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PubMed2001

[Video-assisted parathyroidectomy: learning curve].

STUDY AIM: Minimally invasive video-assisted parathyroidectomy (MIVAP) was introduced in 1997 for the treatment of sporadic primary hyperparathyroidism (sPHPT). The study aim was to review the entire series of patients operated on in order to analyse the learning curve of this procedure. PATIENTS AND METHODS: Between February 1997 to January 2001, 185 patients underwent MIVAP. All these patients were divided into three groups: group A (GA) included 63 patients operated on between February 1997 and September 1998; group B (GB) 64 patients operated on between October 1998 and January 2000; Group C (GC) 64 patients operated on between January 2000 and January 2001. Mean operative time, complications and conversions rates of the three groups were compared. RESULTS: The three groups were well matched for age and gender. Mean operative time was significantly shorter in patients of GC (28.3 +/- 13.6 min) when compared with GA (62.3 +/- 24.6 min) and GB (48.4 +/- 18.1 min). Conversion was required in 3 cases of GA (4.8%), in 8 cases of GB (12.8%) and in 4 cases of GC (6.5%). One transient postoperative recurrent nerve palsy and 4 cases of transient postoperative hypocalcemia were observed among patients of GA. No complications were registered in the other groups. CONCLUSIONS: This study shows that with increasing experience, the operative time of MIVAP was dramatically reduced, as well as postoperative complications rate. The higher percentage of conversion in groups B and C may be explained by the fact that, with increasing experience, more difficult and ambiguous cases were operated with this technique.

Adult↗
PubMed1995

Neuromuscular recovery after parathyroidectomy in primary hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism today is diagnosed in the asymptomatic phase because of the inclusion of serum calcium in sequential multichannel analysis. The purpose of present study was to test for neuromuscular abnormalities in asymptomatic patients and to test the improvement of neuromuscular performance after parathyroidectomy. METHODS: Nine patients with primary hyperparathyroidism and nine patients with nodular goiter were enrolled in this study. Neuromuscular recovery including muscle power, sensation, and fine motor movement was studied before operation and 1 week and 4 weeks after operation. The muscle power was measured as grip power, palm pinch, lateral pinch, and three-chuck pinch. The sensation was measured as touch sensation and two-point discrimination. The fine motor movement was measured with the Purdue Pegboard Test and the Minnesota Manual Dexterity Test. RESULTS: Four weeks after the operation the patients with hyperparathyroidism had increased their muscle strength and had improved fine motor movement but no change was noted in two-point and touch sensation. When the postoperative muscle recovery was compared, there was a reversible correlation (r = -0.62; p < 0.05) with the preoperative muscle strength and no correlation with the preoperative serum calcium, phosphate, alkaline phosphatase, and intact parathyroid hormone levels. No such improvement was detectable among the control subjects. CONCLUSIONS: Surgery can improve muscle strength and fine motor movement but does not affect sensation in asymptomatic patients.

Adult↗
PubMed1999

Clinical course after total parathyroidectomy without autotransplantation in patients with end-stage renal failure.

In patients with chronic renal failure, hyperparathyroidism is a common problem and surgical parathyroidectomy (PTX) is frequently required. The three different surgical approaches are subtotal PTX, total PTX with autotransplantation, and total PTX without autotransplantation. Recurrence of hyperparathyroidism varies from 5% to 80% in different studies for the first two surgical approaches. To minimize the risk for recurrence, and because we fear severe relapses with calciphylaxia, we perform total PTX without autotransplantation. From October 1993 to October 1997, 20 patients (9 men and 11 women) underwent total PTX without autotransplantation (median age, 52 years; range, 23 to 74 years; median dialysis time before PTX, 6.5 years; range, 1 to 22 years). All patients were supplemented with vitamin D analogues postoperatively. Patients were followed up for 1 to 48 months (median, 20 months). Bone pain, when present, disappeared within the first week after total PTX. Postoperatively, most patients had temporary hypocalcemia. In the long term, five patients had asymptomatic hypocalcemia. One patient, however, repeatedly had hypocalcemic seizures. Five patients developed asymptomatic hypercalcemia when supplemented with calcitriol. At the end of the individual's observation time, parathyroid hormone (PTH) levels were less than normal in six patients, normal in seven patients, and increased in seven patients despite total PTX. We conclude that total PTX should be reconsidered an option for the treatment of hyperparathyroidism secondary to renal failure. There was no evidence of clinical bone disease after total PTX. Apparently, remaining ectopic parathyroid tissue accounts for PTH levels after total PTX.

