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PubMed2003

Experienced scintigraphers contribute to success of minimally invasive parathyroidectomy by skilled endocrine surgeons.

Minimally invasive parathyroidectomy (MIP) has become the preferred surgical treatment for selected patients diagnosed with primary hyperparathyroidism (PHPT) at our tertiary-care center. Preoperative scintigraphy establishes the position of a parathyroid adenoma, dictates the incision site, and can minimize incision size and consequent tissue dissection. We reviewed our database and sought to identify factors that led to discordant preoperative imaging and operative findings and to assess the effect of experience on these findings. A retrospective review was performed on all patients with biochemically proven PHPT who underwent Tc-99m sestamibi scintigraphy and surgical intervention. Patient demographics, date of surgical intervention, scintigraphic localization, surgical findings, pre- and postoperative biochemical markers, histopathology, coexisting thyroid pathology, and 6-month follow up were recorded. Preoperative images that were discordant with operative findings were independently reviewed. Parathyroid scintigraphy was performed on 125 consecutive patients for PHPT between November 1999 and January 2002. Seventy-six patients had MIPs, 35 had standard cervical explorations, 11 had MIPs that were converted to standard cervical explorations, and three had surgery directed to an ectopic location. At 6-month follow-up 98.4 per cent were cured. Preoperative imaging and surgical findings were ipsilateral and concordant in 105 of 118 (89%) patients with parathyroid adenoma. The anatomic origin of an adenoma was predicted in only 83 of 118 (68%) patients. Most of the inaccurate scintigraphy readings occurred during the first 13 of the 26 months that MIPs were performed at our institution. Only two discordant cases occurred during the last 9 months of this period. Biochemical markers, prior neck operation, and concomitant thyroid pathology had no correlation with imaging sensitivity. Scintigraphic interpretation of smaller adenomas was less reliable; discordant cases were more common in small adenomas. Communication between endocrine surgeons and nuclear medicine physicians about the MIP technique and anatomic orientation of adenomas led to better scintigraphic localization as experience increased. Now that MIP by skilled endocrine surgeons is becoming the favored treatment for PHPT experienced nuclear medicine physicians may be the most important factor to achieve maximum success.

Adenoma↗
PubMed1992

[Persistent and recurrent hyperparathyroidism following parathyroidectomy].

In a series of 416 parathyroidectomies for primary or secondary hyperparathyroidism, 19 were reoperations for persistence (17 cases) on recurrence (2 cases) of the disease. (1) Preoperative localisation studies were useless in half of the cases. (2) In re-explorations, 72% only of parathyroid glands were discovered, 46% of them in ectopic locations. In reoperations for primary hyperparathyroidism, 56% of cases had more than one pathological gland. (3) Long term results have been less satisfactory after re-explorations than after the first operations.

Adult↗
PubMed2003

Minimally invasive parathyroidectomy: how effective is preoperative sestamibi scanning?

Minimally invasive parathyroidectomy (MIP) guided by preoperative sestamibi scanning has been shown to reduce operative time, hospital stay, and cost in treating primary hyperparathyroidism. However, controversy exists over routine preoperative sestamibi scanning. The purpose of this study was to determine the utility of sestamibi scanning at our institution as part of the MIP protocol and to analyze calcium and parathyroid hormone levels as possible predictors of successful sestamibi scanning. Charts of 37 consecutive patients undergoing MIP at our institution were reviewed, and age, sex, preoperative calcium, and parathyroid (PTH) levels, invasiveness of procedure, and pathologic diagnosis were recorded. Sestamibi scans were reviewed and scored by 4 nuclear medicine faculty based on the level of suspicion for parathyroid adenoma. Neither calcium nor PTH correlated significantly with sestamibi scan score (Spearman coefficient, r = 0.075, P = 0.67 and r = 0.277, P = 0.10, respectively). Receiver-operating-characteristic (ROC) analysis showed sestamibi scanning to have sensitivity and specificity in predicting MIP completion (87% and 68%). Logistic regression showed only sestamibi scan (P = 0.038), not calcium or PTH (P = 0.977 and P = 0.767) to be predictive of MIP completion. In conclusion, sestamibi scanning effectively predicted the ability to perform MIP. However, preoperative calcium and PTH predicted neither sestamibi scan results nor completion of MIP.

