Total parathyroidectomy with autotransplantation in secondary hyperparathyroidism

Five patients with chronic renal failure were undergone total parathyroidectomy and immediate autotransplantation into the muscle of the forearm. All patients had relief of symptoms and restoration of PTH levels to normal. This technique of parathyroid transplantation offers the surgeon versatility in managing patients with hyperparathyroidism.     

Total parathyroidectomy versus total parathyroidectomy with autotransplantation for secondary hyperparathyroidism: systematic review and meta-analysis

Background: Total parathyroidectomy (tPTX) and total parathyroidectomy with autotransplantation (tPTX?+?AT) are effective and inexpensive treatments for secondary hyperparathyroidism (sHPT), but we do not know which one is the optimal approach. Therefore, we undertook a meta-analysis to compare the safety and efficacy of these two surgical procedures.

Methodology: Studies published in English on PubMed, Embase and the Cochrane Library from inception to 27 September 2016 were searched systematically. Eligible studies comparing tPTX with tPTX?+?AT for sHPT were included and Review Manager v5.3 was used.

Results: Eleven studies were included in this meta-analysis. Ten cohort studies and one randomized controlled trial (RCT) involving 1108 patients with sHPT were identified. There was no significant difference in the prevalence of surgical complications (relative risk [RR], 1.71; 95% confidence interval [CI], 0.77–3.79; p?=?.19), all-cause mortality (RR, 0.68; 95% CI, 0.33–1.39; p?=?.29), sHPT persistence (RR, 3.81; 95% CI, 0.56–25.95; p?=?.17) or symptomatic improvement (RR, 1.02; 95% CI, 0.91–1.13; p?=?.79). tPTX could reduce the risk of sHPT recurrence (RR, 0.19; 95% CI, 0.09–0.41; p?p?=?.01) compared with tPTX?+?AT. Simultaneously, tPTX increased the risk of hypoparathyroidism (RR, 2.63; 95% CI, 1.06–6.51; p?=?.04).

Conclusions: We found tPTX and tPTX?+?AT to be useful methods for sHPT treatment. tPTX was superior for reducing the risk of sHPT recurrence and reoperation than tPTX?+?AT but, due to a lack of high statistical-power RCTs, comparative studies will be needed in the future.     

Subtotal parathyroidectomy versus total parathyroidectomy with autotransplantation for secondary hyperparathyroidism

A retrospective review of patients treated for secondary hyperparathyroidism by total parathyroidectomy with parathyroid autotransplantation (tPTX) and subtotal parathyroidectomy (sPTX) is presented. Ten patients underwent tPTX, and 22 patients underwent sPTX between 1977 and 1982. Hypocalcemia and complications of its treatment were a problem in the tPTX patients. One patient in the tPTX group and no patients in the sPTX group have required reoperation for recurrence. Both procedures were highly successful in relieving symptoms of secondary hyperparathyroidism and in reversing renal osteodystrophy. The authors believe that sPTX is a proven, effective operation and the operative treatment of choice for secondary hyperparathyroidism.     

甲状旁腺全切＋自体移植术治疗继发性甲状旁腺功能亢进症疗效分析

目的探讨甲状旁腺全切＋自体移植术(tPTX＋AT)治疗维持性血液透析患者继发性甲状旁腺功能亢进症(SHPT)的有效性、安全性以及术后低钙的危险因素。 方法纳入我院2013年1月至2016年11月因SHPT行tPTX＋AT手术的维持性血液透析患者93例,收集术前术后症状、血钙、磷、碱性磷酸酶(ALP)、全段甲状旁腺激素(iPTH)、病理类型、并发症等临床资料。依据术后24 h血钙水平分为正常血钙组(Ca≥2.11 mmol/L)及低钙血症组(Ca<2.11 mmol/L),应用单因素分析及逐步Logistic回归分析术后早期低钙血症的危险因素。 结果手术成功率92.5%。切除360枚甲状旁腺腺体,异位甲状旁腺10枚。病理结果多为腺瘤样增生(96.4%)。同术前相比,术后血清iPTH、磷、ALP明显下降(P<0.05)。低钙血症是术后最常见并发症,发生率82.8%,血钙水平与术前血钙、年龄正相关(r＝0.300, P<0.01;r＝0.265, P<0.01),与术前iPTH、ALP水平负相关(r＝－0.461, P<0.01;r＝－0.477, P<0.01)。术前低血钙(OR＝0.113, P＝0.045)、高ALP水平(OR＝1.050, P<0.001)、高iPTH水平(OR＝1.002, P＝0.004)是术后早期低钙血症发生的独立危险因素。 结论tPTX＋AT可以安全、有效、快速的降低维持性血液透析患者血清iPTH水平,改善机体的钙磷代谢紊乱,但需重视并积极纠正术后低钙血症。针对存在术前低血钙、高iPTH及高ALP水平等高危因素的患者,术前积极纠正低钙血症可能是预防术后低钙的有效干预方式。     