Adult↗
PubMed1992

[Hypomagnesemia associated with hypocalcemia after undetected parathyroidectomy].

A case is reported of hypomagnesaemia and hypocalcaemia occurring postoperatively in a 59-year-old man operated on for hypopharyngeal carcinoma which had extended to the upper extremity of the oesophagus. Surgery consisted in total pharyngolaryngectomy, ganglion curage, jejunal transplant, thyroidectomy and tracheostomy. Total parathyroidectomy was not mentioned in the surgical report. Hypocalcaemia was first noticed on the day following the procedure. On the tenth postoperative day, the patient became agitated and had myoclonia and muscle fasciculations. Nystagmus and orthostatic hypotension also occurred. There were no cardiac signs. Treatment with calcium alone was insufficient. These symptoms only disappeared once magnesium sulphate had been added.

Calcium Gluconate↗
PubMed2000

Endoscopic parathyroidectomy.

During the last three years, minimally invasive procedures have been adopted for the surgical treatment of primary hyperparathyroidism, because preoperative localization studies such as a high-resolution ultrasonography and sestamibi scintigraphy. guidance by intraoperative scans and the use of a quick, intraoperative PTH assay, have improved. Therefore, endoscopic parathyroidectomy can be performed for patients with primary hyperparathyroidism. The endoscopic procedures range from the 'pure' endoscopic approach characterized by constant gas insufflation and video-assisted gasless techniques. Then, we regard the cosmetic result as important, and adopted the 'pure endoscopic approach because a small incision can be made far from the neck region. We report our technique with no scars in the neck region for endoscopic unilateral neck exploration with primary hyperparathyroidism by an axillary approach and for endoscopic bilateral neck exploration with renal hyperparathyroidism by an anterior chest approach.

Axilla↗
PubMed2002

Total endoscopic parathyroidectomy.

During the last five years, minimally invasive procedures have been adopted for the surgical treatment of hyperparathyroidism, because preoperative localization studies such as high-resolution ultrasonography and sestamibi scintigraphy, guidance by intraoperative scans, and the use of quick, intraoperative parathyroid hormone assay have improved. Endoscopic parathyroidectomy was performed by Gagner in 1996, and surgical procedures using endoscopy have been devised. The endoscopic procedures range from the "pure" endoscopic approach characterized by constant gas insufflation to video-assisted gasless techniques. We adopted the "pure" endoscopic approach, because a small incision can be made far from the neck and the cosmetic result is excellent. We report our technique with no scars in the neck region for endoscopic unilateral neck exploration with primary hyperparathyroidism and for endoscopic bilateral neck exploration with renal hyperparathyroidism.

Adult↗
PubMed1999

The effects of parathyroidectomy on nutritional and biochemical status of hemodialysis patients with severe secondary hyperparathyroidism.

The nutritional and biochemical parameters of 15 chronic hemodialysis (HD) patients with severe secondary hyperparathyroidism who had undergone total parathyroidectomy (PTX), with a forearm implant, were retrospectively studied at 1, 3, 6, and 12 months pre- and post-PTX. The concentrations of serum calcium and phosphorous significantly decreased in the first 6 months post-PTX. The concentration of blood urea nitrogen significantly increased at 6 and 12 months post-PTX. In contrast with control chronic HD patients who had no weight gain after nonparathyroid surgery, there was a progressive weight gain leading to a significantly higher dry weight at 12 months post-PTX. There was no significant change in serum potassium, albumin, cholesterol, transferrin, bicarbonate, hematocrit, normalized protein catabolic rate (nPCR), or erythropoietin dose at any time point post-PTX. The biochemical parameters of the 8 patients who had more than 5% weight gain, during 12 months post-PTX, were not statistically different from the remaining 7 cases who had weight gain less than 5% (or had lost weight) in the same time period. The same was true for 4 patients with weight gain of more than 10% versus the latter group. In conclusion, HD patients with severe secondary hyperparathyroidism are prone to progressive weight gain post-PTX, which reaches significance by the twelfth month. In 53% of the patients, the weight gain is more than 5% above the baseline. The nutritional and biochemical parameters pre-PTX were not helpful in distinguishing those who developed significant weight gain post-PTX.