Adenoma↗
PubMedDate not supplied

[Video-assisted minimally invasive parathyroidectomy with median access. Technical changes: case load 1999-2002].

INTRODUCTION: In 1997 a Minimally Invasive Video Assisted Technique for Parathyroidectomy (MIVAP) was developed in the University of Pisa. In this review we examine the last three years of MIVAP (240 cases) in order to identify the advantages and the limits of the procedure after the first-period development of the technique. RESULTS: In our experience, 65% of patients affected by primary hyperparathyroidism (PHPT) turned out to be eligible for MIVAP. During the first years several selection criteria were strictly followed; more recently, some initially absolute contraindications to the operation have been interpreted more flexibly. Mean operative time is 35 minutes. 18 conversions (7.5%) to traditional open cervicotomy were needed and in 4 cases (1.6%) no affected parathyroid tissue was removed. CONCLUSIONS: At present, we consider absolutely necessary for MIVAP: preoperative localization of an adenoma with at least one imaging study (US or MIBI scintiscan) and the availability of QPTH intraoperative assay. No absolute contraindications other than the size of the lesions and the suspect of parthyroid carcinoma are identified for patients with PHPT. Moreover, MIVAP has proved to have further advantages when compared to other mini invasive procedures such as the demonstrated possibility to perform a traditional bilateral exploration, when indicated. Nevertheless, a great degree of experience is requested for this procedure. In conclusion, MIVAP permits to significantly reduce postoperative pain, size of the incision, days of hospitalisation and, finally, the cost of the entire procedure without affecting in any way the success rate of the traditional operation and without an increase of the complications.

Humans↗
PubMed1992

[Experiences with total parathyroidectomy and autotransplantation of intraoperatively selected parathyroid tissue in reactive renal hyperparathyroidism].

Surgery is indicated in cases of therapy-resistant reactive renal hyperparathyroidism with clinical symptoms and signs. The method of choice is total parathyroidectomy, with autotransplantation of parathyroid tissue into the forearm musculature. Twenty-two patients were parathyroidectomized. In 19 cases the intraoperative selection of tissue for autotransplantation was made by means of a stereoscopic magnifying glass. With one exception, only fragments of type 1a glands and type 1a-like areas obtained from type 2 glands were transplanted. In 18 of the 22 cases parathyroid hormone levels decreased from 1131 +/- 657 preoperatively to 87 +/- 53 pg/ml postoperatively. In 4 patients with postoperative values over 200 pg/ml a transplant-related recurrence of hyperparathyroidism or a remaining 5th gland in the cervical region was suspected. In all 22 patients serum calcium, as well as alkaline phosphatase levels returned to normal and the clinical signs of hyperparathyroidism disappeared.

Adult↗
PubMed2004

Total parathyroidectomy reduces elevated circulating fibroblast growth factor 23 in advanced secondary hyperparathyroidism.

BACKGROUND: Secondary hyperparathyroidism is a common complication in patients with stage 5 chronic kidney disease (CKD), accelerated by hyperphosphatemia. Fibroblast growth factor 23 (FGF-23), a phosphorus-regulating protein, has key roles in several phosphate-wasting disorders. The aim of this study is to examine the association of advanced secondary hyperparathyroidism with circulating FGF-23 levels. METHODS: Fifteen patients with marked secondary hyperparathyroidism (parathyroid hormone [PTH], 990 +/- 118 pg/mL [ng/L]) were enrolled. All underwent parathyroidectomy with forearm autotransplantation (PTX), and their FGF-23 levels were measured before and after PTX (days 1, 3, 7, and 10) by means of sandwich enzyme-linked immunosorbent assay. RESULTS: Preoperative FGF-23 levels correlated positively with phosphorus (P < 0.05), calcium-phosphorus product (Ca x P; P < 0.0005), and PTH values (P < 0.05). Serum FGF-23 levels decreased time dependently after PTX (P < 0.0005). Both serum phosphorus and Ca x P values decreased similarly after PTX ( P = 0.0001). Furthermore, FGF-23 levels days 1 and 3 correlated linearly with serum phosphorus (P < 0.05; P < 0.005, respectively) and Ca x P values (P < 0.01; P < 0.0001, respectively). CONCLUSION: FGF-23 levels correlate positively with serum phosphorus, Ca x P, and PTH values in patients with advanced secondary hyperparathyroidism. Complete ablation of progressive parathyroid glands reduces circulating FGF-23 levels, simultaneously decreasing serum phosphorus and Ca x P values. These findings suggest that hyperplastic parathyroid glands, together with hyperphosphatemia, affect abnormal FGF-23 metabolism in patients with stage 5 CKD with advanced secondary hyperparathyroidism.

