Do the National Institutes of Health consensus guidelines for parathyroidectomy predict symptom severity and surgical outcome in patients with primary hyperparathyroidism?

BACKGROUND: The National Institutes of Health (NIH) consensus guidelines for parathyroidectomy in primary hyperparathyroidism were developed addressing only the classic symptoms and physiologic markers of hyperparathyroidism. The purpose of this study was to assess whether NIH guidelines predict the severity of all symptoms and the outcome of operation. METHODS: Symptom severity measurements using a disease-specific outcome tool called the parathyroidectomy assessment of symptoms (PAS) scores were previously obtained in patients with hyperparathyroidism. Patients were retrospectively stratified into 2 groups: group A, in which 1 or more of the NIH guidelines were met; and group B. in which operation was performed without any of the NIH criteria. For comparison, group C consisted of patients with non-toxic thyroid disease. PAS scores were collected preoperatively, and at 7 days, 3 months, and 12 months postoperatively. RESULTS: There were 95 patients in group A, 22 in group B, and 58 in group C. The median preoperative PAS scores for group A (354) and B (301) were not significantly different, however, both were more symptomatic than group C (176, P <.01). After parathyroidectomy, patients in both group A and B had a significant improvement in their PAS scores (A=177 and B=130, P <.05). CONCLUSIONS: Patients with no NIH criteria for operation are equally symptomatic compared with those who meet the NIH guidelines. Parathyroidectomy significantly improved these symptoms whether or not the patient met the NIH consensus guidelines.     

The NIH criteria for parathyroidectomy in asymptomatic primary hyperparathyroidism: are they too limited?

OBJECTIVE: To determine whether preoperative and postoperative symptoms and outcome differ in patients who meet or fail to meet the NIH criteria for parathyroidectomy. SUMMARY BACKGROUND DATA: The NIH Consensus Conference on primary hyperparathyroidism in 1990 defined criteria for surgical intervention suggesting that some patients can be safely managed without surgery. METHODS: Over a 3-year period, 202 consecutive patients undergoing parathyroidectomy for primary hyperparathyroidism at a tertiary referral center were prospectively given a questionnaire regarding their symptoms and associated conditions during their initial and follow-up office visits as were 63 thyroid control patients. The 178 patients who completed the follow-up questionnaire were assigned to 2 groups according to the NIH criteria for parathyroidectomy. The frequency of preoperative symptoms and conditions associated with primary hyperparathyroidism as well as postoperative improvement in symptoms and surgical outcome were compared. RESULTS: Of the 178 parathyroid patients, 103 met the NIH criteria for parathyroidectomy whereas 75 did not. Patient profiles were similar in each group except mean ages, 55 versus 65, and preoperative serum calcium levels, 11.5 mg/dL versus 11.0 mg/dL (NIH and non-NIH groups, respectively; P < 0.001). The incidence of preoperative nonspecific somatic and neuropsychiatric symptoms and associated conditions was equivalent in both groups and more common than in the 63 thyroid control patients. After parathyroidectomy, symptomatic improvement was dramatic and equal between the 2 parathyroid groups. Postoperative mean serum calcium levels were similar (8.78 mg/dL, NIH group, versus 8.75 mg/dL, non-NIH group). CONCLUSION: Symptoms were more common in patients with primary hyperparathyroidism versus thyroid controls, but were not different between those patients who met the NIH criteria for parathyroidectomy and those who did not. Patients in both parathyroid groups benefited symptomatically after successful parathyroidectomy.     

Phenotypes of primary hyperparathyroidism: Does parathyroidectomy improve clinical outcomes for all?

