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PubMed1996

Ambulatory parathyroidectomy for primary hyperparathyroidism.

OBJECTIVE: To evaluate whether the combined application of preoperative localization and intraoperative monitoring of intact parathyroid hormone (iPTH) levels could facilitate safe outpatient parathyroidectomy. DESIGN: Consecutive patients, who had no antecedent social or medical conditions mandating hospitalization, were prospectively offered ambulatory parathyroidectomy with a mean follow-up of 7 months (range, 1-25 months). SETTING: Tertiary care referral center PATIENTS: From 85 patients who had primary hyperparathyroidism with hypercalcemia and elevated iPTH levels, 57 were offered outpatient parathyroidectomy. Nineteen patients were asymptomatic, 3 had hypercalcemic crisis, and the others gave a history of renal stones or had complaints consistent with bone disease. INTERVENTIONS: Technetium Tc 99m sestamibi scintiscans were used for preoperative localization. Monitoring iPTH levels during parathyroidectomy quantitatively assured the surgeon (G.L.I. only) when all hyperfunctioning glands were excised. MAIN OUTCOME MEASURE: The number of patients without complications and with short operative times who were discharged without hospital admission or overnight stay. RESULTS: The combination of preoperative localization of abnormal parathyroid glands and a decline in circulating iPTH levels predicting postoperative normocalcemia after excision of all hyperfunctioning glands resulted in successful parathyroidectomy in 84 of 85 patients. A decreased operative time (average, 52 minutes) with minimal neck dissection permitted outpatient parathyroidectomy in 42 of 57 eligible patients. CONCLUSIONS: The combination of preoperative parathyroid scintiscan localization and iPTH level monitoring during surgery permitted successful parathyroidectomy in an ambulatory setting in half of a consecutive series of patients with primary hyperparathyroidism. The safety, success, and likely cost savings of this approach suggest wider application.

Adolescent↗
PubMed2004

Recurrent disease after limited parathyroidectomy for sporadic primary hyperparathyroidism.

BACKGROUND: Limited parathyroidectomy guided by intraoperative parathyroid hormone (PTH) assay (QPTH) is highly successful (97% to 99%) in predicting postoperative eucalcemia, usually with less extensive dissection when compared with bilateral neck exploration. Because fewer glands are excised when resection is guided by QPTH as opposed to resection guided by gland size, a higher recurrence rate may occur. Recurrence rate after bilateral neck exploration is 0.4% to 5%, but frequency of recurrence after limited parathyroidectomy is unknown. This study reports outcomes of this operative approach in sporadic primary hyperparathyroidism. STUDY DESIGN: Four-hundred twenty-three patients with sporadic primary hyperparathyroidism undergoing limited parathyroidectomy, followed 6 months or more or considered operative failures, were studied. In most patients, calcium and PTH levels were measured immediately after operation, and then at 2 and 6 months and yearly intervals. Operative failure is defined as hypercalcemia and high PTH within 6 months after operation, and recurrent hyperparathyroidism is hypercalcemia and elevated PTH occurring after a successful parathyroidectomy. Recurrence distributions were estimated using Kaplan-Meier analysis. RESULTS: The success rate of limited parathyroidectomy is 97% (412/423). Four-hundred six patients were eucalcemic over an average of 34 months (median 27, range 6 to 118 months) of followup and recurrent hyperparathyroidism developed in 6 of 412 (1.5%). Estimated 5 years recurrence-free rate was 97% (95% confidence interval, 91% to 99%). Earliest and latest recurrences were diagnosed at 24 and 83 months, respectively. QPTH results did not predict any recurrence. Overall success rate was achieved, with multiple gland resections performed in only 3% of patients. CONCLUSIONS: Recurrence rate after limited parathyroidectomy is similar to rates reported after bilateral neck exploration. Parathyroidectomy guided by QPTH is successful not only in resolving hypercalcemia in the short term, but also in providing longterm eucalcemia.

Calcium↗
PubMed2006

Cost-effectiveness analysis of parathyroidectomy for asymptomatic primary hyperparathyroidism.