Chronic Disease↗
PubMed2004

[Parathyroidectomy for advanced renal hyperparathyroidim in hemodialysis].

Treatment of advanced secondary hyperparathyroidism should be shifted from to avoid progression of bone disease to protection of cardiovascular complications induced by ectopic calcification. Patients who suffer from advanced secondary hyperparathyroidism with uncontrollable hypercalcemia or/and hyperphosphatemia by medical treatment should be referred to surgical treatment at relatively early time. Total parathyroidectomy with forearm autograft is adequate operative procedure especially in patients who require long-term hemodialysis.

Cardiovascular Diseases↗
PubMed2005

[Regional cerebral perfusion before and after parathyroidectomy].

BACKGROUND: Single photon emission computerised 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: 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 two, four and twelve months after parathyroidectomy. The Montgomery and Asberg depression rating scale (MADRS) was used as a parallel clinical test. RESULTS: Reduced (pathological) regional cerebral blood flow was seen before operation in 14 patients, 13 with 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 them asymptomatic and with diffuse hyperplasia, a slight reduction was demonstrated. Eight patients had a pathological preoperative MADRS score, which normalised 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 have bearing upon the case for surgical treatment.

Adenoma↗
PubMedDate not supplied

[Minimally invasive radioguided parathyroidectomy].

The use of a hand-held gamma probe during the operation allows a direct approach to the parathyroid adenoma, which is more active than the thyroid. This procedure is significantly less morbid and can be performed in shorter time than standard neck exploration. Hand-held gamma probe already existed at the Department of Oncology and Nuclear Medicine. As a result of a very good cooperation with Department of Internal medicine and Department of Othorhinolaryngology, for the first time in our country minimally invasive radioguided parathyroidectomy was performed on April 16th, 2002. Until now, 15 patients with primary hyperparathyroidism underwent this type of operation. 700 MBq 99m-Tc-SESTAMIBI was injected two hours before the planned operative procedure. Preoperative scintigraphy was performed 10 and 80 minutes after the administration of radiopharmaceutical. This study deals with our first experience of intra-operative localization of parathyroid adenomas using a hand-held gamma probe, as well as our observations concerning the selection of the patients.

Adenoma↗
PubMed2005

[Successful subtotal parathyroidectomy for giant tumor calcinosis with secondary hyperparathyroidism].

A 54-year-old woman was referred to our hospital for the treatment of secondary hyperparathyroidism due to chronic renal failure. She was on hemodialysis for 7 years and suffered from giant tumor calcinosis of the major joints associated with severe hypercalcemia and hyperphosphatemia. The largest one of the left hip joint caused gait disturbance. Medical therapy was unsuccessful and she underwent subtotal parathyroidectomy. After the operation, although the levels of serum calcium and phosphate were not normalized, the level of parathyroid hormone was lowered to the normal range. The volume of the tumor calcinosis gradually reduced and she became able to walk for a short distance 10 months after the operation.

Calcinosis↗
PubMed2005

[Bone status after parathyroidectomy for primary hyperparathyroidism].

Parathyroidectomy (PTX) is the only option available for the cure of hyperparathyroidism (HPT). After PTX, biochemical bone markers rapidly decrease and return to normal. Bone resorption markers decrease faster than bone formation markers. Increase in bone mineral density (BMD) by PTX is explained by time lag between changes in bone resorption and bone formation markers. Several lines of evidence indicate that PTX preferentially leads to increase in trabecular BMD in primary HPT patients. However, a considerable increase in BMD is obtained after PTX even in asymptomatic patients. Recent studies suggest that PTX reduces the risk of fracture in primary HPT (PHPT) patients. Changes in bone structures after PTX remain to be elucidated.