Total parathyroidectomy with or without autoimplantion in the therapy of secondary hyperparathyroidism

BACKGROUND: Secondary hyperparathyroidism (HPTs) in patients with chronic renal failure is related to a reduction of absorption of calcium with hyperplasia of main cells and an increase of PTH levels: this often leads to complications in dialysis. METHODS: Data from 10 patients (mean age 55 years) with HPTs who underwent total parathyroidectomy from November 1999 to November 2001 were retrospectively collected. Surgical indications included: persistent hypercalcemia, bone fractures, fatigue, joint pain and itching. Median preoperative PTH level was 800 pg/ml. Presurgical work-up included: serum PTH, calcium and alkaline phospha-tases. Thyroid ultrasound and scintigraphy, 99Tc sestamibi scintigraphy, CBM, FNB were also performed. In 5 patients 2 hours prior to the operation 2 MCu of sestamibi 99Tc had been injected. Patients underwent cervical exploration radioguided in 5 cases under general anesthesia. The operation consisted in the removal of all glands with subcutaneous forearm implant in 4 cases. PTH dosage at starting time of operation (time 0) was performed; it was repeated after the removal of each parathyroid gland and postoperatively on days 1 and 3 and then every month for 6 months. RESULTS: Twenty-four hours postoperatively 9 patients showed a great reduction of PTH levels with improved symptoms already on day 1 postoperative. In the patient with persistent HPT an autoimplant had been performed. CONCLUSIONS: Secondary HPT still shows unclear aspects. Parathyroidectomy determines an immediate improvement in symptoms. In all observed patients PTH was significantly reduced, serum calcium returned to normal and in any case hypoparathyroidism was detected.     

Total parathyroidectomy without autotransplantation after renal transplantation for tertiary hyperparathyroidism: long-term follow-up

Introduction  

Renal transplant patients are unique in that bone changes occur on a background of pre-existing chronic kidney disease-mineral bone disorder. In a few cases, there is overt hyperparathyroidism manifested by hypercalcaemia. Traditionally, if severe or persistent, this is treated by parathyroidectomy. At our unit, the default surgical operation is total parathyroidectomy without autotransplantation.     

甲状旁腺全切除加前臂自体移植术治疗肾性继发性甲状旁腺功能亢进的长期疗效

目的: 探究甲状旁腺全切除加前臂自体移植术（total parathyroidectomy with forearm autotransplantation, TPTX+AT）治疗肾性继发性甲状旁腺功能亢进（secondary hyperparathyroidism, SHPT）术后长期疗效。方法: 我院1999年1月至2017年11月行TPTX+AT的SHPT病人124例,分析术后症状改善和血钙、磷、全段甲状旁腺激素（intact parathyroid hormones, iPTH）水平变化,以及术后复发率、持续性甲状旁腺功能低下发生率、死亡率等。结果: 术后病人临床症状均明显改善。术后1个月病人血钙、磷、iPTH及碱性磷酸酶水平均较术前明显降低（均P<0.05）,基本可长期控制在正常水平。随访至2018年5月,10例（8.06%）复发,7例（5.64%）发生持续性甲状旁腺功能低下,19例（15.32%）死亡。结论: TPTX+AT治疗SHPT能长期有效地缓解症状,改善钙磷代谢。术后复发率与持续性甲状旁腺功能低下发生率、死亡率均在较低水平。     

Subtotal parathyroidectomy versus total parathyroidectomy and autotransplantation in secondary hyperparathyroidism: A randomized trial

In a randomized study subtotal parathyroidectomy (sPTX) was compared with total parathyroidectomy and autotransplantation of fresh tissue (PTX+AT) in 40 patients with severe secondary hyperparathyroidism (HPT). After surgery both groups were followed at 19±6 months (PTX +AT) and 19±7 months (sPTX) and at 43±9 months (PTX+AT) and 40±7 months (sPTX). There were 17 patients alive in each group at the time of the second follow-up. After sPTX, 2 patients required re-operation because of recurrent disease originating from the remaining parathyroid gland in the neck and another 2 patients were hypercalcemic at follow-up. After PTX + AT both serum calcium and alkaline phosphatase normalized significantly more often (p <0.03) than after sPTX. Re-operations were not required in this group. Radiological signs also improved significantly more after PTX+AT, as did clinical signs like pruritus (p < 0.005) and muscle weakness (p <0.04). These results and the fact that in recurrent disease a re-operation at the autograft in the forearm is simpler than a re-operation in the neck, lead to the recommendation that PTX+ AT should be considered as the method of choice in the surgical treatment of secondary HPT.