BACKGROUND: Controversy exists concerning the best treatment for asymptomatic primary hyperparathyroidism (PHPT) when the National Institutes of Health consensus conference criteria for parathyroidectomy are not met. We hypothesized that parathyroidectomy would be more cost-effective than observation or pharmacologic therapy for these patients. METHODS: Cost-effectiveness analysis was performed comparing treatment strategies for asymptomatic PHPT. Treatment outcomes, their probabilities, and costs were identified on the basis of literature and cost database review. Outcomes were weighted by using established quality-of-life utility factors. Sensitivity analysis was used to examine the uncertainty of costs and utility estimates in the model. RESULTS: The incremental cost-effectiveness ratio for parathyroidectomy was US dollars 4778 per quality-adjusted life year (QALY) gained. Operation remained cost-effective until the average cost of parathyroidectomy increased from the estimated value of US dollars 4778 to US dollars 14,650. Pharmacologic therapy was not cost-effective unless the annual cost of therapy decreased from an estimated US dollars 7406 (for cinacalcet) to US dollars 221. Parathyroidectomy ceases to be preferred over monitoring if a quality-of-life difference is not demonstrable after curative operation. CONCLUSIONS: Parathyroidectomy is more cost-effective than observation for managing asymptomatic PHPT patients who do not meet National Institutes of Health criteria for parathyroidectomy. Furthermore, pharmacologic therapies with a greater than US dollars 221 annual cost were not cost-effective in this model.

Cinacalcet↗
PubMed2002

Video-assisted parathyroidectomy.

A parathyroid tumor is not larger than other tumors, so minimally invasive surgery has long been a major focus of parathyroid surgeons. Improving endoscopic instruments has facilitated the recent changes in approaches to parathyroid surgery. Endoscopic parathyroidectomy is developed in a totally closed space with CO2 gas insufflation. This method has a risk of complications, such as extensive emphysema or hypercarbia. Minimally invasive video-assisted parathyroidectomy (MIVAP) has greater safety, low cost, easy procedure and flexibility in changing the working space including conversion to open method when compared with endoscopic parathyroidectomy. MIVAP can be performed with only a 1-1.5-cm small incision on the neck. MIVAP is indicated in the patient with parathyroid adenoma or renal hyperplasia that is defined preoperatively using ultrasonography and 99mTc-methoxyisobutylisonitrile (MIBI) scan. Furthermore, the radio-guided technique using nuclear navigation after preoperative administered MIBI is being developed. This method is so useful during MIVAP that we combined MIVAP and radio-guided surgery to develop minimally invasive radio-guided and video-assisted parathyroidectomy (MIRVAP). After injection of 600 MBq of MIBI, intraoperative nuclear mapping was performed using a hand-held gamma probe. Then we expected to find swollen parathyroid tumor at surgery when radioactivity at a level relatively higher than background was found. Following this mapping result, MIVAP was started and succeeded. The radio-guided technique is also indicated for open parathyroidectomy (radio-guided open parathyroidectomy, RGOP) in multiglandular disease (MGD) when it was not possible to identify those lesions completely, for instance in asymmetric hyperplasia, such as multiple endocrine neoplasia (MEN) 1. In conclusion, MIVAP is beneficial for minimal invasiveness and cosmesis. Furthermore, radio-guided parathyroidectomy (MIRVAP and RGOP) is more useful and feasible. Improvement of endoscopic instruments and modification of the dose of MIBI administered might facilitate treating more cases by MIRVAP instead of RGOP.

Animals↗
PubMed2005

Changes in cardiovascular calcification after parathyroidectomy in patients with ESRD.

BACKGROUND: The effect of parathyroidectomy on vascular calcification in patients with end-stage renal disease has been a subject of interest for many years, although studies in this area have not been definitive. The purpose of this investigation is to determine changes in vascular calcification after subtotal parathyroidectomy by using fast-gated helical computed axial tomographic imaging to measure coronary and carotid artery calcification. METHODS: Computed tomographic imaging was performed at baseline and in follow-up on 10 patients who had undergone subtotal parathyroidectomy and 10 reference patients who had not undergone parathyroidectomy. RESULTS: Patients who underwent subtotal parathyroidectomy had a mean change in coronary calcification of -92.3 +/- 469/y, and reference patients had a mean change of +479 +/- 630/y (P = 0.03). The 2 parathyroidectomy patients with the highest baseline scores had significant declines in both coronary and carotid calcification. CONCLUSION: In this study, subtotal parathyroidectomy is associated with a significant decrease in vascular calcification in 2 of 10 dialysis patients with high coronary artery calcium scores and stabilization in 7 of 10 patients with low baseline scores.

