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The American Surgeon Jul 2020
Topics: Biomarkers; Calcium; Costs and Cost Analysis; Diagnosis, Differential; Diagnostic Errors; Humans; Hyperparathyroidism; Hyperparathyroidism, Primary; Parathyroid Glands; Parathyroid Hormone; Parathyroidectomy; Radiopharmaceuticals; Technetium; Ultrasonography
PubMed: 32916068
DOI: 10.1177/0003134820940731 -
The Surgeon : Journal of the Royal... Aug 2022National Institute of Clinical Excellence (NICE) recommend against routinely using Intra-Operative Parathyroid Hormone (IOPTH) for first-time parathyroid surgery due to...
BACKGROUND
National Institute of Clinical Excellence (NICE) recommend against routinely using Intra-Operative Parathyroid Hormone (IOPTH) for first-time parathyroid surgery due to its cost and minimal surgical benefit. The European Society of Endocrine Surgeons differ from this and recommends IOPTH with conflicting pre-operative or single imaging. NICE guidance acknowledged that this may change practice in larger centres. We devised a retrospective single-centre cohort study to analyse the impact of IOPTH on decision-making and cost-effectiveness.
METHODOLOGY
First-time parathyroidectomy procedures for primary hyperparathyroidism were assessed between 2017 and 2019. Ultrasound (US) and Sestamibi with parathyroid single-photon emission with computed tomography (SPECT-CT) were compared with IOPTH. The contribution of IOPTH to cure and cost effectiveness ratio was calculated.
RESULTS
114 cases were included, with IOPTH performed in all cases, SPECT-CT in 112 and US in 108 cases. A cure rate of 99.1% (113/114) was achieved. 11.4% (13/114) of the cure rate was influenced by IOPTH (P 0.01), instigating further exploration when its levels didn't decrease. This included 7.1% (4/56) in the concordant-imaging cohort. IOPTH accuracy (96.5%) was significantly superior (P = 0.03) to both US (80%) and SPECT-CT (81%). Comparing the total costs for IOPTH testing over 2 years (£39,721) with 13 potential re-operative procedures in its absence (£63,536), a positive cost-effectiveness ratio of £1832 per re-operative procedure averted was achieved.
CONCLUSION
Abandoning IOPTH in first-time parathyroid surgery is too ambitious when weighing the cost of re-operative surgery against cost savings obtained by using routine IOPTH to achieve an improved cure rate, even in concordant imaging.
Topics: Clinical Decision-Making; Cost-Benefit Analysis; Humans; Hyperparathyroidism, Primary; Minimally Invasive Surgical Procedures; Parathyroid Hormone; Parathyroidectomy; Practice Guidelines as Topic; Retrospective Studies; Single Photon Emission Computed Tomography Computed Tomography
PubMed: 34090811
DOI: 10.1016/j.surge.2021.04.008 -
Hemodialysis International.... Apr 2023Data on the incidence rates of hungry bone syndrome after parathyroidectomy in patients on dialysis are inconsistent, as the published rates vary from 15.8% to 92.9%.
INTRODUCTION
Data on the incidence rates of hungry bone syndrome after parathyroidectomy in patients on dialysis are inconsistent, as the published rates vary from 15.8% to 92.9%.
METHODS
Between 2009 and 2019, 120 hemodialysis patients underwent parathyroidectomy for secondary hyperparathyroidism at the Chang Gung Memorial Hospital. The patients were stratified into two groups based on the presence (n = 100) or absence (n = 20) of hungry bone syndrome after parathyroidectomy.
FINDINGS
Subtotal parathyroidectomy was the most common surgery performed (76.7%), followed by total parathyroidectomy with autoimplantation (23.3%). Pathological examination revealed parathyroid hyperplasia. Hungry bone syndrome developed within 0.3 ± 0.3 months and lasted for 11.1 ± 14.7 months. After surgery, compared with patients without hungry bone syndrome, patients with hungry bone syndrome had lower levels of nadir corrected calcium (P < 0.001), as well as lower nadir (P < 0.001) and peak (P < 0.001) intact parathyroid hormone levels. During 59.3 ± 44.0 months of follow-up, persistence and recurrence of hyperparathyroidism occurred in 25 (20.8%) and 30 (25.0%) patients, respectively. Furthermore, patients with hungry bone syndrome had a lower rate of persistent hyperparathyroidism than those without hungry bone syndrome (P < 0.001). Four patients (3.3%) underwent a second parathyroidectomy. Patients with hungry bone syndrome received fewer second parathyroidectomies than those without hungry bone syndrome (P < 0.001). Finally, a multivariate logistic regression model revealed that the preoperative blood ferritin level was a negative predictor of the development of hungry bone syndrome (P = 0.038).