Adult↗
PubMed2000

Minimally invasive radioguided parathyroidectomy.

BACKGROUND: Minimally invasive radioguided parathyroidectomy (MIRP) combines technetium sestamibi scan, intraoperative gamma probe, methylene blue dye, and measurement of circulating parathyroid hormone (PTH) levels. STUDY DESIGN: All patients presented with biochemically proved primary hyperparathyroidism. A technetium sestamibi scan was performed preoperatively. Technetium sestamibi and methylene blue dye (7.5 mg/kg) were administered IV on the day of operation. Operative dissection was directed by the gamma probe. Blood samples for PTH assay were obtained before and after excision of an abnormal gland. When an appropriate decrease in the PTH assay was obtained, the exploration was concluded. Persistent PTH elevation instigated further neck exploration. RESULTS: Thirty-six consecutive patients were explored for untreated primary hyperparathyroidism and three for recurrent hyperparathyroidism. Hypercalcemia was corrected in all 39 patients. A single adenoma was found in 32 of 36 patients with untreated primary hyperparathyroidism, and a single abnormal gland was identified in all of those with recurrent hyperparathyroidism. Persistently elevated PTH prompted further exploration in two patients, identifying a second abnormal gland in one and hyperplasia in the other. Minor local complications occurred in 8% (3 of 39) of the patients. Forty-four percent (16 of 36) of the patients were discharged on the day of operation and 83% (30 of 36) within 23 hours after the initial neck exploration for primary hyperparathyroidism. Comparison of charges for MIRP with charges for "standard" neck exploration revealed lower costs with MIRP because of decreased duration of the operation, anesthesia, and hospital stay, and elimination of intraoperative histologic analysis. CONCLUSIONS: MIRP is a safe and effective procedure, resulting in the correction of hypercalcemia in all patients. The combination of intraoperative gamma probe and methylene blue dye allows rapid identification of the abnormal gland with minimal dissection through a small incision. PTH assay after excision provides biochemical confirmation that the abnormal gland has been removed. Most patients undergoing MIRP can be treated on an outpatient basis. Low postoperative complications, a small incision, and rapid return to normal activities resulted in very high patient acceptance of the procedure.

Adenoma↗
PubMed2000

Minimally invasive video-assisted parathyroidectomy: lesson learned from 137 cases.

BACKGROUND: Since February 1997, a technique of minimally invasive video-assisted parathyroidectomy (MIVAP) was developed at our institution for the treatment of sporadic primary hyperparathyroidism (sPHPT). In this study we analyzed the entire series of patients who underwent MIVAP during the last 3 years. STUDY DESIGN: One hundred thirty-seven patients with sPHPT were selected for MIVAP. Selection criteria were: diagnosis of single adenoma based on preoperative localization studies (ultrasonography, sestamibi scintigraphy, or both), and no previous neck surgery or concomitant large multinodular goiter. The procedure, already described, is performed by a gasless video-assisted technique through a single 1.5-cm central skin incision above the sternal notch. Quick, intraoperative parathyroid hormone assay was used in 134 cases (97.8%) to confirm the complete removal of all hyperfunctioning parathyroid tissue. RESULTS: Mean operative time was 54.3 +/- 22.6 minutes. The conversion rate was 8.8%. One laryngeal nerve palsy was registered (0.7%), as was one case of persistent hyperparathyroidism. In six patients (4.4%) a transient symptomatic postoperative hypocalcemia was observed. Two thyroid lobectomies were associated using the same minimally invasive access. At a mean followup of 15.4 +/- 10.6 months, all but two patients were normocalcemic. The cosmetic result was considered excellent by most of the patients (92.8%). CONCLUSIONS: Although not all patients with sPHPT are eligible for MIVAP, this approach can now be proposed in a bigger proportion (67% of patients). As already demonstrated in a previous study, also in a large series of patients, after greater experience has been achieved, the results and the operative time are the same as in traditional surgery, with better cosmetic result and a less painful course.

