Parathyroidectomy: new criteria for evaluating outcome

Following successful parathyroidectomy, subjective improvement in recognized symptoms and in the overall "well being" of asymptomatic primary hyperparathyroid patients has been well documented. Because quantitative methods for measuring parathyroid hormone (PTH) and normal reference ranges of serum calcium have changed in recent years, a revised biochemical criteria for evaluating postoperative outcome has become necessary. Two hundred seventy-one selected patients were followed for an average of 6.3 years after parathyroidectomy. Although 257 patients had serum calcium levels <10.6 mg/dL during the entire follow-up period, 15 per cent of them had elevated intact PTH (iPTH) levels. Fourteen patients had calcium levels > or =10.6 mg/dL at some point during follow-up, with nine patients (64%) showing high iPTH levels and eight (57%) of them developing recurrent hyperparathyroidism (calcium > or =11 mg/dL and iPTH > or =68 pg/mL). Of the 14 remaining patients, 5 had hypercalcemia with normal iPTH levels. In patients with successfully treated primary hyperparathyroidism, the recommended annual follow-up is: 1) monitor total serum calcium only if serum calcium level is <10.6 mg/dL, or if serum calcium level is > or =10.6 mg/dL; and 2) monitor serum calcium and PTH levels, because these patients have an increased incidence of hyperfunctioning parathyroid glands, which may point to late recurrence.     

Normalization of intraoperative parathyroid hormone does not predict normal postoperative parathyroid hormone levels

BACKGROUND: Intraoperative intact parathyroid hormone (iPTH) is being used to confirm complete excision of hyperfunctioning parathyroid tissue. It is uncertain whether normalization of intraoperative iPTH levels accurately predicts long-term postoperative iPTH values. METHODS: Fifty-two consecutive patients with primary or secondary hyperparathyroidism underwent parathyroidectomy with measurement of intraoperative iPTH. Ten patients were excluded due to incomplete laboratory follow-up. Follow-up serum calcium and iPTH levels were measured at 1- and 3-month intervals. RESULTS: Before operation, the mean serum iPTH level was 249 pg/mL (SD=208) and mean serum calcium level was 11.4 +/- 0.9 mg/dL (+/- SD). In all but 4 patients, final intraoperative iPTH levels normalized to less than 67 +/- 41 pg/mL (mean, 35 pg/mL). One week after operation, serum calcium levels had returned to normal (mean, 9.4 +/- 1.1 pg/mL), which directly correlated with the final intraoperative serum iPTH values (Pearson correlation, r = -.434; P <.01). By 1 month, all but 2 patients were normocalcemic (mean, 9.4 +/- 0.9 pg/mL) with a mean iPTH level of 74.8 +/- 82 pg/mL. There was no correlation between final intraoperative and postoperative serum iPTH values (r =.099; P <.533). Both patients with persistent hypercalcemia at 1 month had appropriate intraoperative decreases in iPTH values. CONCLUSIONS: Intraoperative serum iPTH levels significantly correlate with postoperative serum calcium levels but not with postoperative serum iPTH levels. There was a 4.8% failure rate in the correction of postoperative serum calcium levels and a 29% failure rate in the normalization of postoperative serum iPTH levels.     

Long-term management and outcome of parathyroidectomy for sporadic primary multiple-gland disease