Bone Resorption↗
PubMedDate not supplied

Post-parathyroidectomy serum phosphate kinetics is peculiar to female hemodialysis patients with a high body mass index.

BACKGROUND: Persistent hyperphosphatemia is one of the most important factors in the development of secondary hyperparathyroidism (sHPTH). Recently, we demonstrated that a higher body mass index (BMI) and female gender could predispose to a larger phosphate (P) body burden, thereby influencing the severity of sHPTH. METHODS: This prospective study aimed to verify if these two risk factors, i.e. BMI and female gender, also influenced calcium (Ca) and P kinetics in the immediate post-parathyroidectomy (PTx) period in 42 consecutive adult Caucasian anuric hemodialysis (HD) patients referred for first PTx. Serum Ca and P were measured pre-PTx and on the 5 consecutive post-PTx days; serum immunoreactive parathyroid hormone (iPTH) and alkaline phosphatase (ALP) levels were measured pre-PTx and 3 days post-PTx. RESULTS: Ablation of parathyroid tissue determined a significant reduction in serum iPTH, ALP, Ca and P (p = 0.001). The stratification of the cohort into four groups according to the cut-off value of BMI = 25 kg/m(2) and according to gender showed the following: males and females with BMI >25 kg/m(2) (analyzed both separately and as a subgroup including males and females) had significantly higher pre-PTx serum P levels, when compared with the respective sub-groups with BMI <25 kg/m(2) (p < 0.01); a significantly higher mean area under the concentration curve (AUC) of serum P was observed in the high BMI group (males and females), when compared with the low/normal BMI group (p = 0.03); the serum P kinetics in the 5 post-PTx days did not differ between the two groups of male patients (low/normal BMI males vs. high BMI males), whereas a significantly higher mean serum P AUC was observed in the high BMI female patients, when compared with the low/normal BMI female patients (p = 0.003); finally, the serum P kinetics in the 5 post-PTx days did not differ between the two groups of low/normal male and female patients, whereas a significantly higher mean serum P AUC was observed in the high BMI female patients, when compared with the high BMI male patients (p = 0.006). A linear multiple regression analysis with the serum P AUC of each patient as a dependent variable and BMI, gender, age and dialysis duration as independent variables showed that BMI (p = 0.0001) and female gender (p = 0.001) were independent predictors of the serum P AUC. CONCLUSIONS: High BMI and female gender are associated with peculiar serum P kinetics in the immediate post-PTx period, suggesting the existence of a larger P body burden in high BMI female HD patients. The existence of a larger P pool exclusively based on serum P kinetics prompts the need for further studies to better understand such intriguing aspects of bone pathophysiology in response to parathyroid gland removal in chronically uremic patients.

Adult↗
PubMedDate not supplied

[Comparison among ecography, scintigraphy and surgery in the localization of parathyroid glands in uremic patients undergoing parathyroidectomy].

BACKGROUND: Sensitivity and specificity of the most widely employed techniques of parathyroid glands localization, namely echography and scintigraphy, are mostly obtained with short-term follow-up data and do not underline the existence of a methodological problem. As a matter of fact, both methods identify only pathological glands, with no "normal" results; therefore "true negatives" cannot be obtained. Aim of our study was to compare, by means of a statistically appropriate approach, the results of echography, scintigraphy and surgery with the data obtained after a mid term follow-up period, enabling us to discover all parathyroid glands. METHODS: Twenty six consecutive dialysis patients (14M/12F; age 50+/-12 years) underwent echography and scintigraphy immediately before a total parathyroidectomy with autotransplantation and were followed-up for 6 months to recognize all the existing glands (PTH levels and scintigraphy). RESULTS: Total identified glands were: 73 by scintigraphy, 86 by echography, 99 by surgery and 103 by follow-up data. The concordance indexes (K0) between the number of glands effectively present in the individual patient (follow-up data) and those identified with each method were rather low with scintigraphy (0.071) and echography (0.218), and acceptable (0.578) with surgery. The number of patients correctly classified was: 9/26 (34,6%) with scintigraphy, 13/26 (50%) with echography and 22/26 (85%) with surgery. Finally, the number of wrongly identified glands (from zero to three) in each patient was similar with scintigraphy (65,4%) and echography (50%) and significantly better with surgery (15,6%; p<0.01). CONCLUSIONS: The most reliable technique to identify parathyroid glands in uremic subjects is surgery, nonetheless a meticulous clinical follow-up is necessary to recognize all of them.