Adult↗
PubMed2004

The NIH criteria for parathyroidectomy in asymptomatic primary hyperparathyroidism: are they too limited?

OBJECTIVE: To determine whether preoperative and postoperative symptoms and outcome differ in patients who meet or fail to meet the NIH criteria for parathyroidectomy. SUMMARY BACKGROUND DATA: The NIH Consensus Conference on primary hyperparathyroidism in 1990 defined criteria for surgical intervention suggesting that some patients can be safely managed without surgery. METHODS: Over a 3-year period, 202 consecutive patients undergoing parathyroidectomy for primary hyperparathyroidism at a tertiary referral center were prospectively given a questionnaire regarding their symptoms and associated conditions during their initial and follow-up office visits as were 63 thyroid control patients. The 178 patients who completed the follow-up questionnaire were assigned to 2 groups according to the NIH criteria for parathyroidectomy. The frequency of preoperative symptoms and conditions associated with primary hyperparathyroidism as well as postoperative improvement in symptoms and surgical outcome were compared. RESULTS: Of the 178 parathyroid patients, 103 met the NIH criteria for parathyroidectomy whereas 75 did not. Patient profiles were similar in each group except mean ages, 55 versus 65, and preoperative serum calcium levels, 11.5 mg/dL versus 11.0 mg/dL (NIH and non-NIH groups, respectively; P < 0.001). The incidence of preoperative nonspecific somatic and neuropsychiatric symptoms and associated conditions was equivalent in both groups and more common than in the 63 thyroid control patients. After parathyroidectomy, symptomatic improvement was dramatic and equal between the 2 parathyroid groups. Postoperative mean serum calcium levels were similar (8.78 mg/dL, NIH group, versus 8.75 mg/dL, non-NIH group). CONCLUSION: Symptoms were more common in patients with primary hyperparathyroidism versus thyroid controls, but were not different between those patients who met the NIH criteria for parathyroidectomy and those who did not. Patients in both parathyroid groups benefited symptomatically after successful parathyroidectomy.

Adult↗
PubMed2004

The fall and rise of parathyroidectomy in U.S. hemodialysis patients, 1992 to 2002.

Although the therapeutic approach to managing hyperparathyroidism has changed dramatically, it is unknown whether parathyroidectomy rates continue to decline in the United States. Parathyroidectomy rates were studied in successive annual national cohorts, prevalent on hemodialysis on January 1 of 1992 to 2002, with Medicare as primary payer. Parathyroidectomy was defined as International Classification of Diseases, Ninth Revision, Clinical Modification code 068. The annual incidence of parathyroidectomy was 11.6 per 1000 patient-years in 1992. The incidence declined progressively after 1994, reaching a low of 6.8 per 1000 patient-years in 1998. Rates increased progressively after 1998, reaching 11.8 per 1000 patient-years in 2002. Using proportional hazards modeling, with adjustment for comorbidity and 1992 as the reference group, the lowest adjusted hazards ratio, 0.32 (P < 0.0001), was seen in 1998, followed by hazards ratios of 0.39 (P < 0.0001) in 1999, 0.41 (P < 0.0001) in 2000, 0.52 (P < 0.0001) in 2001, and 0.53 (P < 0.0001) in 2002. Other antecedents of parathyroidectomy in multivariate models included ESRD network, younger age, female gender, white race, absence of diabetes, longer duration of previous hemodialysis, use of intravenous vitamin D, previous renal transplantation, several comorbid conditions, and parathyroid hormone measurement in the preceding year. With a case-control method, parathyroidectomy was associated with higher mortality rates immediately after surgery, followed, subsequently, by lower long-term rates. Parathyroidectomy rates in U.S. hemodialysis patients increased between 1998 and 2002, a period in which the therapeutic armamentarium for preventing severe hyperparathyroidism expanded considerably.