Adenoma↗
PubMed2003

Minimally invasive parathyroidectomy: 101 consecutive cases from a single surgeon.

BACKGROUND: Intraoperative rapid parathyroid hormone (iPTH) assay is changing parathyroid surgery. One surgeon's experience at a tertiary care hospital was followed as minimally invasive parathyroidectomy (MIP) was adopted. STUDY DESIGN: In this prospective case study, patients underwent technitium 99m sestamibi scanning, iPTH monitoring, and MIP. A sestamibi-directed incision was made, and iPTH was measured preincision, preexcision of abnormal gland(s), and at 5- and 10-minute intervals. MIP was complete after gland(s) was excised and iPTH fell to less than 50% of preoperative levels. Routine discharge was on the day of surgery with daily calcium and calcitriol to minimize outpatient hypocalcemia. Secondary and tertiary hyperparathyroidism patients were excluded. RESULTS: From December 1999 to June 2002, 101 patients underwent MIP. Patients were 27% men and 73% women, with two reoperations. Preoperation laboratory results averaged serum calcium 11.08 (normal 8.5 to 10.5 mg/dL) and parathyroid hormone (PTH) 169 pg/mL (normal 10 to 55 pg/mL). Average iPTH values at operative intervals were 152, 151, 68, and 50 pg/mL, respectively. Operation demonstrated 12% of patients had four-gland hyperplasia, 3% had double adenomas, 2% had parathyroid carcinomas, and 83% had single adenomas. Discharge on the day of surgery occurred in 83% of single-adenoma patients. Postoperative laboratory results averaged calcium 9.4 mg/dL (p < 0.001 versus preoperation) and PTH 48 pg/mL (p < 0.001). Fifteen patients (16%) had elevated PTH after operation, but without elevated calcium levels. One patient had persistant hyperparathyroidism. CONCLUSIONS: MIP with iPTH monitoring is a safe and effective means of treating hyperparathyroidism. This approach allows for limited dissection and early discharge for the majority of patients.

Adolescent↗
PubMed1999

Primary hyperparathyroidism: short-term changes in bone remodeling and bone mineral density following parathyroidectomy.

Changes in bone remodeling and bone mineral density were observed during a period of 6 months after surgery in 24 patients with primary hyperparathyroidism (20 women and 4 men; age 54+/-12 years, range 26-69 years). All bone markers declined significantly within the 6 month follow-up period, but the time course for changes in renal N-terminal telopeptide of type 1 collagen (NTx) excretion differed from those of the other markers by a steep and significant reduction (p < 0.05) after less than 1 month. During the 6 month period, bone mineral density (BMD) increased significantly at all sites measured (p < 0.05) apart from the femoral neck and the proximal and midforearm. The greatest increase of 4.2% was observed in the trochanteric region (p < 0.001). The increase in BMD in spine, trochanteric, and intertrochanteric regions of the hip correlated inversely with baseline forearm BMD values (p < 0.05). Baseline bone markers (serum alkaline phosphatase [AP], serum bone AP, serum pyridinoline crosslinked telopeptide of type 1 collagen, urinary hydroxyproline, urinary osteocalcin), as well as baseline histomorphometric indices of bone turnover (eroded and labeled surface, bone formation rate, activation frequency, and cortical porosity) were positively correlated with changes in spinal BMD over 6 months (p < 0.05). It was concluded that, within 6 months after parathyroidectomy, patients with primary hyperparathyroidism obtain normalization of bone remodeling and a substantial increase in bone mineral density in regions rich in cancellous bone but no significant changes in regions with predominantly cortical bone.

Aged↗
PubMed2000

[Recurrent hyperparathyroidism in kidney failure patients after total parathyroidectomy and autotransplantation. Case report and review of the literature].

We present the case of a 57-year old man who underwent total parathyroidectomy with autotransplantation into the brachioradial muscle (Wells' method) due to secondary hyperparathyroidism as a complication of chronic renal failure. Three years later the patient developed recurrent secondary hyperparathyroidism due to graft hyperplasia resulting in the removal of the graft. We point out various problems associated with Wells' method and discuss alternative surgical techniques.

