-
Medicina (Kaunas, Lithuania) Aug 2023: Surgical treatment for primary hyperparathyroidism (PHPT) has evolved from bilateral exploration through a long transcervical incision to focused parathyroidectomy...
: Surgical treatment for primary hyperparathyroidism (PHPT) has evolved from bilateral exploration through a long transcervical incision to focused parathyroidectomy with a minimal incision above the pathologic gland. Recently, endoscopic or robot-assisted parathyroid surgery without direct neck incision has been introduced. The aim of this study was to investigate the effectiveness of indocyanine green (ICG) fluorescence as a new method for the visual identification of abnormal hyperfunctioning parathyroid glands in robot-assisted parathyroidectomy using Firefly technology. We also aimed to conduct a comparative analysis between robot-assisted parathyroidectomy and conventional focused parathyroidectomy in order to identify clinical differences between the two surgical approaches. : A total of 37 patients with PHPT underwent parathyroidectomy at a single university hospital between September 2018 and December 2022. Thirty-one patients underwent open focused parathyroidectomy (open group), and six patients underwent robot-assisted parathyroidectomy (robot group). Pre-operative localization via parathyroid SPECT-CT and an intraoperative parathyroid hormone (IOPTH) assay were used to successfully remove the pathologic parathyroid in both groups. ICG was administered only in the robot group. : Pathologic parathyroid showed a persistent fluorescence pattern under near-infrared vision. After the removal of the fluorescent parathyroid gland, IOPTH was normalized in all six patients in the robot group. However, the open group showed shorter hospital stays (1.8 ± 1.2 vs. 3.0 ± 0.0 days, < 0.001) and shorter operation times (91.1 ± 69.1 vs. 152.5 ± 23.6 min, = 0.001) than the robot group. After 6 months of surgery, PTH, calcium, and ionized calcium levels were all normalized without significant differences between the groups. : Robot-assisted parathyroidectomy using ICG is helpful for the visual identification of the pathologic parathyroid gland. The advantage of robot parathyroidectomy is a better cosmetic outcome. However, it still does not show better clinical outcomes than conventional open focused parathyroidectomy.
Topics: Humans; Parathyroidectomy; Indocyanine Green; Robotics; Calcium; Fluorescence; Hyperparathyroidism, Primary; Parathyroid Hormone
PubMed: 37629746
DOI: 10.3390/medicina59081456 -
JAMA Surgery Oct 2023Intraoperative identification of tissues through gross inspection during thyroid and parathyroid surgery is challenging yet essential for preserving healthy tissue and...
IMPORTANCE
Intraoperative identification of tissues through gross inspection during thyroid and parathyroid surgery is challenging yet essential for preserving healthy tissue and improving outcomes for patients.
OBJECTIVE
To evaluate the performance and clinical applicability of the MasSpec Pen (MSPen) technology for discriminating thyroid, parathyroid, and lymph node tissues intraoperatively.
DESIGN, SETTING, AND PARTICIPANTS
In this diagnostic/prognostic study, the MSPen was used to analyze 184 fresh-frozen thyroid, parathyroid, and lymph node tissues in the laboratory and translated to the operating room to enable in vivo and ex vivo tissue analysis by endocrine surgeons in 102 patients undergoing thyroidectomy and parathyroidectomy procedures. This diagnostic study was conducted between August 2017 and March 2020. Fresh-frozen tissues were analyzed in a laboratory. Clinical analyses occurred in an operating room at an academic medical center. Of the analyses performed on 184 fresh-frozen tissues, 131 were included based on sufficient signal and postanalysis pathologic diagnosis. From clinical tests, 102 patients undergoing surgery were included. A total of 1015 intraoperative analyses were performed, with 269 analyses subject to statistical classification. Statistical classifiers for discriminating thyroid, parathyroid, and lymph node tissues were generated using training sets comprising both laboratory and intraoperative data and evaluated on an independent test set of intraoperative data. Data were analyzed from July to December 2022.