Aged↗
PubMed2000

Minimally invasive parathyroidectomy: 50 consecutive cases.

OBJECTIVE: To determine the effectiveness and outcomes of minimally invasive parathyroidectomy. DESIGN: Prospective, non-randomised, non-blinded trial. SETTING: Affiliated university teaching hospitals of the Northern Clinical School, University of Sydney, New South Wales, May 1998 to October 1999. PATIENTS: 50 consecutive patients who underwent minimally invasive parathyroidectomy for primary hyperparathyroidism, and 150 consecutive patients undergoing open parathyroidectomy over the same period. RESULTS: Minimally invasive parathyroidectomy was successfully completed and resulted in cure (normocalcaemia) in 42 of 50 patients (84%). Seven patients (14%) required conversion to an open procedure, all of which also resulted in normocalcaemia, giving an overall cure rate of 98%. One patient had persistent hyperparathyroidism after minimally invasive parathyroidectomy which was cured at subsequent open reoperation. Three patients had a temporary recurrent laryngeal nerve palsy. Open parathyroidectomy was successful in 147 of 150 patients (98%) at initial operation; one patient had a temporary recurrent laryngeal nerve palsy. Intraoperative measurement of parathyroid hormone levels by a quick technique in 23 of the patients (13 having minimally invasive and 10 open procedures) correctly identified the presence of multiple-gland disease. CONCLUSION: Minimally invasive parathyroidectomy is a feasible procedure, although there are concerns about the complication rate.

Adenoma↗
PubMed1988

Long-term effects of parathyroidectomy on cardiac and autonomic nervous system functions in haemodialysis patients.

Ten patients receiving regular haemodialysis therapy who underwent parathyroidectomy for secondary hyperparathyroidism were investigated to evaluate the effects of parathyroid hormone on left ventricular and autonomic nervous system functions. The study which included M-mode echocardiography and autonomic nervous system tests (hormonal and cardiovascular response to the postural test, cold pressor test, handgrip test, diving reflex test and Valsalva manoeuvre) were performed prior to parathyroidectomy, and 5-8 months after, on a nondialysis day. The cardiovascular response and plasma noradrenaline changes to postural test remained unchanged following parathyroidectomy. The resting heart rate decreased from 73.1 +/- 2.4 to 66.4 +/- 2.3 beats/min (P less than 0.05) but mean blood pressure did not change post-parathyroidectomy. Mean blood pressure and heart rate changes during the cold pressor test, handgrip test, diving test and Valsalva manoeuvre were unaffected by parathyroidectomy. End-diastolic and end-systolic dimensions, fractional fibre shortening, mean velocity of fibre shortening and the ratio of the pre-ejection period to the left ventricular ejection time were normal prior to parathyroidectomy and remained unchanged following it. This study suggests that the reduction in parathyroid hormone concentrations obtained by parathyroidectomy does not significantly modify heart function and autonomic nervous system activity in the long term.

Adult↗
PubMed1987

Lack of effect of parathyroidectomy or calcium channel blockade on serum gastrin concentration and gastric acid secretion in a patient with hyperparathyroidism and Zollinger-Ellison syndrome.

Management of patients with multiple endocrine neoplasia type I (Wermer's syndrome) who have concurrent hypercalcemia and hypergastrinemia is controversial. The usual therapeutic approach has been to perform parathyroidectomy first before surgery for ulcer disease in an effort to decrease serum calcium concentration and presumably remove one of the stimuli for both gastrin and gastric acid secretion. We present the history of a 48-year-old man with primary hyperparathyroidism and Zollinger-Ellison syndrome who underwent acid secretory studies and secretin stimulation tests before and after parathyroidectomy. We also studied the effect of calcium channel blockade on gastrin and gastric acid secretion, since calcium influx into endocrine cells, such as the gastrinoma cell, is thought to be critical in hormone secretion. Although parathyroidectomy reduced serum calcium and parathormone levels to normal, basal serum gastrin concentration and basal acid output remained unchanged. The peak rise in serum gastrin concentration after secretin injection was less after parathyroidectomy than before parathyroidectomy but was still abnormal. During administration of verapamil, a calcium channel antagonist, no change was seen in the serum gastrin concentration, secretin test response, or acid secretion. Basal acid output was 45.4 mmol/hr before parathyroidectomy or verapamil and 54.0 and 50.4 mmol/hr after parathyroidectomy or verapamil, respectively. In contrast, a small but significant decrease (p less than 0.05) in serum parathormone concentration occurred during treatment with verapamil, an observation that to the best of our knowledge has not been previously reported in humans.