Humans↗
PubMed2000

Calcium supplement necessary to correct hypocalcemia after total parathyroidectomy for renal osteodystrophy.

BACKGROUND: Prediction of the extent of calcium supplement will facilitate safe and efficient management of hypocalcemia in the early postoperative stage of total parathyroidectomy with autotransplantation (PTXa) in patients with renal osteodystrophy. METHODS: The correlation between the extent of calcium deficiency, estimated by the amount of calcium supplement over 48 h after PTXa and using various parameters such as carboxy terminal parathyroid hormone (c-PTH), intact PTH (i-PTH), alkaline phosphatase (ALP), serum calcium, serum phosphorus, duration of hemodialysis, total weight of resected parathyroid glands and degree of subperiosteal resorption of the middle phalanx was examined in 49 patients who underwent PTX with subcutaneous autotransplantation. Bone mineral density (BMD) was also determined before, 3 months and 1 year after PTXa with dual energy X-ray absorptiometry (DEXA) in 13 patients. RESULTS: There was a positive correlation between pre-operative i-PTH level (r=0.56, P<0.0005) or ALP level (r=0.50, P<0.0005) and the amount of calcium supplement over 48 h after PTXa in these patients. Furthermore, the degree of subperiosteal resorption, determined by Jensen's classification, was significantly correlated with the amount of calcium supplement after PTX (P<0.05). Bone mineral density 3 months after (P<0.0005) and 1 year after PTXa (P<0.001) significantly increased compared with BMD before PTXa in all patients examined. CONCLUSION: These findings suggest that the pre-operative determination of i-PTH, ALP levels and degree of subperiosteal resorption allow the management of hypocalcemia safely and efficiently in renal osteodystrophy patients after PTXa.

Adult↗
PubMed2001

Development of low-turnover bone diseases after parathyroidectomy and autotransplantation.

Parathyroidectomy and immediate autotransplantation (PTX-AT) has been shown to decrease bone pain and increase bone mineral density. However, adynamic bone disease (ABD) has been predicted to develop if the serum intact parathyroid hormone (i-PTH) level remains lower than normal for a long period of time. Therefore, we investigated the bone histology of patients whose serum i-PTH levels did not increase over 70 pg/mL for 1 year after PTX-AT. Four chronic hemodialysis patients were investigated. The serum intact osteocalcin (i-OC) level was measured and histomorphometry for cancellous bone was performed 1 year after the operation. Tetracycline hydrochloride was administered in the 12 weeks after PTX-AT. The serum i-PTH levels were 20.5 +/- 15.0 pg/mL and i-OC levels were 19.5 +/- 0.9 ng/mL. Histomorphometric analyses showed the osteoclast surface to be 0.1% in two cases and 0% in the other two cases, the eroded surface was 7.7 +/- 6.1%, and the fibrosis volume and osteoblast surface were 0% in all four cases. Osteoid volume, osteoid surface and osteoid thickness were lower in cases 1-3, but higher in case 4. All tetracycline labelings were in contact with the mineralization front in cases 1 and 3, but some were not in cases 2 and 4. Serum i-PTH and i-OC levels indicated that ABD developed in these four cases. Histomorphometric analyses revealed that ABD developed in case 1, while either ABD or low-turnover osteomalacia developed in cases 2 and 4, and low-turnover osteomalacia was observed in case 3 after PTX-AT. In conclusion, i-PTH should not be maintained at lower levels to avoid low-turnover bone diseases.

Bone Diseases, Metabolic↗
PubMed2001

Uraemic gangrene syndrome: is parathyroidectomy always necessary?

This report presents a case of uraemic gangrene syndrome with multiple ulcerations and calcium (Ca) deposits in the vessel walls. High-dosage oral calcium carbonate (CaCO3) treatment alone resulted in rapid wound healing with decreased serum phosphorus (P), Ca x P product and parathormone and only slightly increased Ca levels. We suggest that this should be the first choice of treatment in such cases because positive clinical response can achieve symptom-free status for the patient until kidney transplantation, thus making parathyroidectomy unnecessary.

Adult↗
PubMed2003

IL-1beta, TNF-alpha, TGF-beta, and bFGF expression in bone biopsies before and after parathyroidectomy.

