Effect analysis of different surgical methods for secondary hyperparathyroidism / 中国耳鼻咽喉头颈外科

OBJECTIVE To analyze and compare the clinical efficacy of subtotal-parathyroidectomy and totalparathyroidectomy with forearm autotransplantation in the treatment of hyperparathyroidism secondary to uremia. METHODS The clinical data of 31 cases of secondary hyperparathyroidism(SHPT) who were operated in Dalian Friendship Hospital from January 2012 to June 2018 were retrospectively analyzed. The cases were divided into two groups. Subtotal parathyroidectomy was performed in group one(20 cases) and total parathyroidectomy with forearm autotransplantation were performed in group two(11 cases). Preoperative, postoperative one week, 1 month, 3 months, 6 months of patients with the levels of blood calcium, blood phosphorus and blood iPTH, clinical symptom improvement degree and other data were analyzed. RESULTS Postoperative, the levels of blood calcium, blood phosphorus and blood iPTH all decreased significantly compared with that before operation, and the difference was statistically significant(P ＜0.05). There was no significant difference in preoperative and postoperative levels of blood calcium, blood phosphorus and blood iPTH at 6 months after surgery between the two groups(P ＞0.05). Postoperative bone pain, skin itching and restless leg syndrome were significantly reduced in both groups. There was no significant difference in symptom relief between the two groups(P ＞0.05). CONCLUSION Both of the surgical methods can effectively manage the hyperparathyroidism secondary to uremia, they have high surgical safety, there was no significant difference in the effects of serum calcium and phosphorus between the two groups, and the parathyroid hormone decreased more significantly in the parathyroid total excision and forearm autologous transplantation group in the short term. Both of them have the possibility of recurrence. The second operation in total parathyroidectomy and forearm autotransplantation group is simple and easy, which has certain advantages.

Therapeutic effect of subtotal parathyroidectomy for 72 uremic patients with secondary hyperparathyroidism / 中国现代普通外科进展

Objective:To retrospectively analyze the therapeutic effect of subtotal parathyroidectomy (sT-PTX) on uremic patients with secondary hyperparathyroidism (SHPT).Methods:Seventy two SHPT patients treated with sT-PTX in our hospital were enrolled in this study.Serum parathyroid hormone(PTH),calcium(Ca) and phosphorus(P) obtained in the preoperative,postoperative and followup periods were collected and compared.Their symptoms,postoperative complications and relapse were recorded.Results:(1)sT-PTX operation performed successfully in 70/72 patients(97.2％).(2)After sT-PTX,bone pain and itching improved rapidly,with the improvement of nutritional status,Partial patients with renal hypertension were remitted compared with preoperative.Thirteen cases can walk without wheelchair after sT-PTX.(3)Serum PTH,Ca,and P decreased significantly after sT-PTX for one week,one month and 6 months as compared with those before sT-PTX(P＜0.05).(4)Postoperative hypocalcemia was frequently seen(53/72,53.6％) but could be effectively controlled by intravenous calcium infusion.(5)SHPT recurred in the 6 months after sT-PTX in 4 cases (5.7％).Conclusions:T-PTX can effectively decrease PTH level and improve symptoms,and is a safe measure for the treatment of uremic patients with SHPT.

Effect of subtotal parathyroidectomy on secondary hyperparathyroidism in uremic patients / 中华内分泌外科杂志