Calcium Channel Blockers↗
PubMed2001

Long-term management and outcome of parathyroidectomy for sporadic primary multiple-gland disease.

HYPOTHESIS: For a specific subset of patients with sporadic primary multiple-gland parathyroid disease, subtotal parathyroidectomy results in long-term normocalcemia in the majority of patients, with a minimal complication rate. DESIGN: Retrospective analysis of outcomes in patients undergoing parathyroidectomy performed by a single surgeon (A.E.G.) between 1984 and 1999. SETTING: A multidisciplinary endocrine service based at a tertiary referral center. PATIENTS: Patients undergoing subtotal parathyroidectomy for primary hyperparathyroidism due to sporadic multiple-gland disease identified from a single surgeon's operative records (A.E.G.). MAIN OUTCOME MEASURES: Data analyzed included demographic factors, operative and pathologic findings, and postoperative and long-term clinical and laboratory results, including calcium and intact parathyroid hormone levels. RESULTS: Of 379 patients undergoing parathyroidectomy for hyperparathyroidism between 1984 and 1999, 49 (13%) had sporadic multiple-gland disease. Median preoperative calcium and intact parathyroid hormone (iPTH) levels were 2.7 mmol/L (10.8 mg/dL) and 11.79 pmol/L, respectively. Postoperative calcium and iPTH levels were available in 39 patients, and median values were 2.28 mmol/L (9.1 mg/dL) and 2.84 pmol/L, respectively. Long-term follow-up was available for 36 patients (73%), and duration ranged from 6 to 180 months (median, 44 months). Median calcium and iPTH levels at follow-up were 2.3 mmol/L (9.2 mg/dL) and 3.26 pmol/L, respectively, with 3 (8%) of 36 patients having evidence of persistent or recurrent hyperparathyroidism. No patient had biochemical evidence of hypoparathyroidism at long-term follow-up. Five patients (14%) had persistent elevated iPTH levels (range, 8.11-10.95 pmol/L) and normal calcium levels. CONCLUSIONS: Subtotal parathyroidectomy for sporadic primary multiple-gland disease resulted in a long-term normocalcemia rate of 92%, with minimal complications. Selective subtotal parathyroidectomy can yield excellent long-term results in patients with multiple-gland disease.

Adult↗
PubMed2001

Parathyroidectomy can improve bone mineral density in patients with symptomatic secondary hyperparathyroidism.

HYPOTHESIS: The recovery of osteoporosis or bone mineral density (BMD) after parathyroidectomy and autotransplantation can be improved in patients with symptomatic secondary hyperparathyroidism. DESIGN: Case series. SETTING: Tertiary referral center. PATIENTS: Forty-five patients with symptomatic secondary hyperparathyroidism who underwent total parathyroidectomy and autotransplantation were included. They were divided into an osteoporotic group (n = 20) and a nonosteoporotic group (n = 25) according to preoperative T scores less than -2.5 at either the lumbar spine (L1-L4) or the femoral neck (FN). INTERVENTIONS: Serum levels of calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone were checked before surgery and 1 day, 1 week, and 3 months after surgery. The BMDs of the FN and L1-L4 were measured using dual-energy x-ray absorptiometry before surgery and 6 months after surgery. RESULTS: Patients with osteoporosis were older (mean +/- SD, 50.2 +/- 14.0 years) than those without osteoporosis (42.7 +/- 9.1 years) (P =.04). Except for bone fractures found in 2 women in the osteoporotic group, there were no significant differences between the 2 groups in sex, clinical manifestations, duration of dialysis, weight of removed parathyroid tissue, and types of dialysis. Also, serum levels of calcium, phosphorus, alkaline phosphatase, and intact parathyroid hormone were similar in both groups. Both 1 day and 1 week after total parathyroidectomy and autotransplantation, serum levels of calcium and intact parathyroid hormone decreased rapidly and then gradually increased 3 months later; however, serum levels of alkaline phosphatase increased rapidly and then gradually decreased 3 months later. Six months after parathyroidectomy, BMD, T score, and Z score at L1-L4 and the FN increased significantly (P<.001). The increment was much better in the osteoporotic group than in the nonosteoporotic group (P<.001). Also, osteopenia or osteoporosis improved significantly after parathyroidectomy at both L1-L4 and the FN (P<.001 for both). CONCLUSION: Parathyroidectomy and autotransplantation can improve BMD of symptomatic secondary hyperparathyroidism at L1-L4 and the FN.