DISCUSSION
Hungry bone syndrome is common (83.3%) after parathyroidectomy for secondary hyperparathyroidism in patients undergoing hemodialysis, and this complication should be monitored and managed appropriately.
Topics: Humans; Renal Dialysis; Hypocalcemia; Hyperparathyroidism, Secondary; Calcium; Parathyroidectomy; Parathyroid Hormone; Retrospective Studies
PubMed: 36719854
DOI: 10.1111/hdi.13067 -
Therapeutische Umschau. Revue... Nov 2020Primary hyperparathyroidism Primary hyperparathyroidism is a common endocrine disease that comes along with a disruption of the calcium homeostasis and is accompanied...
Primary hyperparathyroidism Primary hyperparathyroidism is a common endocrine disease that comes along with a disruption of the calcium homeostasis and is accompanied by a variety of downstream disorders. These are often overlooked as patients present with a multitude of unspecific symptoms or may even be asymptomatic. The diagnosis of primary hyperparathyroidism can be made with the determination of calcium and parathyroid hormone levels, including the measurement of calcium in the 24-hours urine. The operation is the only therapy to cure primary hyperparathyroidism. To successfully conduct focused parathyroidectomy an accompanying visual imaging methodology is of great value and improves the operation success rate. Furthermore, an intraoperative parathyroid hormone monitoring is applied. A bilateral neck exploration technique is applicable in selected cases. The endocrine surgical expertise is pivotal in particular for re-operations, hereditary primary hyperparathyroidism and carcinomas. If surgery is not possible, a medication-based therapy is applied. This medical therapy requests a continuous therapy progress monitoring. In conclusion, to treat primary hyperparathyroidism an interdisciplinary team approach with endocrinologists and endocrine surgeons shows the best results.
Topics: Humans; Hyperparathyroidism, Primary; Monitoring, Intraoperative; Parathyroid Hormone; Parathyroidectomy; Reoperation
PubMed: 33146098
DOI: 10.1024/0040-5930/a001215 -
Langenbeck's Archives of Surgery Dec 2019In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the... (Review)
Review
BACKGROUND/PURPOSE
In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe.
METHODS
A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate.
RESULTS
For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs.
CONCLUSIONS
Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.
Topics: Adrenalectomy; Career Choice; Clinical Competence; Education, Medical, Graduate; Endocrine Surgical Procedures; Europe; Female; Humans; Internship and Residency; Male; Parathyroidectomy; Surveys and Questionnaires; Thyroidectomy
PubMed: 31701231
DOI: 10.1007/s00423-019-01828-4 -
Journal of Laparoendoscopic & Advanced... Jan 2021It has been reported that the incidence of recurrent laryngeal nerve (RLN) injury is higher in an operational procedure in the thyroid and parathyroid region. Elevating... (Review)
Review
It has been reported that the incidence of recurrent laryngeal nerve (RLN) injury is higher in an operational procedure in the thyroid and parathyroid region. Elevating voice pitch is achieved by the cricothyroid contraction, which in turn is innervated by the external branch of the superior laryngeal nerve (EBSLN). Due to the subtle nature and clinical variability of EBSLN damage, diagnosis may be difficult. The use of intraoperative neuromonitoring (IONM) as a supplement to enhance surgical identification in thyroid and parathyroid operation appeared to have collected momentum with operators. IONM clinical usage rationale, efficiency, and safety profile are discussed in this overview in thyroid and parathyroid surgery. IONM usage incurred numerous skepticisms in decreasing the frequency of EBSLN or RLN injury. However, a recent article has shown the efficacy and benefits of using IONM in thyroid and parathyroid procedures. IONM facilitates the recognition of RLN and EBSLN, verifies its functional integrity, localizes the site of a nerve injury, and gives postsurgical function feedback. This technique has been successful in reducing rates of bilateral laryngeal paralysis, with the elevated safety profile for surgical patients. It is recommended using IONM in all thyroidectomies and in high-risk parathyroidectomies.