Objective To study the clinical effect of subtotal parathyroidectomy on secondary hyperparathyroidism(SHPT) in uremic patients undergoing hemodialysis.Methods The data of 10 uremic patients undergoing hemodialysis who received subtotal parathyroidectomy from Jun.2006 to Jun.2011 in our hospital were retrospectively analyzed.Intact parathyroid hormone (iPTH),serum calcium,phosphorus and calcium-phosphorus product were analyzed statistically before operation,1 week,1 month,3 months,and 6 months after the operation.The joint pain relief and postoperative complications were studied.Results ①All of the 10 patients were successfully operated.No complication occurred.The intraoperative site of the parathyroid was consistent with that positioned by the preoperative B ultrasound guidance.②Postoperative bone pain and pruritus were obviously relieved.③iPTH decreased significantly at 1 week,1 month,3 months,6 months after surgery compared with that before surgery.The difference had statistical significance(P ＜ 0.05).④Postoperative serum calcium,serum phosphorus and calcium-phosphorus product decreased significantly at 1 week,1 month,3 months,6 months after surgery compared with that before surgery.The difference had statistical significance (P ＜ 0.05).Conclusions Preoperative localization for neck parathyroid by ultrasound scan is feasible.Subtotal parathyroidectomy can be effective in treatment of SHPT in uremic patients.The surgery were safe and with satisfactory treatment outcome.

Parathyroidectomy for refractory secondary hyperparathyroidism with severe bone disease / Journal of the ASEAN Federation of Endocrine Societies

Advances in the medical management of secondary hyperparathyroidism due to renal failure have decreased the use of parathyroidectomy as a treatment option. However, some patients with end-stage renal disease still progress to refractory hyperparathyroidism and debilitating bone disease, for which parathyroidectomy may be warranted. We describe a case of a 35-year-old female on chronic hemodialysis who presented with bone pains, deformities, decrease in height and recurrent pathologic fractures. She had markedly elevated parathyroid hormone (PTH), vitamin D deficiency, persistent hyperphosphatemia and hypocalcemia despite therapeutic measures. Subtotal parathyroidectomy was done with eventual improvement of biochemical abnormalities, resolution of bone pains and healing of fractures.

Primary hyperparathyroidism in multiple endocrine neoplasia type 1: when to perform surgery?

Primary hyperparathyroidism is a common endocrinological disorder. In rare circumstances, it is associated with familial syndromes, such as multiple endocrine neoplasia type 1. This syndrome is caused by a germline mutation in the multiple endocrine neoplasia type 1 gene encoding the tumor-suppressor protein menin. Usually, primary hyperparathyroidism is the initial clinical expression in carriers of multiple endocrine neoplasia type 1 mutations, occurring in more than 90% of patients and appearing at a young age (20-25 years). Multiple endocrine neoplasia type 1/primary hyperparathyroidism is generally accompanied by multiglandular disease, clinically manifesting with hypercalcemia, although it can remain asymptomatic for a long time and consequently not always be recognized early. Surgery is the recommended treatment. The goal of this short review is to discuss the timing of surgery in patients when primary hyperparathyroidism is associated with multiple endocrine neoplasia type 1.

Surgical approach in patients with hyperparathyroidism in multiple endocrine neoplasia type 1: total versus partial parathyroidectomy

Usually, primary hyperparathyroidism is the first endocrinopathy to be diagnosed in patients with multiple endocrine neoplasia type 1, and is also the most common one. The timing of the surgery and strategy in multiple endocrine neoplasia type 1/hyperparathyroidism are still under debate. The aims of surgery are to: 1) correct hypercalcemia, thus preventing persistent or recurrent hyperparathyroidism; 2) avoid persistent hypoparathyroidism; and 3) facilitate the surgical treatment of possible recurrences. Currently, two types of surgical approach are indicated: 1) subtotal parathyroidectomy with removal of at least 3-3 K glands; and 2) total parathyroidectomy with grafting of autologous parathyroid tissue. Transcervical thymectomy must be performed with both of these procedures. Unsuccessful surgical treatment of hyperparathyroidism is more frequently observed in multiple endocrine neoplasia type 1 than in sporadic hyperparathyroidism. The recurrence rate is strongly influenced by: 1) the lack of a pre-operative multiple endocrine neoplasia type 1 diagnosis; 2) the surgeon's experience; 3) the timing of surgery; 4) the possibility of performing intra-operative confirmation (histologic examination, rapid parathyroid hormone assay) of the curative potential of the surgical procedure; and, 5) the surgical strategy. Persistent hyperparathyroidism seems to be more frequent after subtotal parathyroidectomy than after total parathyroidectomy with autologous graft of parathyroid tissue. Conversely, recurrent hyperparathyroidism has a similar frequency in the two surgical strategies. To plan further operations, it is very helpful to know all the available data about previous surgery and to undertake accurate identification of the site of recurrence.

