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Annals of the Royal College of Surgeons... Jan 2021Reoperative parathyroidectomy for persistent and recurrent primary hyperparathyroidism is dependent on radiology. This study aimed to compare outcomes in reoperative... (Comparative Study)
Comparative Study
INTRODUCTION
Reoperative parathyroidectomy for persistent and recurrent primary hyperparathyroidism is dependent on radiology. This study aimed to compare outcomes in reoperative parathyroidectomy at a single centre using a combination of traditional and newer imaging studies.
MATERIALS AND METHODS
Retrospective case note review of all reoperative parathyroidectomies for persistent and recurrent primary hyperparathyroidism over five years (June 2014 to June 2019; group A). Imaging modalities used and their positive predictive value, complications and cure rates were compared with a published dataset spanning the preceding nine years (group B).
RESULTS
From over 2000 parathyroidectomies, 147 were reoperations (101 in group A and 46 in group B). Age and sex ratios were similar (56 vs 62 years; 77% vs 72% female). Ultrasound use remains high and shows better positive predictive value (76% vs 57 %). 99mTc-sestamibi use has declined (79% vs 91%) but the positive predictive value has improved (74% vs 53%). 4DCT use has almost doubled (61% vs 37%) with better positive predictive value (88% vs 75%). 18F-fluorocholine positron emission tomography-computed tomography and ultrasound-guided fine-needle aspiration for parathyroid hormone are novel modalities only available for group A. Both carried a positive predictive value of 100%. Venous sampling with or without angiography use has decreased (35% vs 39%) but maintains a high positive predictive value (86% vs 91%). Cure rates were similar (96% vs 100%). Group A had 5% permanent hypoparathyroidism, 1% permanent vocal cord palsy and 1% haematoma requiring reoperation. No complications for group B.
CONCLUSION
Optimal imaging is key to good cure rates in reoperative parathyroidectomy. High-quality, non-interventional imaging techniques have produced a shift in the preoperative algorithm without compromising outcomes.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Biopsy, Fine-Needle; Female; Four-Dimensional Computed Tomography; Humans; Hyperparathyroidism, Primary; Male; Middle Aged; Parathyroid Glands; Parathyroid Hormone; Parathyroidectomy; Positron Emission Tomography Computed Tomography; Radionuclide Imaging; Recurrence; Reoperation; Retrospective Studies; Secondary Prevention; Technetium Tc 99m Sestamibi; Treatment Outcome; Ultrasonography; Young Adult
PubMed: 32829647
DOI: 10.1308/rcsann.2020.0185 -
European Annals of Otorhinolaryngology,... Apr 2019There is at present no consensus concerning surgical techniques for secondary hyperparathyroidism (SHPT) in end-stage renal disease (ESRD). Although both subtotal and... (Observational Study)
Observational Study
OBJECTIVE
There is at present no consensus concerning surgical techniques for secondary hyperparathyroidism (SHPT) in end-stage renal disease (ESRD). Although both subtotal and total parathyroidectomy provide low rates of recurrence, they may induce hypoparathyroidism, damaging the bone and cardiovascular systems. The aim of our study was to compare 3/4 and 7/8 parathyroidectomy in this population and to discuss the potential benefit of more conservative treatment.
STUDY DESIGN
Prospective observational study in a university teaching hospital between 2010 and 2014.
METHODS
The study included 34 consecutive ESRD patients with SHPT: 19 underwent 3/4 parathyroidectomy (group A*3/4) and 15 underwent 7/8 parathyroidectomy (group B*7/8). Serum intact 1-84 PTH levels (before and 6 months after surgery) and hospital stay were compared between the two groups.
RESULTS
Before surgery, PTH levels were similar between the two groups. At month 6 following surgery, median PTH levels were significantly higher in group A*3/4 than in group B*7/8 (109 versus 24pg/mL, respectively; P<0.0006). Hospital stay was shorter in group A*3/4 (4.79 versus 6.80 days, respectively; P=0.008). Postoperative hypoparathyroidism requiring long-term calcium and 1alpha(OH) D3 treatment was reported in 5% of patients in group A*3/4 and 26% of patients in group B*7/8 (P=0.04).
CONCLUSIONS
In this preliminary study, 3/4 conservative parathyroidectomy seemed effective and safe, with less reported morbidity than 7/8 parathyroidectomy, as assessed by lower rates of irreversible hypoparathyroidism and shorter hospital stay.