Topics: Humans; Intraoperative Complications; Intraoperative Neurophysiological Monitoring; Outcome Assessment, Health Care; Parathyroidectomy; Recurrent Laryngeal Nerve Injuries; Thyroidectomy
PubMed: 32614658
DOI: 10.1089/lap.2020.0293 -
FP Essentials Mar 2022Parathyroid hormone (PTH) helps regulate calcium homeostasis in a complex relationship with the gastrointestinal tract, kidneys, bone, and parathyroid glands....
Parathyroid hormone (PTH) helps regulate calcium homeostasis in a complex relationship with the gastrointestinal tract, kidneys, bone, and parathyroid glands. Abnormalities in PTH production can result in many conditions, including hypoparathyroidism, and primary, secondary, and tertiary hyperparathyroidism. Management of each abnormality centers on maintaining normal or near-normal serum calcium values to prevent complications. Most cases of hypoparathyroidism are caused by neck surgery and may result in acute hypocalcemia. Patients with chronic hypoparathyroidism are treated with a combination of calcium, vitamin D analogs, and, occasionally, exogenous PTH. A single parathyroid adenoma causes most cases of primary hyperparathyroidism, with multiglandular disease and cancer as other possible etiologies. All patients with symptomatic primary hyperparathyroidism and many with asymptomatic hyperparathyroidism undergo partial or full parathyroidectomy to correct the underlying condition. Chronic kidney disease-mineral and bone disorder (CKD-MBD) is the most common cause of secondary and tertiary hyperparathyroidism, in which hypocalcemia stimulates PTH production. Most patients with CKD-MBD are treated medically with phosphate binders, vitamin D analogs, and calcimimetics, but rare cases are managed with parathyroidectomy. Severe calcium or vitamin D deficiency also causes secondary hyperparathyroidism and is managed with calcium and vitamin D replacement.
Topics: Calcium; Humans; Hyperparathyroidism, Secondary; Parathyroid Glands; Parathyroid Hormone; Parathyroidectomy; Thyroid Gland; Vitamin D
PubMed: 35235284
DOI: No ID Found -
Journal of Robotic Surgery Dec 2020Minimal invasive techniques in endocrine surgery were lately adopted by surgical teams due to significant complications related to inadequate operative space and high... (Review)
Review
Minimal invasive techniques in endocrine surgery were lately adopted by surgical teams due to significant complications related to inadequate operative space and high risk of injuring crucial surrounding structures, such as vessels and nerves. Over the last years, technological improvements introduced robotic systems and approaches in endocrine surgery. Several case reports and series have described the safety and efficacy of these procedures such as robotic thyroidectomy and robotic parathyroidectomy. In the current review, we included 15 studies which described robotic-assisted parathyroidectomy for cervical parathyroid adenoma, in patients diagnosed with primary hyperparathyroidism or secondary hyperparathyroidism. No significant negative short-term outcomes were observed, in terms of postoperative complications, such as temporary or permanent injury of RLN, postoperative hypoparathyroidism and blood loss. The cosmetic result was, definitely, superior in comparison to conventional open parathyroidectomy. Despite the fact that RAP is an effective and curative method for patients with PHPT or secondary hyperparathyroidism, there are no available randomized clinical trials to establish this modern procedure as a gold-standard treatment strategy for these patients.
Topics: Adenoma; Female; Humans; Hyperparathyroidism, Primary; Hyperparathyroidism, Secondary; Male; Parathyroid Neoplasms; Parathyroidectomy; Robotic Surgical Procedures; Treatment Outcome
PubMed: 32661866
DOI: 10.1007/s11701-020-01119-x -
Osteoporosis International : a Journal... Mar 2023The incidence of hip and major osteoporotic fracture was increased in patients with primary hyperparathyroidism even in patients not referred for parathyroidectomy. The...