Paratireoidectomia subtotal no tratamento do hiperparatireoidismo secundário à doença renal crônica / Subtotal parathyroidectomy in the treatment of secondary hyperparathyroidism to chronic renal disease

Objetivos: apresentar os resultados obtidos com a paratireoidectomia (PTX) subtotal em pacientes com hiperparatireoidismo (HPT) secundário àinsuficiência renal crônica (IRC), enfocando a contribuição e as dificuldades técnicas da cirurgia. Pacientes e Métodos: no período de janeiro de 1998 ajunho de 2005 foram operados consecutivamente no Hospital Universitário Antonio Pedro, 33 pacientes renais crônicos portadores de HPT secundário. Ascirurgias foram realizadas pelo mesmo cirurgião e a mesma equipe de nefrologista se encarregou do controle pré e pós-operatório. Esse grupo foiconstituído por 19 homens e 14 mulheres com idade média de 40,5 (16/68) anos e todos se encontravam em tratamento dialítico regular, com tempo médiode diálise de 113 (20/189) meses. Além dos cuidados habituais, todos os pacientes receberam calcitriol após as três últimas sessões de diálise queantecederam a cirurgia. Resultados: os resultados mais expressivos se refletiram sobre o aparelho músculo-esquelético e foram muito significativas as remissões das queixas de dor ósteo-articular, fraqueza e prurido; as calcificações não vasculares foram reabsorvidas e sinais de remineralização ósseaforam identificados após a cirurgia. As complicações pós-operatórias mais freqüentes foram a rouquidão transitória (21%), a hiperpotassemia (12%) e osangramento pós-operatório (12%). Nesse grupo há uma recidiva comprovada e já reoperada e dois pacientes encontram-se em fase de investigação, por provável insucesso na cirurgia, já que o PTH continua elevado. Os resultados menos favoráveis foram mais freqüentes nos casos onde foram encontradas apenas três glândulas paratireóides. Não houve mortalidade operatória. Conclusões: a PTX subtotal pode ser realizada com segurança e é efetiva para a remissão de diversas manifestações do HPT secundário, desde que continuem sob rigoroso controle clínico para evitar possíveis recidivas por hiperplasia do resíduo glandular.

Objective: to report the results obtained with subtotal parathyroidectomy (PTX) in patients with hyperparathyroidism (HPT) secondary to chronic renaldisease (CRD), focusing on the contribution and technical difficulties of the surgery. Methods: From January of 1998 to June of 2005, thirty-three end-stagerenal disease (ESRD) patients consecutively underwent PTX in the university hospital. Their mean age was 40.5 years; Nineteen were male, and 14 female.Mean time on dialysis was 113 months. Surgeries were accomplished by the same surgeon and the same nephrologist was in charge of the pre- andpostoperative care of the whole patients. Among the clinical manifestations those related to the osteopathy were the most prevalent ones. All patientsunderwent preoperative care and received calcitriol after the last three dialysis sessions that preceded the surgery. Results: the most expressiveimprovements pertained to the muscle-skeletal system. The alleviation of bone pain, joint pain, muscle weakness and itch were marked. Extra-vascularcalcifications were reabsorbed and radiological signs of bone remineralization were identified after the surgery. The most frequent postoperativecomplications were temporary hoarseness (21%), hyperkalemia (12%), and postoperative bleeding (12%). So far, we have faced one proven recurrencethat was managed by a surgical reintervention. In addition, PTH continues to be high in two patients who are undergoing prepare for a new surgery. Bad results seemed to be more frequent on patients in which only three parathyroid glands were found during the operation. Surgery was not associated to fatalities. Conclusions: subtotal PTX can be accomplished with safety in ESRD patients being effective for the alleviation of several manifestations of the secondary HPT. Patients should be maintained under strict clinical control to monitor for recurrences due to hyperplasia of the residual glandular tissue.