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Resumen En un estudio randomizado se compararon la paratiriodectomía subtotal (sPTX) con la paratiroidectomía total con autotrasplante de tejido fresco (PTX + AT) en 40 pacientes con hiperparatiroidismo secundario severo (HPT). Ambos grupos fueron valorados dos veces después de la cirugía; a los 19±6 meses (PTX + AT) y 19±7 meses (sPTX) y a los 43±9 meses (PTX + AT) y los 40±7 meses (s(PTX). Se encontraron 17 pacientes vivos en cada grupo en el momenta de la segunda valoración. Después de sPTX 2 pacientes requirieron reoperación por enfermedad recurrente originada en la glándula paratiroides remanente en el cuello y otros 2 aparecieron hipercalcémicos. Después de PTX + AT tanto el calcio sérico como la fosfatasa alcalina se normalizaron significativamente con mayor frecuencia (p<0.03) que después de sPTX; no se requirieron reoperaciones en este grupo. Los signos radiológicos también mejoraron significativamente con mayor frecuencia después de PTX + AT, tal como lo hicieron signos clínicos tales como prurito (p<0.005) y debilidad muscular (p<0.04). Estas resultados, junto con el hecho de que en la enfermedad recurrente una reoperación sobre el autoinjerto en el antebrazo es más simple que una operación en el cuello, da lugar a recommendar que la PTX + AT es el método de escogencia en el manejo quirÚrgico del sHPT.

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Résumé Dans une étude randomisée, la parathyroÏdectomie subtotale (sPTX) a été comparée à la parathyroÏdectomie totale avec autotransplantation (PTX + AT) chez 40 patients ayant une hyperparathyroÏdie secondaire sévère (HPT). Après l'operation, les deux groupes de patients one été revus deux fois: à 19 ± 6 et à 43 ± 9 mois pour le groupe PTX + AT, et à 19 ± 7 et à 40 ± 7 mois pour le groupe sPTX. Dix-sept patients étaient en vie dans chaque groupe à la deuxième visite de contrÔle. Après sPTX, deux patients ont du Être réopérés en raison de tissu parathyroÏden résiduel; deux autres patients sont restés hypercalémiques. Après PTX + AT, la calcémie et le taux de phosphatases alcalines se sont normalisés plus souvent(P < 0.03) qu'après sPTX. Aucune réopération n'a été nécessaire dans le group PTX + AT. De mÊme, les signes radiologiques, les signes cliniques tels le prurit (p<0.005) et la faiblesse musculaire (p< 0.04) se sont améliorés plus souvent de faÇon significative dans le groupe PTX + AT. Ces résultats et le fait que lors des récidives, une autogreffe à l'avant-bras est plus simple qu'une réexploration cervicale, nous amène à préconiser la PTX + AT comme méthode de choix dans le traitement chirurgical de l'HPT.

     

Subtotal parathyroidectomy versus total parathyroidectomy with autotransplantation in secondary hyperparathyroidism. A randomized study

In this randomised study subtotal parathyroidectomy (PTX) is being compared with total parathyroidectomy including autotransplantation (PTX + AT) in 40 patients with secondary hyperparathyroidism. Both groups were followed up twice, first 19 +/- 6 months (PTX + AT) respectively 19 +/- 7 months (subtotal PTX) and secondly 43 +/- 9 respectively 40 +/- 7 months after surgery. In each group there were 17 patients alive at the time of the second postoperative follow-up. In the meantime 2 patients with subtotal PTX required reoperation because of recurrences originating from the remaining parathyroid tissue, another 2 patients of this group were hypercalcaemic. After PTX + AT serum-calcium normalized significantly more often (p less than 0.03), a corresponding result was seen in alkaline phosphatase. Reoperation was not required in this group. Also radiological alterations reformed significantly more often after PTX + AT, so did clinical signs like pruritus (p less than 0.005) and muscular weakness (p less than 0.04). Considering these results and the fact that in case of recidive a reoperation of the autograft in the forearm is much easier to perform than a reoperation in the neck, PTX + AT is recommended as method of choice in surgical treatment of sHPT.     