MAIN OUTCOMES AND MEASURES
Accuracy for each tissue type was measured for classification models discriminating thyroid, parathyroid, and lymph node tissues using MSPen data compared to gross analysis and final pathology results.
RESULTS
Of the 102 patients in the intraoperative study, 80 were female (78%) and the median (IQR) age was 52 (42-66) years. For discriminating thyroid and parathyroid tissues, an overall accuracy, defined as agreement with pathology, of 92.4% (95% CI, 87.7-95.4) was achieved using MSPen data, with 82.6% (95% CI, 76.5-87.4) accuracy achieved for the independent test set. For distinguishing thyroid from lymph node and parathyroid from lymph node, overall training set accuracies of 97.5% (95% CI, 92.8-99.1) and 96.1% (95% CI, 91.2-98.3), respectively, were achieved.
CONCLUSIONS AND RELEVANCE
In this study, the MSPen showed high performance for discriminating thyroid, parathyroid, and lymph node tissues intraoperatively, suggesting this technology may be useful for providing near real-time feedback on tissue type to aid in surgical decision-making.
Topics: Humans; Female; Middle Aged; Aged; Male; Parathyroid Glands; Thyroid Gland; Parathyroidectomy; Thyroidectomy; Prognosis
PubMed: 37531134
DOI: 10.1001/jamasurg.2023.3229 -
American Journal of Otolaryngology 2023Parathyroid carcinoma is rarely encountered in clinical practice. When faced with this clinical challenge, there is currently a paucity of evidence available for the... (Review)
Review
OBJECTIVE
Parathyroid carcinoma is rarely encountered in clinical practice. When faced with this clinical challenge, there is currently a paucity of evidence available for the optimal management of patients with parathyroid carcinoma. This systematic review synthesizes the available literature to evaluate the optimal management approach, thus providing guidance for future management.
METHODS
A systematic review was conducted according to PRISMA guidelines using Ovid MEDLINE, EMBASE, and PubMed databases for studies, published in English, reporting on parathyroid carcinoma. Full text of potentially eligible articles were reviewed by two authors independently and eligible studies selected. Treatment options and associated outcomes were evaluated. Descriptive statistics were used to describe pooled patient cohorts.
RESULTS
3203 articles were initially identified using the search criteria with 59 full-text articles then screened for eligibility. Seven articles, all retrospective studies, concerning 2307 patients (median 224/study). Parathyroidectomy alone was the most frequently utilised surgical approach across all studies, followed by en-bloc resection (with adjacent thyroid and/or nodal tissue). There was no difference in post-operative morbidity, mortality or survival between surgical approaches (p < 0.005). Patients who underwent either form of surgery had longer overall survival than those managed non-operatively (p < 0.005).
CONCLUSION
Surgical resection is the optimal treatment of parathyroid carcinoma. However there remains no consensus on the optimal extent of surgery, and as such future randomised prospective studies are necessary to evaluate the effects of different surgical approaches on morbidity, mortality and oncologic outcomes. Following resection, long-term surveillance with PTH is advised.
Topics: Humans; Parathyroid Neoplasms; Prospective Studies; Retrospective Studies
PubMed: 36989753
DOI: 10.1016/j.amjoto.2023.103843 -
Clinical Endocrinology Sep 2023The use of parathyroid lesion aspiration in preoperative adenoma localisation is controversial. Concerns have been raised regarding both immediate safety (hematoma,... (Review)
Review
OBJECTIVE
The use of parathyroid lesion aspiration in preoperative adenoma localisation is controversial. Concerns have been raised regarding both immediate safety (hematoma, infection, alterations on a subsequent histologic preparate) and long-term safety (seeding). We aimed to evaluate the short- and long-term safety, and the efficacy, of parathyroid fine-needle aspiration with parathyroid hormone washout as a localisation modality of parathyroid adenoma in patients with primary hyperparathyroidism.