UNLABELLED
The incidence of hip and major osteoporotic fracture was increased in patients with primary hyperparathyroidism even in patients not referred for parathyroidectomy. The risk of death was also increased which attenuated an effect on fracture probabilities. The findings argue for widening the indications for parathyroidectomy in mild primary hyperparathyroidism.
INTRODUCTION
Primary hyperparathyroidism (PHPT) is associated with an increase in the risk of fracture. In FRAX, the increase in risk is assumed to be mediated by low bone mineral density (BMD). However, the risk of death is also increased and its effect on fracture probability is not known.
OBJECTIVE
The aim of this study was to determine whether PHPT affects hip fracture and major osteoporotic fracture risk independently of bone mineral density (BMD) and whether this and any increase in mortality affects the assessment of fracture probability.
METHODS
A register-based survey of patients with PHPT and matched controls in Denmark were identified from hospital registers. The incidence of death, hip fracture, and major osteoporotic fracture were determined for computing fracture probabilities excluding time after parathyroidectomy. The gradient of risk for fracture for differences in BMD was determined in a subset of patients and in BMD controls. The severity of disease was based on serum calcium and parathyroid hormone levels.
RESULTS
We identified 6884 patients with biochemically confirmed PHPT and 68,665 matched population controls. On follow-up, excluding time after parathyroidectomy in those undergoing surgery, patients with PHPT had a higher risk of death (+52%), hip fracture (+48%), and major osteoporotic fracture (+36%) than population controls. At any given age, average 10-year probabilities of fracture were higher in patients with PHPT than population controls. The gradient of fracture risk with differences in BMD was similar in cases and controls. Results were similar when confined to patients not undergoing parathyroidectomy. Fracture probability decreased with the severity of disease due to an increase in mortality rather than fracture risk.
CONCLUSION
The risk of hip and other major osteoporotic fracture is increased in PHPT irrespective of the disease severity. Fracture probability was attenuated due to the competing effect of mortality. The increased fracture risk in patients treated conservatively argues for widening the indications for parathyroidectomy in mild PHPT.
Topics: Humans; Hyperparathyroidism, Primary; Osteoporotic Fractures; Bone Density; Hip Fractures; Parathyroidectomy; Parathyroid Hormone; Probability
PubMed: 36525071
DOI: 10.1007/s00198-022-06629-y -
The American Surgeon May 2022Intraoperative parathyroid hormone (iPTH) testing is often used to confirm successful removal of hypersecreting parathyroid glands during parathyroidectomy....
BACKGROUND
Intraoperative parathyroid hormone (iPTH) testing is often used to confirm successful removal of hypersecreting parathyroid glands during parathyroidectomy. Unfortunately, the iPTH test can be a time-consuming and highly variable process that occurs while the patient is under anesthesia. We set out to improve iPTH lab efficiency and variability.
METHODS
We performed a retrospective review of 85 patients who underwent parathyroidectomy at our institution from October 2017 to October 2019. Each step of the iPTH lab reporting process was recorded and analyzed. Three simulations were performed of the entire process. We then established interventions to modify inefficiencies in the process and studied 21 patients who underwent parathyroidectomy at our institution from November 2019 to March 2020.
RESULTS
Twenty-five minutes of time inherent to the process were identified. Four critical steps were identified as modifiable steps in the process:1. Operating room (OR) blood draw ---> lab receipt.2. Lab receipt ---> placement on centrifuge.3. Removal from centrifuge ---> placement on PTH machine.4. PTH machine result ---> OR verbal report.We improved iPTH lab efficiency by 19%, decreasing the average lab result from 45 to 36 minutes ( = .001). We improved iPTH lab variability by 62%, decreasing the standard deviation from 21 to 8 minutes ( = .001).
DISCUSSION
Utilizing a team-based approach to identify and expedite critical steps in the iPTH lab process can make a significant improvement in iPTH lab efficiency, improving patient care by decreasing total anesthesia time.
Topics: Humans; Parathyroid Glands; Parathyroid Hormone; Parathyroidectomy; Retrospective Studies
PubMed: 34841912
DOI: 10.1177/00031348211054556