BackgroundPrimary hyperparathyroidism consists of 3 biochemical phenotypes: classic, normocalcemic, and normohormonal primary hyperparathyroidism. The clinical outcomes of patients with normocalcemic primary hyperparathyroidism and normohormonal primary hyperparathyroidism are not well described.MethodA retrospective review of patients who underwent parathyroidectomy at a single institution was performed. A logistical regression analysis of postoperative nephrolithiasis and highest percentage change in dual-energy x-ray absorptiometry scan comparison using Kruskal-Wallis test and Cox proportional hazard analysis of recurrence-free survival were performed.ResultsA total of 421 patients were included (340 classic, 39 normocalcemic primary hyperparathyroidism, 42 normohormonal primary hyperparathyroidism). Median follow-up was 8.8 months (range 0–126). Higher rates of multigland disease were seen in normocalcemic primary hyperparathyroidism (64.1%) and normohormonal primary hyperparathyroidism (56.1%) compared to the classic (25.8%), P < .001. There were no differences in postoperative complications. The largest percentage increases in bone mineral density at the first postoperative dual-energy x-ray absorptiometry scan were higher for classic (mean ± SD, 6.4 ± 9.1) and normocalcemic primary hyperparathyroidism (4.8 ± 11.9) compared to normohormonal primary hyperparathyroidism, which remained stable (0.2 ± 14.2). Normocalcemic primary hyperparathyroidism were more likely to experience nephrolithiasis postoperatively, 6/13 (46.2%) compared to 11/68 (16.2%) classic, and 2/13 (15.4%) normohormonal primary hyperparathyroidism, P = .0429. Normocalcemic primary hyperparathyroidism was the only univariate predictor of postoperative nephrolithiasis recurrence (odds ratio [95% confidence interval] 4.44 [1.25–15.77], P = .029). Normocalcemic primary hyperparathyroidism was significantly associated with persistent disease with 6/32 (18.8%) compared to 1/36 (2.8%) and 3/252 (1.2%) in normohormonal primary hyperparathyroidism and classic (P < .001).ConclusionThree phenotypes of primary hyperparathyroidism are distinct clinical entities. Normocalcemic primary hyperparathyroidism had higher incidence of persistent disease and postoperative nephrolithiasis but demonstrated improvements in postoperative bone density. These data should inform preoperative discussions with patients with normocalcemic primary hyperparathyroidism and normohormonal primary hyperparathyroidism regarding postoperative expectations.     

Does the pre-operative serum phosphate level predict early hypocalcaemia following parathyroidectomy for primary hyperparathyroidism?

Background and objectivesHypocalcaemia is a significant post-operative complication following parathyroidectomy. Early identification of risk factors can help pre-empt hypocalcaemia and avoid serious sequelae. It can also help identify those patients that are not suitable for day-case surgery. The aim of this study was to analyse the predictive value of the pre-operative serum phosphate level as an indicator for developing hypocalcaemia post-operatively in patients undergoing parathyroidectomy for primary hyperparathyroidism.MethodsWe performed a retrospective review of all patients who underwent parathyroidectomy between 2008 and 2010 at the Southern General Hospital in Glasgow. Data collected included the number of parathyroid glands excised and their histology, pre-operative adjusted calcium (aCa) and phosphate levels, post-operative aCa at 6 and 24 h following surgery, and the fall in aCa levels in the first 6 h and 24 h following surgery. Minitab Statistical Analysis (Version 15) was used for data analysis.ResultsFifty-six patients underwent parathyroidectomy in the study period. Twelve patients were excluded for various reasons including incomplete records and secondary hyperparathyroidism. Patients given calcium or Vitamin D supplements immediately post-operatively were also excluded. Statistical analysis showed no significant correlation between the pre-operative phosphate level and the post-operative decline in aCa level 6 h or 24 h following surgery.ConclusionsPatients with a lower phosphate level pre-operatively were not at risk of a more drastic fall in calcium levels following parathyroidectomy. The pre-operative phosphate level was not found to be predictive of post-operative hypocalcaemia in our study.     

Surgery for patients with primary hyperparathyroidism and negative sestamibi scintigraphy—a feasibility study

Background  We report the surgical treatment of a consecutive series of scan negative patients with the intention of unilateral parathyroid exploration with the aid of intraoperative quick PTH (qPTH). Materials and methods  The study included 35 consecutive sestamibi scan negative patients (27 women, eight men) with sporadic pHPT subjected to first time surgery. Median age was 70 years and median preoperative calcium level 2.8 mmol/L. Results  Thirty-three patients had a histological diagnosis of a parathyroid adenoma (median weight 0.48 g [range 0.12 g–2.5 g]). Nineteen patients were explored bilaterally and 16 patients (46%) were operated unilaterally. The median operation time was 40 min in the unilateral group and 95 min in the bilateral group (p < 0.001). Three patients were treated for postoperative hypocalcemia after bilateral exploration versus none in the unilateral group (p = 0.23). With a minimum of 12 months of follow-up, 33 patients (94.3%) were cured. One case of recurrent HPT presented after bilateral exploration with visualization of four glands. One case of persistent HPT was observed after unilateral exploration. qPTH was predictive of operative failure in both patients. Conclusion  Forty-six percent of the patients in our study could be operated unilaterally with a total cure rate of 94%. Patients in the unilateral group had a significant shorter operation time and a lower incidence of postoperative hypocalcemia. In conclusion our investigation shows that limited parathyroid exploration can safely be performed on patients with negative sestamibi scintigraphy by the aid of qPTH. Best of Endocrine Surgery in Europe 2009     

Is total parathyroidectomy the treatment of choice for hyperparathyroidism in multiple endocrine neoplasia type 1?