DESIGN
A retrospective study.
PATIENTS
The sample comprised 29 patients with primary hyperparathyroidism who underwent minimally invasive parathyroidectomy at a tertiary referral centre, following localisation with parathyroid hormone washout.
MEASUREMENTS
We reviewed all parathyroid hormone washout procedures performed during 2011-2021. Clinical, biochemical, and imaging information; and cytology, surgery, and pathology reports were extracted from electronic medical records.
RESULTS
Parathyroid hormone levels from the needle wash were 2.1-112.5 times the upper limit of the serum norm. Other than mild neck discomfort, no immediate procedure complications were documented. Fibrotic changes and necrosis were reported in two patients, with no effect on the final pathologic diagnosis or surgery course. No long-term complications (seeding, or parathyromatosis) were found. A total of 26 (90%) patients who were operated following a positive parathyroid hormone washout result were normocalcemic at the end of a mean 38.1-month follow-up period.
CONCLUSIONS
Parathyroid fine-needle aspiration with parathyroid hormone washout was accurate. Immediate, surgical, or delayed complications were not demonstrated in our series. This approach might be considered for selected patients.
Topics: Humans; Parathyroid Neoplasms; Parathyroid Hormone; Retrospective Studies; Hyperparathyroidism, Primary; Biopsy, Fine-Needle; Parathyroidectomy; Technetium Tc 99m Sestamibi
PubMed: 37287384
DOI: 10.1111/cen.14939 -
American Journal of Surgery Nov 2023Racial disparities in care exist for diseases with heterogeneous treatment guidelines. The impact of these disparities on outcomes after parathyroidectomy for...
BACKGROUND
Racial disparities in care exist for diseases with heterogeneous treatment guidelines. The impact of these disparities on outcomes after parathyroidectomy for secondary(2HPT) and tertiary hyperparathyroidism(3HPT) was explored.
METHODS
The 2015-2019 NSQIP datasets were used. Patients who underwent parathyroidectomy for 2HPT and 3HPT were identified and analyzed separately. Patients were stratified by race (white vs. non-white); demographics, comorbidities, and outcomes were compared. Studied outcomes included 30-day morbidity, mortality, unplanned reoperation, readmission, and postoperative length of stay(LOS).
RESULTS
There were 1,150 patients with 2HPT and 262 with 3HPT. For 2HPT, 65.5% were non-white; morbidity, reoperation, and prolonged LOS(>3days) occurred disproportionately more often in non-white patients. Non-white race was independently associated with morbidity; higher ASA class and alkaline phosphatase levels were associated with prolonged LOS. For 3HPT, 53.1% were non-white; a prolonged LOS(>1day) occurred disproportionately more often in non-white patients. Higher alkaline phosphatase levels were independently associated with prolonged LOS.
CONCLUSION
Race and markers of advanced disease negatively impact outcomes after parathyroidectomy for 2HPT and 3HPT. Attention to racial disparities and earlier referral may positively impact outcomes.
Topics: Humans; Parathyroidectomy; Alkaline Phosphatase; Hyperparathyroidism; Morbidity; Reoperation; Hyperparathyroidism, Secondary; Retrospective Studies
PubMed: 37453804
DOI: 10.1016/j.amjsurg.2023.07.013 -
Nephrology, Dialysis, Transplantation :... Jul 2023This trial aimed to evaluate oral cinacalcet versus total parathyroidectomy (PTx) with forearm autografting on cardiovascular surrogate outcomes and health-related... (Randomized Controlled Trial)
Randomized Controlled Trial
Parathyroidectomy versus oral cinacalcet on cardiovascular parameters in peritoneal dialysis patients with advanced secondary hyperparathyroidism (PROCEED): a randomized trial.