BACKGROUND: There is growing evidence pointing to an involvement of cytokines and growth factors in renal osteodystrophy. In this study, the expression of interleukin-l beta (IL-1 beta), tumor necrosis factor-alpha (TNF-alpha), transforming growth factor-beta (TGF-beta), and basic fibroblast growth factor (bFGF) in bone biopsies taken from uremic patients before and 1 year after parathyroidectomy (PTX) was evaluated. Biochemical features and histomorphometric outcome were also studied. METHODS: Iliac bone biopsies were taken before and 1 year after PTX in nine uremic patients with severe hyperparathyroidism (HPT). Immunohistochemical techniques were used to identify the expression of IL-1 beta, TNF-alpha, TGF-beta, and bFGF in these bone samples. RESULTS: At the time of the second bone biopsy, the mean serum total alkaline phosphatase activity was normal, whereas mean serum intact parathyroid hormone (iPTH) level was slightly above the upper limit of normal values. Histomorphometric analysis showed a decrease in resorption parameters and static bone formation parameters after PTX. Dynamically, mineral apposition rate (MAR) and mineralization surface (MS/BS) decreased significantly. There was a marked local expression of IL-1beta, TNF-alpha, TGF-beta, and bFGF in bone biopsies before PTX, particularly in fibrous tissue and resorption areas. One year after PTX, IL-1beta decreased from 23.6 +/- 7.5% to 9.9 +/- 3.1%, TNF-alpha from 4.5 +/- 1.5% to 0.7 +/- 0.8%, TGF-beta from 49.6 +/- 9.8% to 15.2 +/- 4.6%, and bFGF from 50.9 +/- 12.7% to 12.9 +/- 7.9% (P < 0.001). A significant correlation was documented between cytokines and growth factors expression in bone with iPTH levels before and after PTX (P < 0.05). CONCLUSIONS: Based on these results, we suggest that IL-1beta, TNF-alpha, TGF-beta, and bFGF are involved in bone remodeling regulation, acting as local effectors, possibly under the control of PTH.

Adolescent↗
PubMed2003

Parathyroidectomy: whom and when?

Hyperparathyroidism (HPT) is common in patients on dialysis, and parathyroidectomy (PTx) is often required. We present a retrospective, descriptive analysis of data corresponding to 148 patients on dialysis undergoing PTx due to severe refractory HPT (PTH 1401 +/- 497 pg/mL, Ca 10.6 +/- 0.8 mg/dL, P 6.9 +/- 1.7 mg/dL). Demographic data were compared with those recorded in 309 patients on dialysis not subjected to PTx who were managed at the same hospital. In the PTx group, the factors age (49.3 +/- 14 years), male gender (48.6%), and diabetes (0.7%) were significantly lower than in the non-PTx group (61.5 +/- 14.9 years, male gender 59%, diabetes 19.4%), while time on dialysis was longer (8.6 +/- 5.8 vs. 5.5 +/- 5.4 years). In 129 of the study patients (87.4%), four or more glands were identified, and total PTx plus autotransplantation (AT) in the forearm was performed. In the remaining 19 patients, two to three glands were identified, and AT was not undertaken. Four of the 19 patients were successfully operated on again for persistent HPT, seven showed PTH levels <250 pg/mL, and eight maintained severe HPT. Perioperative complications included one death due to cardiac insufficiency, two repeat operations due to bleeding, and one patient with chronic hoarseness. Hospital stay was prolonged in 20% of patients due to a hungry bone syndrome. Among those patients with PTx and AT, HPT recurred in 21 patients (16.2%) at 3.1 +/- 2.3 years. In 13 of these patients, autograft was removed at 7.5 +/- 2.9 years. Serum calcium and phosphate levels improved after PTx, and these results were maintained for 5 years (9.6 +/- 0.8 and 4.2 +/- 1.2 mg/dL, respectively). In conclusion, PTx with AT is a safe option for the treatment of severe HPT that is accompanied by low morbidity and mortality and a good outcome. Medical treatment should not be prolonged at the expense of long repeated bouts of hypercalcemia and/or hyperphosphatemia with their irreversible consequences.

Aged↗