LEVEL OF EVIDENCE
3b, individual case-control study.
Topics: Adult; Aged; Case-Control Studies; Conservative Treatment; Female; Humans; Hyperparathyroidism, Secondary; Hypoparathyroidism; Kidney Failure, Chronic; Length of Stay; Male; Middle Aged; Parathyroid Hormone; Parathyroidectomy; Postoperative Complications; Prospective Studies; Statistics, Nonparametric; Young Adult
PubMed: 30327179
DOI: 10.1016/j.anorl.2018.09.003 -
Journal of Clinical Laboratory Analysis Mar 2019The objective of this study was to assess the effect of parathyroidectomy (PTX) treatment on prolonging overall survival (OS) as well as decreasing levels of intact...
Parathyroidectomy decreases serum intact parathyroid hormone and calcium levels and prolongs overall survival in elderly hemodialysis patients with severe secondary hyperparathyroidism.
BACKGROUND
The objective of this study was to assess the effect of parathyroidectomy (PTX) treatment on prolonging overall survival (OS) as well as decreasing levels of intact parathyroid hormone (iPTH), calcium (Ca), and phosphorus (P) in elderly hemodialysis patients with severe secondary hyperparathyroidism (SHPT).
METHODS
A total of 304 elderly hemodialysis patients with severe SHPT were consecutively enrolled in this cohort study. According to whether PTX operations were applied, patients were classified into PTX group (N = 112) and Control group (N = 192) and were followed up for 3 years. Mortality rate and OS were evaluated, and iPTH, Ca, and P levels were recorded.
RESULTS
Compared to control group, increased iPTH (P < 0.001), higher Ca (P = 0.003), elevated AST (P = 0.022), and lower Hb (P = 0.049) concentrations were observed in the PTX group at baseline. The 1-year mortality (P < 0.001), 2-year mortality (P < 0.001), and 3-year mortality (P < 0.001) was reduced in PTX group compared to Control group, and PTX was correlated with prolonged OS (P < 0.001). Multivariate Cox's regression analysis further revealed that PTX treatment (P < 0.001, HR = 0.177) was an independent factor for better OS. Moreover, patients in PTX group had decreased iPTH (P < 0.05) and Ca (P < 0.05) levels compared to Control group at M1-M36, while no difference was found in serum P level between the two groups at M1-M36.
CONCLUSION
Parathyroidectomy decreases iPTH and Ca levels, and it associates with favorable survival in elderly hemodialysis patients with severe SHPT.
Topics: Aged; Calcium; Female; Humans; Hyperparathyroidism, Secondary; Male; Middle Aged; Parathyroid Hormone; Parathyroidectomy; Prospective Studies; Renal Dialysis
PubMed: 30485538
DOI: 10.1002/jcla.22696 -
Multimedia Manual of Cardiothoracic... Dec 2020Mediastinal ectopic parathyroid glands are uncommon. Traditionally, median sternotomies were performed to treat this type of lesion, resulting in a long, painful...
Mediastinal ectopic parathyroid glands are uncommon. Traditionally, median sternotomies were performed to treat this type of lesion, resulting in a long, painful postoperative period and poor aesthetic results. With the advent of video-assisted thoracoscopic surgery, procedures were performed more frequently by this route with the same surgical and oncological results as those achieved with conventional surgery. The introduction of more sophisticated imaging studies, such as computed tomography, computed tomography-technetium-99m sestamibi scintigraphy, and single-photon emission computed tomography, facilitated identification of the exact location of the lesion. Video-assisted thoracoscopy became a safe approach and the treatment of choice for resection.
Topics: Aged; Female; Humans; Hyperparathyroidism, Primary; Parathyroid Glands; Parathyroidectomy; Thoracic Surgery, Video-Assisted; Tomography, Emission-Computed, Single-Photon
PubMed: 33645929
DOI: 10.1510/mmcts.2020.071 -
Transplantation Dec 2021Secondary hyperparathyroidism (SHPT) affects nearly all patients on maintenance dialysis therapy. SHPT treatment options have considerably evolved over the past 2...
BACKGROUND
Secondary hyperparathyroidism (SHPT) affects nearly all patients on maintenance dialysis therapy. SHPT treatment options have considerably evolved over the past 2 decades but vary in degree of improvement in SHPT. Therefore, we hypothesize that the risks of adverse outcomes after kidney transplantation (KT) may differ by SHPT treatment.