HYPOTHESIS: For a specific subset of patients with sporadic primary multiple-gland parathyroid disease, subtotal parathyroidectomy results in long-term normocalcemia in the majority of patients, with a minimal complication rate. DESIGN: Retrospective analysis of outcomes in patients undergoing parathyroidectomy performed by a single surgeon (A.E.G.) between 1984 and 1999. SETTING: A multidisciplinary endocrine service based at a tertiary referral center. PATIENTS: Patients undergoing subtotal parathyroidectomy for primary hyperparathyroidism due to sporadic multiple-gland disease identified from a single surgeon's operative records (A.E.G.). MAIN OUTCOME MEASURES: Data analyzed included demographic factors, operative and pathologic findings, and postoperative and long-term clinical and laboratory results, including calcium and intact parathyroid hormone levels. RESULTS: Of 379 patients undergoing parathyroidectomy for hyperparathyroidism between 1984 and 1999, 49 (13%) had sporadic multiple-gland disease. Median preoperative calcium and intact parathyroid hormone (iPTH) levels were 2.7 mmol/L (10.8 mg/dL) and 11.79 pmol/L, respectively. Postoperative calcium and iPTH levels were available in 39 patients, and median values were 2.28 mmol/L (9.1 mg/dL) and 2.84 pmol/L, respectively. Long-term follow-up was available for 36 patients (73%), and duration ranged from 6 to 180 months (median, 44 months). Median calcium and iPTH levels at follow-up were 2.3 mmol/L (9.2 mg/dL) and 3.26 pmol/L, respectively, with 3 (8%) of 36 patients having evidence of persistent or recurrent hyperparathyroidism. No patient had biochemical evidence of hypoparathyroidism at long-term follow-up. Five patients (14%) had persistent elevated iPTH levels (range, 8.11-10.95 pmol/L) and normal calcium levels. CONCLUSIONS: Subtotal parathyroidectomy for sporadic primary multiple-gland disease resulted in a long-term normocalcemia rate of 92%, with minimal complications. Selective subtotal parathyroidectomy can yield excellent long-term results in patients with multiple-gland disease.     

Parathormone levels after subtotal and total (autotransplantation): Parathyroidectomy for secondary hyperparathyroidism

To compare results of subtotal versus total parathyroidectomy with autotransplantation in dialysis patients with secondary hyperparathyroidism, pre- and postoperative calcium, phosphorus, alkaline phosphatase, and immunoreactive parathormone (iPTH) were measured. In eight patients with subtotal parathyroidectomy, the mean preoperative iPTH of 903 ± 139 μl-eq/ml decreased to a mean of 26.6 ± 9 μl-eq/ml, 6 to 29 months postoperatively. In six patients with total parathyroidectomy and autotransplantation the mean preoperative iPTH of 1289 ± 248 μl-eq/ml decreased to a mean peripheral iPTH of 32 ± 7 μl-eq/ml, 4 to 18 months postoperatively. Both groups were similar in (1) pre- and postoperative iPTH levels, (2) the absence of postoperative clinical or chemical hyperparathyroidism, (3) improvement in symptoms, and (4) demonstrable functioning parathyroid tissue. None of the patients required reexploration for persistent hyperparathyroidism. Subtotal parathyroidectomy and total parathyroidectomy with autotransplantation appear to be equally effective modalities for treatment of secondary hyperparathyroidism in patients with end-stage renal disease.     

甲状旁腺切除术对肾性继发性甲状旁腺功能亢进患者NLR、PLR的影响

目的 探讨甲状旁腺切除术对肾性继发性甲状旁腺功能亢进(secondary hyperpar-athyroidism,SHPT)患者中性粒细胞/淋巴细胞比值(neutrophil-to-lymphocyte ratio,NLR)、血小板/淋巴细胞比值(platelet-to-lymphocyte ratio,PLR)的影...     