Supernumerary Parathyroid Gland

A 66-year old presented with hypercalcemia with a 6 month duration. She was a MEN-I patient with a pancreas islet cell tumor and a pituitary adenoma. The clinical examination revealed no mass lesion of the neck. The serum calcium was elevated. Parathyroid scintigraphy showed a high uptake of 4 parathyroid glands that were compatible with hyperparathyroidism. During the operation, five parathyroid glands were identified, two at the right side and three at the left. All five glands were found to have hyperplasia by the pathologist. She underwent subtotal parathyroidectomy. She was discharged on the 8th post operative day and has been followed up without any evidence of recurrence for 36 months.

The Experience of Surgical Management for Parathyroid Hyperplasia / 대한내분비외과학회지

Parathyroid hyperplasia is a pathologic finding that can be found in hyperparathyroidism. Unlike parathyroid adenoma, treatment of parathyroid hyperplasia is still quite controversial. In addition, the relative merits of two alternative surgical approaches-subtotal parathyroidectomy versus total parathyroidectomy with autotransplantation have not been clearyly elucidated. The records of 10 patients who had parathyroid hyperplaisa and who underwent parathyroid surgery at the Department of Surgery, Hanyang University Hospital, between April 1992 and April 2003 were retrospectively reviewed. The 10 patients were comprised of 3 males and 7 females. The age distribution was between 29 and 73 years. The presenting clinical manifestations were associated with bone pain in 8 patients, muscle weakness in 4, headache in 4, gastrointestinal symptoms in 3, renal symptoms in 3 and psychologic symptoms in 2. The serum parathyroid hormone level was elevated in all patients. The serum alkaline phosphatase level was elevated in seven among the ten patients. Histopathologic findings revealed chief cell hyperplasia in all patients. Postoperative transient hypocalcemia occurred in 5 patients and they were supplied with oral calcium and calcitriol for several months. There were no major complications. The results indicate that a subtotal parathyroidectomy can be performed without mortality or morbidity and provides good control of primary parathyroid hyperplasia, A total prathyroidectomy with autotransplantation can be performed without mortality or morbidity and provides good contril of secondary and tertiary parathyroid hyperplaisa.

2 Cases of Surgical Experience of Secondary Hyperparathyroidism / 대한내분비외과학회지

Secondary hyperparathyroidism is the condition is which parathyroid hormone(PTH) is over secreted to compensate for a chronically low serum calcium level and chronic renal failure is the most common cause. In 1934, Albreight reported an association between hyperparathyroidism and the chronic renal failure and in 1960, Stanbury first reported subtotal parathyroidectomy for the treatment of secondary hyperparathyroidism. The physiologic mechanism leading to secondary hyperparathyroidism in the chronic renal failure are well known and relatively well controled with medical management, but sometimes may necessitate surgical intervention in medically intractable cases. In Korea, the surgery for secondry hyperparathyroidism is not frequently performed yet as in western countries. We experienced two cases of secondary hyperparathyroidism recently and report its results of subtotal parathyrodiectomy.

A Case of Tertiary Hyperparathyroidism Combined with Thyroid Papillary Carcinoma / 대한이식학회지

Secondary hyperparathyroidism is the condition which leads to excessive production of the parathyroid hormone secreted to compensate for longstanding hypocalcemia in chronic renal failure. After restoration of normal renal function, some patients continue to have autonomous parathyroid hyperfunction. In 1963 St. Goar termed it tertiary hyperparathyroidism. Hyperparathyroidism in the chronic renal failure is mostly well managed medically, but sometimes may require surgical intervention in refractory hyperparathyroidism. Recently, we have experienced a female patient diagnosed as tertiary hyperparathyroidism with persistent hypercalcemia after renal transplantation and report the results of subtotal parathyroidectomy and thyroid right lobectomy due to hyperparathyroidism and thyroid papillary carcinoma found coincidentally.