OBJECTIVE: The aim of the present report is to describe the results obtained with total parathyroidectomy (TPTX) guided by rapid intraoperative parathyroid hormone (PTH) evaluation, followed by immediate parathyroid autograft with fresh tissue. SUMMARY BACKGROUND DATA: Surgery for hyperparathyroidism (HPT) in multiple endocrine neoplasia type 1 (MEN1) is performed with various surgical approaches. METHODS: We report our 16-year experience of surgical treatment of 51 MEN1-HPT patients using TPTX and thymectomy. Forty-five patients underwent TPTX as the first surgical procedure, whereas for 6 patients, a parathyroid operation was the second surgical procedure. PTH intraoperative values less than 10 pg/mL, at the end of the surgery, were indicative for reimplantation of a few fragments ( approximately 7) of fresh parathyroid tissue in the brachioradial muscle of the forearm. Parathyroid autograft was performed in all patients, except 3 in whom the fourth parathyroid gland was not found. RESULTS: Persistent hypoparathyroidism occurred in 13 patients (25%), with higher incidence in patients undergoing a second surgical revision for cervical recurrence than in patients submitted to the first surgery. At follow-up, 5 recurrences ( approximately 10%) in the forearm were observed after a mean time of 7 +/- 5 (M +/- SD) years. No cervical recurrence was documented. The forearm recurrence was treated with removal of 1 or 2 enlarged fragments obtaining the resolution of HPT in all but 1 case. CONCLUSIONS: Based on the occurrence of complications in our experience, TPTX followed by autograft and guided by intraoperative PTH monitoring represents a better surgical option in MEN1-HPT compared with other surgical approaches.     

Intraoperative parathyroid hormone measurement during parathyroidectomy for treatment of primary hyperparathyroidism: When should you end the operation?

IntroductionThe study objective was to evaluate the intraoperative 50% decrease in PTH level ± PTH normalization for its accuracy and efficiency in predicting cure during parathyroidectomy (PTx) for the treatment of primary hyperparathyroidism (PHP).MethodsA retrospective review of patients undergoing PTx was conducted. The timepoints at which the 50% PTH decrease was reached were recorded. The accuracy of intraoperative PTH for predicting cure, defined as normocalcemia at 6 months postoperatively, was evaluated.ResultsThe study population was made up of 248 PHP patients, with 247 patients achieving normocalcemia at 6 months postoperatively. If a 50% PTH decrease was used to indicate operation conclusion, 1 patient would not be cured. Persistent PTH elevation above normal range at T10 had a PPV of 77%, NPV of 99.5%, sensitivity of 95.2% and specificity of 97.3% for predicting the presence of a contralateral pathological parathyroid gland. For the study cohort, 24.5 h of cumulative operating time would be saved if the 50% PTH decrease triggered operation conclusion.DiscussionA decrease in the pre-excision PTH level to 50% of the baseline level, or a decrease in the higher of the baseline or pre-excision PTH levels by 50% at 5 or 10 min post pathological parathyroid gland removal, regardless of whether the PTH level normalizes, reliably predicts cure from PHP and should be used to guide the surgeon during parathyroidectomy.     

Do indomethacin and propofol cause cerebral ischemic damage? Diffusion-weighted magnetic resonance imaging in patients undergoing craniotomy for brain tumors