METHODS
Using the Scientific Registry of Transplant Recipients and Medicare claims data, we identified 5094 adults (age ≥18 y) treated with cinacalcet or parathyroidectomy for SHPT before receiving KT between 2007 and 2016. We quantified the association between SHPT treatment and delayed graft function and acute rejection using adjusted logistic models and tertiary hyperparathyroidism (THPT), graft failure, and death using adjusted Cox proportional hazards; we tested whether these associations differed by patient characteristics.
RESULTS
Of 5094 KT recipients who were treated for SHPT while on dialysis, 228 (4.5%) underwent parathyroidectomy, and 4866 (95.5%) received cinacalcet. There was no association between treatment of SHPT and posttransplant delayed graft function, graft failure, or death. However, compared with patients treated with cinacalcet, those treated with parathyroidectomy had a lower risk of developing THPT (adjusted hazard ratio, 0.56; 95% confidence interval, 0.35-0.89) post-KT. Furthermore, this risk differed by dialysis vintage (Pinteraction = 0.039). Among patients on maintenance dialysis therapy for ≥3 y before KT (n = 3477, 68.3%), the risk of developing THPT was lower when treated with parathyroidectomy (adjusted hazard ratio, 0.43; 95% confidence interval, 0.24-0.79).
CONCLUSIONS
Parathyroidectomy should be considered as treatment for SHPT, especially in KT candidates on maintenance dialysis for ≥3 y. Additionally, patients treated with cinacalcet for SHPT should undergo close surveillance for development of tertiary hyperparathyroidism post-KT.
Topics: Adult; Aged; Cinacalcet; Humans; Hyperparathyroidism, Secondary; Kidney Failure, Chronic; Medicare; Parathyroidectomy; Renal Dialysis; United States
PubMed: 33534525
DOI: 10.1097/TP.0000000000003653 -
Asian Journal of Surgery Jul 2018Primary hyperparathyroidism (PHPT) can occur at any age. This study aimed to compare the necessity, feasibility, safety, and outcomes of parathyroidectomy in the...
BACKGROUND
Primary hyperparathyroidism (PHPT) can occur at any age. This study aimed to compare the necessity, feasibility, safety, and outcomes of parathyroidectomy in the management of minor-symptomatic or asymptomatic PHPT patients according to age (young vs. old).
METHODS
We retrospectively reviewed the medical records of 146 consecutive patients who underwent surgery for PHPT from January 2005 to June 2016 in our institution. The patients ranged in age from 12 to 85 years. For the analysis, the included patients (n = 137) were separated into young (age <50 years; n = 31, 22.6%) and old (age ≥50 years; n = 106, 77.4%) patients. The biochemical characteristics (parathyroid hormone, calcium, and creatinine levels), T-score of bone densitometry, surgical reports, pathology reports, perioperative intensive care unit care, and 30-day mortality were reviewed.
RESULTS
The average medical treatment course after diagnosis tended to be longer in the old group (33.3 vs. 26.2 weeks, p = 0.62). During the medical treatment course, the old group had a higher risk of developing new symptoms or severe complications (5.6% vs. 3.2%, p = 0.05), and the older patients seemed to have a longer postoperative hospitalization (p = 0.17). However, there were no significant differences in the 30-day mortality, immediate complications, and follow-up duration.
CONCLUSION
In older patients, surgical treatment of PHPT is safe and feasible, with comparable outcomes to in younger patients, and helps prevent the development or progression of symptoms and complication. Hence, parathyroidectomy should be the recommended treatment and should be performed in PHPT patients as early as possible, regardless their age and initial symptoms.
Topics: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Child; Female; Follow-Up Studies; Humans; Hyperparathyroidism, Primary; Male; Middle Aged; Parathyroidectomy; Retrospective Studies; Treatment Outcome; Young Adult
PubMed: 28689731
DOI: 10.1016/j.asjsur.2017.05.001 -
Renal Failure Dec 2022Chronic kidney disease (CKD) is a global public health problem. With the deterioration of renal function, a certain proportion of CKD patients enter the uremic stage,...
BACKGROUND
Chronic kidney disease (CKD) is a global public health problem. With the deterioration of renal function, a certain proportion of CKD patients enter the uremic stage, and secondary hyperparathyroidism (SHPT) becomes a challenge. For refractory hyperparathyroidism, parathyroidectomy (PTX) plays a key role in reducing mortality and improving prognosis. Nevertheless, no consensus has been reached on the optimal surgical method. We aimed to provide evidence for the effectiveness of surgical treatment by summarizing the experience from our center.