Absorptiometry, Photon↗
PubMed2002

Radioguidance is not necessary during parathyroidectomy.

BACKGROUND: Improvements in the accuracy of preoperative localization and the availability of the rapid parathyroid hormone assay have permitted minimally invasive parathyroidectomy in patients with primary hyperparathyoidism. HYPOTHESIS: The use of intraoperative radioguidance is beneficial during targeted parathyroid operations. DESIGN: A retrospective analysis of a prospective database of patients. SETTING: Tertiary care referral center. PATIENTS: During a 2(1/2)-year period, 130 patients underwent minimally invasive, targeted parathyroidectomy with intraoperative monitoring of the parathyroid hormone level. Of these, 60 patients underwent radioguided parathyroidectomy. Prior to surgery, a solitary parathyroid adenoma was visualized on technetium Tc 99m sestamibi scintigraphy in all patients selected for radioguided parathyroidectomy. A gamma probe was used to guide the surgical dissection. RESULTS: All patients were cured following radioguided parathyroidectomy. In 29 patients (48%), the probe provided confusing or inaccurate information; however, a unilateral neck exploration with excision of a parathyroid adenoma was successfully completed in each of these patients. Forty-three cases were completed under local anesthesia and 85% were discharged home on the same day of surgery. There was 1 temporary recurrent laryngeal nerve palsy. CONCLUSION: In the era of improved preoperative localization and intraoperative parathyroid hormone monitoring, the routine use of radioguidance is not recommended during parathyroidectomy.

Adenoma↗
PubMed2006

Subtotal parathyroidectomy as an adequate treatment for primary hyperparathyroidism in multiple endocrine neoplasia type 1.

HYPOTHESIS: The most appropriate surgical approach for hyperparathyroidism (HPT) in multiple endocrine neoplasia type 1 remains controversial. It has been advocated that reoperations for recurrent disease are easier to perform after total parathyroidectomy (TP) with autotransplantation than after subtotal parathyroidectomy (SP). In view of our large experience in patients with secondary HPT for whom TP with autotransplantation did not simplify reoperations, SP remains our preferred treatment for patients with HPT and multiple endocrine neoplasia type 1. DESIGN: Retrospective cohort study. SETTING: Tertiary referral medical center. PATIENTS: A total of 29 consecutive patients (22 women, 7 men; mean age, 42.2 years) with multiple endocrine neoplasia type 1 who underwent definitive cervical exploration for HPT. MAIN OUTCOME MEASURES: Temporary and permanent hypocalcemia, pattern of parathyroid disease, and sites and timing of recurrent HPT. Definitive primary surgery included SP in 21 patients, TP with autotransplantation in 4 patients, and less-than-subtotal parathyroidectomy in 4 selected patients. RESULTS: The mean follow-up was 88.5 months (range, 8-285 months). Four patients died during follow-up; 2 of these deaths were related to multiple endocrine neoplasia. No patients had persistent HPT. Temporary hypocalcemia occurred in 12 SP cases (57%), 4 TP with autotransplantation cases (100%), and 0 less-than-subtotal parathyroidectomy cases. Permanent hypocalcemia requiring long-term treatment occurred in 2 SP cases (10%), 1 TP with autotransplantation case (25%), and 0 less-than-subtotal parathyroidectomy cases. Four patients developed recurrent disease, including 1 with SP, 2 with TP with autotransplantation, and 1 with less-than-subtotal parathyroidectomy at 57 months, 197 and 180 months, and 164 months, respectively, representing 14% of all of the patients and 43% of patients with more than 10 years of follow-up. CONCLUSIONS: Recurrent HPT occurs many years after definitive primary surgery (median, 14.3 years). Surgical treatment should therefore aim to minimize the risk of permanent hypocalcemia and facilitate future surgery. When correctly performed, SP fulfills these objectives.