BACKGROUND
This trial aimed to evaluate oral cinacalcet versus total parathyroidectomy (PTx) with forearm autografting on cardiovascular surrogate outcomes and health-related quality of life (HRQOL) measures in dialysis patients with advanced secondary hyperparathyroidism (SHPT).
DESIGN
In this pilot prospective randomized trial conducted in two university-affiliated hospitals, 65 adult peritoneal dialysis patients with advanced SHPT were randomized to receive either oral cinacalcet or PTx. Primary endpoints were changes in left ventricular (LV) mass index by cardiac magnetic resonance imaging and coronary artery calcium scores (CACS) over 12 months. Secondary endpoints included changes in heart valves calcium scores, aortic stiffness, biochemical parameters of chronic kidney disease-mineral bone disease (CKD-MBD) and HRQOL measures over 12 months.
RESULTS
Changes in LV mass index, CACS, heart valves calcium score, aortic pulse wave velocity and HRQOL did not differ between groups or within groups, despite significant reductions in plasma calcium, phosphorus and intact parathyroid hormone in both groups. Cinacalcet-treated patients experienced more cardiovascular-related hospitalizations than those who underwent PTx (P = .008) but the difference became insignificant after adjusting for baseline difference in heart failure (P = .43). With the same monitoring frequency, cinacalcet-treated patients had fewer hospitalizations due to hypercalcemia (1.8%) than patients who underwent PTx (16.7%) (P = .005). No significant changes were observed in HRQOL measures in either group.
CONCLUSIONS
Both cinacalcet and PTx effectively improved various biochemical abnormalities of CKD-MBD and stabilized but did not reduce LV mass, coronary artery and heart valves calcification, or arterial stiffness, or improve patient-centered HRQOL measures in PD patients with advanced SHPT. Cinacalcet may be used in place of PTx for treating advanced SHPT. Long-term and powered studies are required to evaluate PTx versus cinacalcet on hard cardiovascular outcomes in dialysis patients. Trial registration: ClinicalTrials.gov identifier: NCT01447368.
Topics: Adult; Humans; Chronic Kidney Disease-Mineral and Bone Disorder; Cinacalcet; Hyperparathyroidism, Secondary; Kidney Failure, Chronic; Parathyroidectomy; Peritoneal Dialysis; Prospective Studies; Quality of Life; Renal Dialysis; Renal Insufficiency, Chronic
PubMed: 36869794
DOI: 10.1093/ndt/gfad043 -
The Journal of Surgical Research Apr 2024Traditional parathyroid registries are labor-intensive and do not always capture long-term follow-up data. This study aimed to develop a patient-driven international... (Review)
Review
INTRODUCTION
Traditional parathyroid registries are labor-intensive and do not always capture long-term follow-up data. This study aimed to develop a patient-driven international parathyroid registry and leverage community connections to improve patient-centered care for hyperparathyroidism.
METHODS
An anonymous voluntary online survey was developed using Qualtrics and posted in an international patient and advocate-run social media group affiliated with over 11,700 members. The survey was developed from a literature review, expert opinion, and discussion with the social media group managers. It consists of seven sections: patient demographics, past medical history, preoperative symptoms, laboratory evaluation, preoperative imaging studies, operative findings, and operative outcomes.
RESULTS
From July 30, 2022, to October 1, 2022, 89 complete responses were received. Participants were from 12 countries, mostly (82.0%) from the United States across 31 states. Most participants were female (91.4%), White (96.7%) with a mean (±standard deviation) age of 58 ± 12 y. The most common preoperative symptoms were bone or joint pain (84.3%) and neuropsychiatric symptoms: including fatigue (82.0%), brain fog (79.8%), memory loss (79.8%), and difficulty with concentration (75.3%). The median (interquartile range) length from symptom onset to diagnosis was 40.0 (6.8-100.5) mo. Seventy-one percent of participants had elevated preoperative serum calcium, and 73.2% had elevated preoperative parathyroid hormone. All participants obtained preoperative imaging studies (88.4% ultrasound, 86.0% sestabimi scan, and 45.3% computed tomography). Among them, 48.8% of participants received two, and 34.9% had three imaging studies. The median (interquartile range) time from diagnosis to surgical intervention was 3 (2-9) mo. Twenty-two percent of participants traveled to different cities for surgical intervention. Forty-seven percent of participants underwent outpatient parathyroidectomy. Eighty-four percent of participants reported improved symptoms after parathyroidectomy, 12.4% required oral calcium supplementation for more than 6 mo, 32.6% experienced transient hoarseness after parathyroidectomy, and 14.6% required reoperation after initial parathyroidectomy.