Adult↗
PubMed1991

Systemic hemodynamic pattern in primary hyperparathyroidism and its changes after parathyroidectomy.

Twelve patients (7 men and 5 women) with an average age of 53 years (range 37-69) were hospitalized for renal stones and found to have primary hyperparathyroidism. Five were hypertensive and 7 normotensive. The systemic hemodynamics, plasma renin activity and glomerular filtration rate were evaluated before and at least 6 months after removal of a parathyroid adenoma. After surgery the mean intra-arterial blood pressure fell in almost all patients, due to some reduction in the peripheral vascular resistance index with no change in the cardiac index. However, the hemodynamic variations were not uniform in all patients. No change was seen in plasma renin activity and glomerular filtration rate. A positive correlation between the percent change in mean arterial pressure and percent decrease in total serum calcium was found. The results obtained indicate that it is likely that hypercalcemia plays some role both in patients with high and those with normal blood pressure. The systemic hemodynamic changes after parathyroidectomy indicate that the fall in peripheral vascular resistance could have a certain influence.

Adult↗
PubMed1991

Thyroidectomy and parathyroidectomy in the dog and cat.

Thyroidectomy has become a fairly common surgical procedure in small animals because of the increasing incidence of thyroid tumors. Surgical removal of the thyroid gland can be routine or quite challenging, depending on the species (cat vs. dog) and the size and aggressiveness of the tumor. Many problems may be encountered with these patients, associated both with the disease and with the surgical treatment. Both thyroid and parathyroid tumors result in many alterations in the animal's homeostasis. These alterations must be recognized by the surgeon to maximize the chance of a successful outcome. This chapter deals with thyroidectomy and parathyroidectomy in dogs and cats. Indications for surgery, pathophysiology of thyroid and parathyroid neoplasia, preoperative care, surgical procedures, and postoperative care and complications will be discussed.

Animals↗
PubMed1991

[Secondary hyperparathyroidism in chronic renal failure. Role of subtotal parathyroidectomy].

Fourteen patients with chronic renal failure and secondary hyperparathyroidism were treated by subtotal parathyroidectomy. Bone pain and hypercalcemia were the main indications to surgery respectively in 13 and 1 patients. Bone pain disappeared or was significantly reduced in 12/14 patients. Two patients had a persistent hyperparathyroidism. Serum alkaline phosphatase returned to normal in 12 patients and PTH in 11 of 12 patients with pretreatment high levels.

Adult↗
PubMed1991

[Kinetics of PTH metabolism after total parathyroidectomy and autograft at forearm in patients with secondary hyperparathyroidism due to chronic renal failure].

Five patients with secondary hyperparathyroidism (2(0) HPT) due to chronic renal failure were investigated for PTH metabolism kinetics after total parathyroidectomy and autograft at the forearm (PTxG). We studied the kinetics of PTH for 24 hours after surgical treatment and gradually increased PTH levels when the parathyroid grafts became functional. It has been well known that the secreted intact PTH is peripherally cleaved in the region of reside 34 to yield amino- and carboxyl-terminal fragments. In this study, specific assays were used for intact PTH (INT-PTH), middle (HS-PTH, MM-PTH) and carboxyl-terminal (C-PTH) fragments. Half-lives were calculated from the mean values of all experiments by a two-compartment system; INT-PTH: 11.1 +/- 3.9 min, HS-PTH: 9.6 +/- 1.7 hrs., MM-PTH: 11.1 +/- 2.9 hrs., C-PTH: 10.1 +/- 1.2 hrs. (Mean +/- SD). The disappearance rate of biologically active intact PTH was rapid, whereas those of middle and carboxyl-terminal biologically inactive fragments were prolonged in the patients with chronic renal failure. The graft function was examined by PTH gradient between the venous samples in the grafted arm as compared to the non-grafted arm. PTH gradient of INT-PTH assay was over 1.5 one week following PTxG in all patients. This suggests that the intact PTH assay is a reliable predictor of clinical response to the graft function after PTxG.

Forearm↗