Adult↗
PubMed1997

Sestamibi scanning is inadequate for directing unilateral neck exploration for first-time parathyroidectomy.

OBJECTIVE: To determine whether technetium Tc 99m sestamibi scanning is accurate enough to allow surgeons to perform unilateral neck exploration for first-time parathyroidectomy in patients with primary hyperparathyroidism. DESIGN: Retrospective review. SETTING: University tertiary care center. PATIENTS: Forty patients with primary hyperparathyroidism who underwent sestamibi scanning before first-time parathyroidectomy, of whom 28 had single adenomas, 9 had multiple adenomas, and 3 had hyperplasia. INTERVENTIONS: All 40 patients underwent bilateral neck exploration with identification of 4 parathyroid glands. MAIN OUTCOME MEASURES: We compared the results of preoperative sestamibi scanning with operative and histologic findings. We then used these data to calculate the projected success rates of parathyroidectomy if unilateral neck explorations had been performed based on the results of sestamibi scanning, instead of bilateral explorations. RESULTS: Sestamibi scanning was correct in 20 (71%) of 28 patients with single adenomas, 4 (44%) of 9 patients with multiple adenomas, and 0 (0%) of 3 patients with hyperplasia. If unilateral neck explorations had been performed on the basis of localization by sestamibi scanning, parathyroidectomy would have failed in 4 (10%) of 40 patients. CONCLUSIONS: Sestamibi scanning, although helpful, is inadequate for directing unilateral neck exploration for first-time parathyroidectomy. Surgeons who perform unilateral neck exploration based on the results of sestamibi scanning will record a higher failure rate and incur higher costs than those who perform bilateral neck exploration for first-time parathyroidectomy.

Adolescent↗
PubMed2005

Sequential changes in plasma intact and whole parathyroid hormone levels during parathyroidectomy for secondary hyperparathyroidism.

Most commercial assays for intact parathyroid hormone (iPTH) cross-react with non-PTH1-84 fragments (likely to be PTH7-84). We aimed to evaluate a whole PTH assay that measured only PTH1-84 by comparing it with an assay measuring iPTH levels during parathyroidectomy in secondary hyperparathyroidism (HPT). Twenty-eight patients with secondary HPT who underwent total parathyroidectomy with autotransplantation served as subjects. Blood samples for postoperative assay were drawn after anesthesia; immediately prior to excision of the last parathyroid gland; and at 5, 10, and 15 minutes after excision. The PTH7-84 level was calculated by subtracting the whole PTH value from the iPTH value. Plasma whole PTH decreased more rapidly than iPTH after parathyroidectomy (p < 0.0001). PTH levels that decreased by 50% or more from levels prior to excision to 10 minutes after excision were used to predict successful parathyroidectomy; decreases in whole PTH substantiated curative surgery for all patients without introducing false-positive and false-negative results. iPTH levels decreased by at least 50% in only 16 patients at 10 minutes after excision without false-positive results. Out of 11 cases in which iPTH decreased less than 50%, two were true-negatives and nine were false-negatives. Decreases in whole PTH levels more accurately reflect surgical outcome than do decreases in iPTH levels during parathyroidectomy in secondary HPT patients. Even though the quick iPTH assay is used infrequently during surgery for secondary HPT, our results suggest that a quick whole PTH assay may be more useful than the iPTH assay currently used in parathyroidectomy procedures for secondary HPT.

Female↗
PubMed2005

Incidental parathyroidectomy during thyroid surgery: an underappreciated complication of thyroidectomy.