METHODS
Clinical data from 1500 patients undergoing parathyroidectomy were recorded, which included 1419 patients in a total parathyroidectomy without autotransplantation (tPTX) group, 54 patients in a total parathyroidectomy plus autotransplantation (tPTX + AT) group, and 27 patients in the other group. Perioperative basic data, intact parathyroid hormone (i-PTH) levels, serum calcium levels, serum phosphorus levels, pathological reports, coexisting thyroid diseases, short-term outcomes and complications were analyzed. Moreover, postoperative complications were compared between the tPTX and tPTX + AT groups.
RESULTS
Parathyroid hormone, serum calcium and phosphorus levels decreased significantly post-surgery. Two patients died during the perioperative period. As the two most common complications, the incidences of severe hypocalcemia and hyperkalemia were 36.20% (543 cases) and 24.60% (369 cases), respectively. Pre-iPTH levels (OR = 1.001, 95% CI: 1.001-1.001, < 0.01), serum alkaline phosphatase (ALP) levels (OR = 1.002, 95% CI: 1.001-1.002, < 0.01) and the mass of excised parathyroid gland (OR = 3.06, 95% CI: 1.24-7.55, = 0.02) were positively associated with postoperative severe hypocalcemia, while age and serum calcium were negatively associated with it. Pathological reports of resected parathyroid and thyroid glands indicated that 96.49% had parathyroid nodular hyperplasia, 13.45% had thyroid nodular hyperplasia, and 4.08% had thyroid papillary carcinoma.
CONCLUSIONS
Parathyroidectomy is a safe and effective treatment for refractory secondary hyperparathyroidism. Severe hypocalcemia is the main complication, and coexistent thyroid diseases should never be neglected.
Topics: Adult; Calcium; China; Female; Humans; Hyperkalemia; Hyperparathyroidism, Secondary; Hypocalcemia; Logistic Models; Male; Middle Aged; Parathyroid Hormone; Parathyroidectomy; Phosphorus; Postoperative Complications; Renal Dialysis; Renal Insufficiency, Chronic; Retrospective Studies
PubMed: 35094636
DOI: 10.1080/0886022X.2021.2016445 -
BMJ Case Reports Dec 2018Calcific uremic arteriolopathy (CUA), widely known as calciphylaxis, is a rare and lethal disease that usually affects patients with end-stage renal disease. It is...
Calcific uremic arteriolopathy (CUA), widely known as calciphylaxis, is a rare and lethal disease that usually affects patients with end-stage renal disease. It is characterised by widespread vascular calcification leading to tissue ischaemia and necrosis and formation of characteristic skin lesions with black eschar. Treatment options include sodium thiosulfate, cinacalcet, phosphate binders and in resistant cases, parathyroidectomy. We report a case of recurrent, treatment-resistant CUA successfully treated with parathyroidectomy. Her postoperative course was complicated by hungry bone syndrome and worsening of her wounds before they completely healed. We then discuss the morbidity of CUA, including the controversy around the use of parathyroidectomy and risk of aggressive management of hungry bone syndrome.
Topics: Adult; Bone Diseases; Calciphylaxis; Female; Humans; Hypocalcemia; Parathyroidectomy; Postoperative Complications; Syndrome
PubMed: 30580300
DOI: 10.1136/bcr-2018-226696 -
JAMA Internal Medicine Jan 2022Primary hyperparathyroidism (PHPT) contributes to the development and progression of osteoporosis in older adults. The effectiveness of parathyroidectomy for reducing...
IMPORTANCE
Primary hyperparathyroidism (PHPT) contributes to the development and progression of osteoporosis in older adults. The effectiveness of parathyroidectomy for reducing fracture risk in older adults is unknown.
OBJECTIVE
To compare the incidence of clinical fracture among older adults with PHPT treated with parathyroidectomy vs nonoperative management.
DESIGN, SETTING, AND PARTICIPANTS
This was a population-based, longitudinal cohort study of all Medicare beneficiaries with PHPT from 2006 to 2017. Multivariable, inverse probability weighted Cox proportional hazards and Fine-Gray competing risk regression models were constructed to determine the association of parathyroidectomy vs nonoperative management with incident fracture. Data analysis was conducted from February 17, 2021, to September 14, 2021.
