage↗
PubMed2007

Successful implant of long-term cryopreserved parathyroid glands after total parathyroidectomy.

BACKGROUND: Parathyroid cryopreservation is essential in some cases of parathyroid surgery. The fate of autografted tissue after long-term cryopreservation is not fully discussed in the literature. METHODS: The successful experience with the use of parathyroid tissues preserved for 21 months and 30 months is reported. RESULTS: Both patients were women with renal hyperparathyroidism who underwent total parathyroidectomy without autotransplantation. Patient 1 was a 40-year-old woman. At 21 months of follow-up, her parathyroid hormone (PTH) level was undetectable, and despite oral calcium supplements, she was hypocalcemic. Forty-five cryopreserved fragments were thawed and implanted in her forearm. Calcium levels improved, and PTH steadily increased in both arms. PTH levels at 18 months after the autograft were 37.0 pg/mL in the contralateral arm and 1150.0 pg/mL in the implant arm. Patient 2 was a 44-year-old woman. After 30 months, her PTH was undetectable, and she underwent cryopreserved tissue implantation. CONCLUSION: These cases show that parathyroid tissue may remain viable even after long-term storage.

Adult↗
PubMed1993

Longitudinal study of bone mass in end-stage renal disease patients: effects of parathyroidectomy for renal osteodystrophy.

The effectiveness of parathyroidectomy (PTHX) for the control of secondary hyperparathyroidism was assessed in 46 adult end-stage renal disease (ESRD) patients whose bone mineral content at the midshaft and distal radius was measured using single-photon absorptiometry (SPA) every 6 months before and after the surgery. They were compared to 46 age-, race-, and sex-matched ESRD patient controls who had not undergone surgery but who had had at least five SPA studies at similar intervals. Presurgery midradius bone mass was significantly lower for PTHX patients compared to controls. Comparing changes in bone mass of PTHX patients across surgery to controls in comparable time periods showed that PTHX patients lost significantly less bone mass after surgery. Similar results were obtained when rates of change in bone mass were evaluated. When patient characteristics were examined, the effect of surgery was found to be diminished in elderly patients and in oophorectomized patients. It is concluded that PTHX can have a salutary effect on renal osteodystrophy in the appendicular skeleton, but factors other than bone mass also need to be considered in identifying those patients who will benefit from surgery.

Absorptiometry, Photon↗