Total parathyroidectomy with autotransplantation for a rare disease derived from uremic secondary hyperparathyroidism,the uremic leontiasis ossea

Summary

We described six uremic leontiasis ossea (ULO) patients who underwent total parathyroidectomy with autotransplantation. ULO demonstrated more a systemic disease than a simple craniofacial deformation. The surgery seemed an effective treatment to alleviate secondary hyperparathyroidism and to improve patients’ quality of life. ULO may have a high postoperative recurrence tendency.

Introduction

ULO is a rare disease derived from uremic secondary hyperparathyroidism (SHPT). Previous studies mostly focused on the craniofacial deformations. This study aims to investigate the systemic features of the disease and the surgical outcomes.

Methods

The present study retrospectively assessed six ULO patients who underwent total parathyroidectomy (TPTX) with autotransplantation (AT). Follow-up data were recorded. The follow-up status was considered as “effectiveness” if serum intact parathyroid hormone (iPTH) levels were <150 pg/mL in the first 3 days after surgery, or as “recurrence” if serum iPTH gradually increased >300 pg/mL during follow-up in patients whose status was initially considered as “effectiveness”.

Results

Craniofacial deformations, short stature, thoracocyllosis, spine malformations, osteodynia, and muscle weakness were observed in all patients. Abnormal pulmonary functions were observed in five patients. After surgery, one patient died from respiratory failure. Surgery was effective in the remaining five patients with relieved osteodynia and stopped craniofacial deformation. A mean follow-up of 7.6 (4 to 12) months was available. Three patients suffered from recurrence of hyperparathyroidism originating from autografts.

Conclusions

Our data suggests that ULO is not only a simple disease with craniofacial malformations but is a severe systemic disease leading to increased surgical risks. TPTX with AT seems an effective treatment to relieve SHPT and to improve quality of life. ULO may have a high postoperative recurrence tendency.     

Clinical study of total parathyroidectomy and autotransplantation for secondary hyperparathyroidism]

From April 1983 to September 1991 total parathyroidectomy (PTX) and parathyroid autotransplantation were carried out in 27 patients for secondary hyperparathyroidism. Of these patients, 13 were males and 14 were females. Their average age was 43 years old and their mean duration of dialysis was 126.4 months. As preoperative clinical symptoms, bone pain was observed in 19 cases, joint pain in 18, decrease of height in 7, pruritus in 3, muscle pain in 2, red eyes in 2 and others in 2. As roentgenographic findings, subperiosteal bone resorption and skull-salt and pepper were demonstrated in 26 cases, rugger jersey spine in 15, soft tissue calcification in 11, and pathological fractures in 4. Four parathyroid glands were removed in 23 cases, three glands in 4. Serum calcium level decreased remarkably within 24 hours after parathyroidectomy in all cases. The average total weight of parathyroid glands was 4.48 g. The preoperative diagnostic accuracy of echogram was 94% and that of CT scan was 90%. The clinical improvement after PTX was excellent in 12 cases and good in 11. The roentgenographic improvement of skull and/or finger bone more than one year after PTX was excellent in 11 cases and good in 11. Judging from histopathological findings of the bone, the clinical and roentgenographic improvement was observed better in the osteitis fibrosa group than in mild group. A significant correlation was found between the level of preoperative c-PTH and the weight of resected parathyroid glands. The level of preoperative ALP correlated with intact-PTH and was higher in the osteitis fibrosa group than in the mild group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Total parathyroidectomy versus subtotal parathyroidectomy in the treatment of tertiary hyperparathyroidism

The purposes of this study are to evaluate the merits of surgical treatment, including subtotal parathyroidectomy (SP) and total parathyroidectomy (TP), in patients with tertiary hyperparathyroidism (THPT) and compare the outcome of the two surgical options. Medical records of patients undergoing parathyroidectomy for THPT were retrospectively reviewed and long-term outcomes between the two groups were compared. Fourteen out of 488 renal transplantation recipients required parathyroidectomy for THPT during a 24-year follow-up period with a median follow-up of 35.5 [interquartile range (IQR), 19.3-133.3] months. All patients had hypercalcemia, whereas 13 had varying symptoms and one was asymptomatic. Median serum calcium level decreased from 12.4 (IQR, 11.9-12.6) mg/dL preoperatively to 8.9 (IQR, 8.1-9.4) mg/dL postoperatively (P = 0.001), whereas median intact parathyroid hormone (iPTH) dropped from a preoperative level of 340.5 (IQR, 247-540) pg/mL to 55.1 (IQR, 24.4-66.4) pg/mL after surgery (P = 0.018). Comparison between patients receiving TP and SP revealed no difference in incidence of recurrence or permanent complications, whereas the former had significantly lower calcium levels (P = 0.048) and higher phosphorus levels (P = 0.017) compared with the latter. Moreover, a significant reduction in calcium level was noted in TP group on long-term follow-up compared with their immediately postoperative level (8.1 vs 9.0 mg/dL, respectively, P < 0.05), whereas there was no significant decrease in SP group. We concluded that parathyroidectomy is efficient and safe in treating THPT. Because TP would increase the risk of hypocalcemia, a less radical procedure (SP) is preferred.     