MAIN OUTCOMES AND MEASURES
The primary outcome was clinical fracture at any anatomic site not associated with major trauma during the follow-up period.
RESULTS
Among the 210 206 Medicare beneficiaries with PHPT (mean [SD] age, 75 [6.8] years; 165 637 [78.8%] women; 183 433 [87.3%] White individuals), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis, and 147 070 (70.0%) were managed nonoperatively. During a mean (SD) follow-up period of 58.5 (35.5) months, the unadjusted incidence of fracture was 10.2% in patients treated with parathyroidectomy. During a mean (SD) follow-up of 52.5 (33.8) months, the unadjusted incidence of fracture was 13.7% in patients observed nonoperatively. On multivariable analysis, parathyroidectomy was associated with lower adjusted rates of any fracture (hazard ratio [HR], 0.78; 95% CI, 0.76-0.80]) and hip fracture (HR, 0.76; 95% CI, 0.72-0.79). At 2, 5, and 10 years, parathyroidectomy was associated with adjusted absolute fracture risk reduction of 1.2% (95% CI, 1.0-1.4), 2.8% (95% CI, 2.5-3.1), and 5.1% (95% CI, 4.6-5.5), respectively, compared with nonoperative management. On subgroup analysis, there were no significant differences in the association of parathyroidectomy with fracture risk by age group, sex, frailty, history of osteoporosis, or meeting operative guidelines. Fine-Gray competing risk regression confirmed parathyroidectomy was associated with a lower probability of any fracture and hip fracture when accounting for the competing risk of death (HR, 0.84; 95% CI, 0.82-0.85; and HR, 0.83; 95% CI, 0.80-0.85, respectively).
CONCLUSIONS AND RELEVANCE
This longitudinal cohort study found that parathyroidectomy was associated with a lower risk of any fracture and hip fracture among older adults with PHPT, suggesting a clinically meaningful benefit of operative management in this population.
Topics: Aged; Antihypertensive Agents; Cohort Studies; Female; Humans; Hyperparathyroidism, Primary; Longitudinal Studies; Male; Middle Aged; Parathyroidectomy; Retrospective Studies; Risk Factors; Severity of Illness Index; Treatment Outcome; United States
PubMed: 34842909
DOI: 10.1001/jamainternmed.2021.6437 -
American Journal of Otolaryngology 2019To assess the utility of rapid parathyroid hormone (PTH) values in predicting transient post-operative hypocalcemia in patients with unplanned parathyroidectomy during...
OBJECTIVE
To assess the utility of rapid parathyroid hormone (PTH) values in predicting transient post-operative hypocalcemia in patients with unplanned parathyroidectomy during total or completion thyroidectomy.
METHODS
All patients who underwent total or completion thyroidectomy between January 2010 and January 2015 were reviewed. Incidences of post-operative hypocalcemia were compared in patients with and without unplanned parathyroidectomy. Unplanned parathyroidectomy was defined as intra-operative incidental or intentional parathyroidectomy. Logistic regression assessed for predictors of hypocalcemia and optimum amount of calcium supplementation.
RESULTS
Thirty-eight (13.6%) patients had evidence of incidental parathyroidectomy and 39/280 (13.9%) patients had parathyroid autotransplantation intra-operatively. Central neck dissection and malignancy were identified as risk factors for unplanned parathyroidectomy (p = 0.001, p = 0.060). Patients with unplanned parathyroidectomy were more likely to have hypocalcemia (p = 0.002) and hypoparathyroidism (p < 0.0005). PTH value was the only significant predictor of hypocalcemia in these patients. In patients with a post-operative PTH of ≤15, initial calcium supplementation ≥ 1000 mg decreased the risk of hypocalcemia (p < 0.05).
CONCLUSION
Post-operative PTH value predicts hypocalcemia in patients undergoing total and completion thyroidectomy with unplanned parathyroidectomy. In patients with a post-operative PTH < 15, initial calcium supplementation with ≥1000 mg of elemental calcium is recommended.
Topics: Adult; Biomarkers; Calcium; Female; Humans; Hypocalcemia; Incidence; Male; Middle Aged; Parathyroid Hormone; Parathyroidectomy; Postoperative Complications; Predictive Value of Tests; Risk Factors; Thyroidectomy
PubMed: 31027850
DOI: 10.1016/j.amjoto.2019.04.006