The aim of this study was to investigate the incidence, risk factors, and clinical relevance of incidental parathyroidectomy during thyroid surgery. Prospective analysis of data in patients following thyroidectomy, specifically regarding the presence of parathyroid parenchyma in the thyroidectomy specimens, the underlying thyroid pathology, and the presence of postoperative hypocalcemia (biochemical/clinical). The clinical records of 158 patients who underwent thyroid surgery during a 2-year period were reviewed. Pathology reports were carefully reviewed for the nature of the underlying thyroid disease, the presence, number, and size of incidentally resected parathyroid gland(s), their location, and possible parathyroid pathology. Serum calcium levels were measured preoperatively, on the day of surgery, and on postoperative days 1, 2, and 7 or even later as needed. Two groups of patients were studied: a group with incidental parathyroidectomy following thyroidectomy (group A) and a group without incidental parathyroidectomy after thyroidectomy (group B). Total/near-total thyroidectomy was the procedure of choice and was performed in 154 patients; total lobectomy and contralateral subtotal lobectomy was performed in the other 4 patients. Elective central neck lymph node dissection was performed in four patients with neck lymphadenopathy. Inadvertently removed parathyroid tissue was found in 28 cases (17.7 %); in 6 of these patients (21%) the parathyroid tissue was intrathyroidal. The percentage of women in group A was significantly higher than in group B (93% vs. 58.5%, P = 0.0002). There was no statistically significant difference between the two groups (A and B) regarding the preoperative (presumed) diagnosis, the histologic diagnosis of thyroid disease (benign versus malignant), the type/extent of surgery, or the presence of thyroiditis. Biochemical and clinical hypocalcemia was observed in 6 (21%) and 2 (7%) patients in group A, respectively, and in 30 (23%) and 8 (6%) patients of group B, respectively. There was no statistically significant difference regarding the occurrence of postoperative hypocalcemia (clinical/biochemical) between the two groups (P = 0.33). Incidental parathyroidectomy is not uncommon following thyroidectomy and in a significant percentage of cases it may be due to the intrathyroidal location of the parathyroid glands. Incidental parathyroidectomy was not found to be associated with postoperative hypocalcemia (biochemical/clinical). Incidental parathyroidectomy may be considered as a potentially preventable but clinically minor complication of thyroid surgery.

Adolescent↗
PubMed2002

Total parathyroidectomy without autotransplantation as a standard procedure in the treatment of secondary hyperparathyroidism.

BACKGROUND: Total parathyroidectomy with autografting of parathyroid tissue and subtotal resection of the parathyroid glands are currently considered as standard surgical procedures for the treatment of severe secondary hyperparathyroidism. However, a considerable recurrence rate following these procedures ranges from 5% to 80%. We present a retrospective analysis of the results of parathyroidectomy with autotransplantation to the forearm versus parathyroidectomy alone. PATIENTS AND METHODS: We analyzed the clinical course of 11 consecutive patients who had undergone parathyroidectomy between 1995 and 1999, and who were not simultaneously autografted. Controls were 11 patients in whom autotransplantation of parathyroid tissue into the forearm had been routinely performed between 1993 and 1996 at our institution. Clinical symptoms and recurrence of hyperparathyroidism were assessed for comparison of the alternative treatment modalities. Recurrence of disease was defined by elevated parathormone (PTH) levels (>7.6 pmol/l) with clinical symptoms and/or need for reoperation. RESULTS: No recurrence of hyperparathyroidism was observed in patients without autotransplantation after a mean follow-up of 23 months (range 1-49). Measurement of intact serum PTH revealed residual PTH secretion even after removal of four glands (mean 2.02 pmol/l). Clinical symptoms improved substantially after surgery. In the historical control group 3 of the 11 autotransplanted patients (27%) required resection of transplanted tissue. Additionally, two patients (18%) presented with increased PTH secretion and clinical symptoms of recurrent hyperparathyroidism during follow-up. Thus, a total of five patients (45%) experienced relapsing hyperparathyroidism caused by the implanted tissue. CONCLUSIONS: Total parathyroidectomy without autotransplantation is a safe procedure with a low rate of recurrent hyperparathyroidism when compared to parathyroidectomy with autotransplantation to the forearm in a historical control. These preliminary results mandates further investigations including a randomized trial.

Adult↗