CONCLUSIONS
This international online parathyroid registry provides a valuable collection of patient-entered clinical outcomes. The high number of responses over 10 wk demonstrates that participants were willing to be involved in research on their disease. The creation of this registry allows global participation and is feasible for future studies in hyperparathyroidism.
Topics: Humans; Female; Male; Calcium; Feasibility Studies; Parathyroid Hormone; Parathyroid Glands; Hyperparathyroidism; Parathyroidectomy; Hypercalcemia; Tomography, X-Ray Computed; Registries; Retrospective Studies
PubMed: 38286100
DOI: 10.1016/j.jss.2024.01.004 -
Chirurgie (Heidelberg, Germany) Jul 2023Renal hyperparathyroidism results from pathophysiologic changes induced and maintained by terminal renal failure. Surgical treatment is possible using various resection... (Review)
Review
BACKGROUND
Renal hyperparathyroidism results from pathophysiologic changes induced and maintained by terminal renal failure. Surgical treatment is possible using various resection strategies.
AIM OF THE WORK (RESEARCH QUESTION)
The aim of this work is to illustrate the indications, techniques and resection strategies for surgical treatment of renal hyperparathyroidism.
MATERIAL AND METHODS
National and international guidelines regarding the surgical treatment of renal hyperparathyroidism were analyzed. Furthermore, our own practical experience was integrated into the article.
RESULTS
While the indications for surgery according to the Surgical Working Group Endocrinology (CAEK) guidelines are given in cases of clinical impairment and renal hyperparathyroidism that cannot be controlled by medication, international guidelines additionally refer to the absolute parathyroid hormone level for deciding for surgery.
DISCUSSION
Individual patient consultation is necessary in the case of renal hyperparathyroidism in order to determine the right time for surgical treatment as well as the most suitable surgical technique, taking into account the individual risk profile and other therapeutic perspectives, including renal transplantation.
Topics: Humans; Hyperparathyroidism, Secondary; Parathyroid Glands; Parathyroid Hormone; Kidney Failure, Chronic; Parathyroidectomy
PubMed: 37140660
DOI: 10.1007/s00104-023-01878-x -
Langenbeck's Archives of Surgery Oct 2023Transient hypoparathyroidism is the most common complication after total thyroidectomy, and accidental parathyroidectomy (AP) may be a cause. The aim of this study was...
PURPOSE
Transient hypoparathyroidism is the most common complication after total thyroidectomy, and accidental parathyroidectomy (AP) may be a cause. The aim of this study was to investigate the incidence of AP and its impact on postoperative calcemia.
MATERIALS AND METHODS
From February 2016 to May 2018, 766 patients undergoing total thyroidectomy were prospectively included. Surgical indications, hormonal status, definitive histology, and postoperative calcium and PTH levels were analyzed.
RESULTS
578/(75.45%) were women and 188/(24.55%) men with mean age of 53.4 years. Parathyroid tissue on the thyroid specimen was observed in 40 (5.2%) patients: 30 APs and 10 parathyroid fragments. Among the 30 APs, 12 glands were intrathyroid and 18 (2.3%) in eutopic location. 97 (12.6%) patients were treated for postoperative hypocalcemia: 90 (11.7%) had transient and 5 (0.6%) definitive hypoparathyroidism; 2 were lost in follow-up. 13/30 (43.3%) with AP had transient hypoparathyroidism. A strong correlation was found (p < 0.0001) between AP and postoperative hypocalcemia. 1/30 (3.3%) patient with APs had definitive hypoparathyroidism. Transient and persistent nerve palsies were found in 10 (1.3%) and 3 (0.4%) patients, respectively.