Factors predictive of critical value of hypocalcemia after total parathyroidectomy without autotransplantation in patients with secondary hyperparathyroidism

Background: Severe hypocalcemia is the most dangerous complication occurring after total parathyroidectomy without autotransplantation (TPTX) for secondary hyperparathyroidism (SHPT). We aim to identify the prevalence and potential risk factors of very severe hypocalcemia in patients with SHPT undergoing TPTX.

Methods: From April 2012 to August 2015, 157 patients with SHPT undergoing TPTX were reviewed. The critical value of hypocalcemia (CVH) was postoperative serum Ca²⁺ levels of ≤1.5?mmol/L.

Results: Univariate analysis showed that patients in the CVH group were significantly younger than those in the non-CVH group. Sex ratio was significantly different between the two groups. The CVH group had significantly higher levels of preoperative PTH and ALP. Male sex and preoperative levels of PTH and ALP were significant independent risk factors by logistic regression analysis.

Conclusions: Male sex, preoperative PTH and ALP were significantly associated with CVH in patients with SHPT undergoing TPTX.     

Technique and problems of total parathyroidectomy with autotransplantation in secondary hyperparathyroidism]

Between 1982 and 1990, 20 patients with chronic renal failure underwent total para-thyroidectomies and autotransplantations as treatment for secondary hyperparathyroidism. Fourteen cases were cured of their symptoms and their serum PTH levels was restored to normal. Recurrent hyperparathyroidism developed in 6 cases. In 3 of the 6 cases, excision of parathyroid tissue from the forearm could easily be performed under local anesthesia. Of the other cases, 2 had five and one had six glands. Several localizing methods should be performed before operation, in order to overlook the parathyroid glands in different anatomic positions.     

腔镜下甲状旁腺全切加自体前臂移植术在继发性甲旁亢中的应用

目的:探讨腔镜下甲状旁腺全切术加自体前臂移植术在继发性甲旁亢中的临床应用价值。方法:2013年6月至2015年6月为收治的15例继发性甲状旁腺功能亢进患者行腔镜下甲状旁腺全切加自体前臂种植术,对其临床资料进行回顾性分析。结果:15例患者均完成腔镜手术,无一例中转开放手术。手术时间平均(95.4±20.7)min,术中出血量平均(15.7±6.3)ml,平均下床时间(1.2±0.6)d,术后平均住院(2.6±1.1)d。术后患者骨痛、瘙痒症状明显缓解,无一例发生术后出血、声音嘶哑、呛咳等并发症。1例患者术后发生手脚麻木,经补充钙制剂后症状缓解。随访中,1例患者于术后4个月甲状旁腺激素轻度升高,无其他不适症状,予以继续随访。结论:腔镜下甲状旁腺全切加自体前臂移植术具有患者创伤小、痛苦轻、康复快及美容效果好等优点,并可借助良好的照明、清晰的术野减少出血及神经损伤等并发症的发生,值得推广应用。     

Total parathyroidectomy improves survival of hemodialysis patients with secondary hyperparathyroidism

Background and aims: To compare the prognosis of chronic hemodialysis patients with or without parathyroidectomy. Methods: Among 158 chronic hemodialysis patients who underwent total parathyroidectomy between July 1998 and April 2009, 88 patients were matched with 88 controls for sex, age, underlying disease and prior dialysis history. Then a retrospective evaluation of their prognosis was performed over a median observation period of 4.41 years. Results: The overall survival rate was 90.4% in the parathyroidectomy group and 67.4% in the control group. The cardiovascular death-free survival rate was 94.6% in the parathyroidectomy group and 76.3% in the control group. During observation, intact parathyroid hormone was measured every 6 months, and its average serum level was 37 ± 92 ng/L in the total parathyroidectomy group versus 274 ± 233 ng/L in the control group (p=0.0001). The total parathyroidectomy group had a significantly lower corrected calcium level and higher serum albumin level. Multivariate analysis revealed that parathyroidectomy, atrial fibrillation and serum albumin were significant factors for both total and cardiovascular mortality. Conclusion: Total parathyroidectomy was associated with better survival, probably due to decreased cardiovascular mortality.