BACKGROUND: Diffusion-weighted magnetic resonance imaging was used to determine whether indomethacin and propofol induce cerebral ischemic damage in patients undergoing craniotomy for cerebral tumors. As a secondary aim, the authors investigated whether low jugular bulb oxygen saturation values were associated with brain parenchymal damage as evaluated by diffusion-weighted imaging. METHODS: Nine patients subjected to craniotomy for supratentorial brain tumors in propofol-fentanyl anesthesia were studied. Magnetic resonance imaging including diffusion- and perfusion-weighted and structural sequences were performed (1) on the day before surgery, (2) before and (3) 20 min after administration of indomethacin (bolus of 0.2 mg/kg followed by infusion of 0.2 mg.kg.h) in the propofol-fentanyl-anesthetized patient, and (4) 2 days after surgery. Apparent diffusion coefficient maps were calculated. Jugular bulb oxygen saturation, arteriovenous oxygen difference, mean arterial blood pressure, and arterial oxygen and carbon dioxide tensions were measured simultaneously with the magnetic resonance examinations performed during anesthesia. RESULTS: No ischemic lesions were detected in the diffusion-weighted or apparent diffusion coefficient images. A nonsignificant decrease in jugular bulb oxygen saturation from 51% (range, 40-61%) to 43% (range, 37-63%) and increase in arteriovenous oxygen difference from 4.4 mm (range, 2.7-4.6 mm) to 4.7 mm (range, 2.9-5.2 mm) was observed after indomethacin administration. CONCLUSION: Administration of indomethacin during propofol anesthesia is not associated with evidence of ischemic damage in patients with brain tumors, as evaluated by diffusion-weighted imaging.     

Do psoas muscle area and volume correlate with postoperative complications in patients undergoing rectal cancer resection?

Background

Increasingly, patients with multiple co-morbidities undergo surgery for rectal cancer. We aimed to evaluate if decreased psoas muscle area and volume, as measures for sarcopenia, were associated with postoperative morbidity.

Thyroid suppression in patients with primary hyperparathyroidism: does it improve the pre-surgical scintigraphy localisation?

Introduction

Scintigraphy with technetium-sestamibi (MIBI) is the test of choice for localising adenomas in patients with primary hyperparathyroidism (PHPT). In some studies it has emerged that the increase in sensitivity of this test could be associated with a decrease in the uptake of the radiotracer by the thyroid gland. The aim of this study is to analyse our experience in patients with a negative scintigraphy with MIBI, and in whom the study was repeated after suppression of thyroid function with thyroxine.

Material and methods

A prospective evaluation was performed on 17 patients who, between January 2006 and April 2011, had PHPT and negative imaging using scintigraphy with MIBI and who had the test repeated after the administration of thyroxine. The scintigraphy data and the correlation with the findings in the surgical intervention are reviewed.

Results

The mean TSH at the time of repeating the MIBI was 0.12 + 0.1 mlU/L. Of the 17 patients included, the scintigraphy under thyroid suppression was positive in 13 of them (76.5%), and in the other 4 (23.5%) patients no image suggestive of adenoma was found. In the cases where the MIBI was positive after suppression, the positive predictive value (PPV) was 100%.

Conclusion

Suppression of thyroid function by giving thyroxine can help to improve the sensitivity of MIBI in patients with previously negative scintigraphy studies and help in the minimally invasive treatment of patients with PHPT.     

What is the link between nonlocalizing sestamibi scans, multigland disease, and persistent hypercalcemia? A study of 401 consecutive patients undergoing parathyroidectomy

BACKGROUND: We hypothesized that nonlocalizing sestamibi scans would correlate with multigland disease and persistent primary hyperparathyroidism. METHODS: We reviewed records for 401 consecutive patients who underwent parathyroidectomy from 1999 to 2004. Gender, age, preoperative imaging, surgical findings, gland weight and volume, and 6-month calcium levels (Ca) were examined. RESULTS: We identified 289 women and 112 men, 297 of whom had a preoperative sestamibi scan localized to a single gland (localized group; LG). Ninety-six percent of the LG were found to have single-gland disease, and 4% had multigland disease (MGD). In the nonlocalized group (NLG), 76% had single-gland disease and 24% MGD. Mean gland weight was greater in the LG than in the NLG (1128 mg vs 699 mg; P < .05). Mean gland volume was larger in the LG (1.34 cc vs 0.89 cc; P < .05). A localizing sestamibi scan had a positive predictive value (PPV) of 96% and a likelihood ratio of 2.29 for predicting "curative" intraoperative parathyroid hormone drop after removal of a single abnormal gland. Patients were stratified into normocalcemic (NCa) and hypercalcemic (HCa) groups based on 6-month postoperative serum calcium data (n = 328). HCa incidence at 6 months did not differ significantly between the LG (5%) and NLG (3%). A localizing scan had a PPV of 95% for normocalcemia at 6 months. A nonlocalizing scan had a PPV of 21% for HCa at 6 months. CONCLUSIONS: Nonlocalizing sestamibi scans were more common in primary hyperparathyroidism with MGD and were associated with smaller-volume abnormal glands found at operation. Preoperative sestamibi scan-results did not predict HCa at 6 months.