DISCUSSION
A careful examination of the thyroid gland after resection help to identify an AP that could be autotransplanted. Surgeon and hospital activity volume per years seem to reduce the risk of hypoparathyroidism.
CONCLUSION
Total thyroidectomy and intrathyroid localization of parathyroid glands are risk factors for the AP. The incidence of AP was 2.3%, and this remains low due to our longstanding experience in thyroid and parathyroid surgery.
Topics: Male; Humans; Female; Middle Aged; Parathyroidectomy; Thyroidectomy; Hypocalcemia; Incidence; Hypoparathyroidism; Parathyroid Glands; Postoperative Complications; Parathyroid Hormone
PubMed: 37817055
DOI: 10.1007/s00423-023-03130-w -
European Journal of Endocrinology Jul 2023Limited evidence supports kidney dysfunction as an indication for parathyroidectomy in asymptomatic primary hyperparathyroidism (PHPT).
IMPORTANCE
Limited evidence supports kidney dysfunction as an indication for parathyroidectomy in asymptomatic primary hyperparathyroidism (PHPT).
OBJECTIVE
To investigate the natural history of kidney function in PHPT and whether parathyroidectomy alters renal outcomes.
DESIGN
Matched control study.
SETTING
A vertically integrated health care system serving 4.6 million patients in Southern California.
PARTICIPANTS
6058 subjects with PHPT and 16 388 matched controls, studied from 2000 to 2016.
EXPOSURES
Biochemically confirmed PHPT with varying serum calcium levels.
MAIN OUTCOMES
Estimated glomerular filtration rate (eGFR) trajectories were compared over 10 years, with cases subdivided by severity of hypercalcemia: serum calcium 2.62-2.74 mmol/L (10.5-11 mg/dL), 2.75-2.87 (11.1-11.5), 2.88-2.99 (11.6-12), and >2.99 (>12). Interrupted time series analysis was conducted among propensity-score-matched PHPT patients with and without parathyroidectomy to compare eGFR trajectories postoperatively.
RESULTS
Modest rates of eGFR decline were observed in PHPT patients with serum calcium 2.62-2.74 mmol/L (−1.0 mL/min/1.73 m2/year) and 2.75-2.87 mmol/L (−1.1 mL/min/1.73 m2/year), comprising 56% and 28% of cases, respectively. Compared with the control rate of −1.0 mL/min/1.73 m2/year, accelerated rates of eGFR decline were observed in patients with serum calcium 2.88-2.99 mmol/L (−1.5 mL/min/1.73 m2/year, P < .001) and >2.99 mmol/L (−2.1 mL/min/1.73 m2/year, P < .001), comprising 9% and 7% of cases, respectively. In the propensity score–matched population, patients with serum calcium >2.87 mmol/L exhibited mitigation of eGFR decline after parathyroidectomy (−2.0 [95% CI: −2.6 to −1.5] to −0.9 [95% CI: −1.5 to 0.4] mL/min/1.73 m2/year).
CONCLUSIONS AND RELEVANCE
Compared with matched controls, accelerated eGFR decline was observed in the minority of PHPT patients with serum calcium >2.87 mmol/L (11.5 mg/dL). Parathyroidectomy was associated with mitigation of eGFR decline in patients with serum calcium >2.87 mmol/L.
Topics: Humans; Hyperparathyroidism, Primary; Calcium; Parathyroidectomy; Kidney; Hypercalcemia; Parathyroid Hormone
PubMed: 37449311
DOI: 10.1093/ejendo/lvad081