Effect of Cinacalcet in Kidney Transplant Patients With Hyperparathyroidism

ObjectiveIn dialysis patients, cinacalcet could be an effective alternative to parathyroidectomy for treating hyperparathyroidism. In the present study, we aimed to determine the characteristics of subjects with persistent hyperparathyroidism who require parathyroidectomy despite the use of cinacalcet.MethodsNine kidney transplant patients (7 men, 2 women; mean age 53.2 [SD, 8.9] years) who had tertiary hyperparathyroidism were reviewed in a single center. Pre- and postcinacalcet levels of calcium, phosphorous, intact parathyroid hormone (iPTH), and renal function were analyzed to evaluate the effect of cinacalcet treatment in these patients. The baseline parameters before cinacalcet treatment were compared in patients who did and did not undergo parathyroidectomy.ResultsCinacalcet reduced serum calcium levels in all patients (11.48 [SD, 0.73] mg/dL to 10.20 [0.70] mg/dL; P = .008). Serum phosphorous levels significantly increased from 2.28 (SD, 0.77) mg/dL to 3.02 (SD, 0.65) mg/dL (P = .03). The iPTH levels in 7 patients decreased, while the mean level remained unchanged in total subjects. The iPTH levels increased even with cinacalcet treatment in 2 patients. In 3 patients, serum calcium levels abruptly increased after cinacalcet withdrawal. Five patients who showed persistent hypercalcemia due to hyperparathyroidism underwent parathyroidectomy. These 5 patients had significantly different characteristics compared with 4 patients who did not undergo parathyroidectomy: hypercalcemia (11.92 [SD, 0.68] mg/dL vs 10.93 [SD, 0.26] mg/dL; P = .02), hypophosphatemia (1.74 [SD, 0.36] mg/dL vs 2.95 [SD, 0.58] mg/dL; P = .03), and hyperparathyroidism (252.2 [SD, 131.4] pg/dL vs 101.5 [SD, 18.4] pg/dL; P = .02).ConclusionCinacalcet reduced hypercalcemia due to hyperparathyroidism in the transplant patients. However, patients who had pre-existing higher iPTH, hypercalcemia, and hypophosphatemia needed parathyroidectomy. Therefore, cinacalcet could be considered an alternative to parathyroidectomy in selected patients.     

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??Risk factors of hypocalcemia after parathyroidectomy for primary hyperparathyroidism HU Ya, LIAO Quan, CAO Shao-bo, et al.Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences & Peking Union Medical College, Beijing 100730, China
Corresponding author: ZHAO Yu-pei, E-mail: zhao8028@263.net
Abstract Objective Hypocalcemia is a common condition after parathyroidectomy in the patients with primary hyperparathyroidism. The risk factors of post-operative hypocalcemia was sought to identify in this study. Methods A database about parathyroid lesions in Peking Union Medical College Hospital was searched for the patients with primary hyperparathyroidism who underwent successful parathyroidectomy between January 2009 and March 2015. Patients with malignant or familial parathyroid lesions were excluded. The possible risk factors were investigated including gender, age, preoperative calcium, phosphate, intact parathyroid hormone (iPTH) and alkaline phosphatase (ALP) levels. Results Of the 641 patients included in this study, 118 (18.4%) and 210 (32.8%) patients were diagnosed with postoperative hypocalcemia with biochemical criteria and symptomatic criteria, respectively. By applying multivariate stepwise logistic regression analysis, age, pre-operative serum phosphate and ALP level had predictive value for development of early hypocalcemia with symptomatic criteria. And the pre-operative serum iPTH level was the risk factors for the hyopcalcemia with biochemical criteria. Conclusions The age, pre-operative serum phosphate, ALP and iPTH levels were related with postoperative hypocalcemia. Patients with one or more of these factors should be monitored for possible complications with hypocalcemia.     

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。     

The relation of serum calcium and immunoparathormone levels to parathyroid size and weight in primary hyperparathyroidism

This study was designed to determine whether the serum calcium or immunoparathormone (iPTH) level would be of value in predicting the size or weight of the parathyroid gland in patients with single-gland enlargement caused by primary hyperparathyroidism. Ninety-two patients who underwent parathyroidectomy with removal of a single enlarged gland at the North Carolina Memorial Hospital (1974 to 1984) were reviewed. The preoperative calcium and immunoparathormone levels were correlated to the weight and calculated volume of the removed gland. The calcium level was found to be significantly associated with parathyroid gland weight and volume (p less than 0.001), as determined by linear regression analysis. Despite the statistical association, the correlation coefficient (calculated with the Pearson correlation matrix) was low, 0.16 for the relation of calcium to gland weight and 0.25 for the relation of calcium to calculated gland volume. The calculated coefficients of correlation of iPTH (three different assays) to gland weight and volume were similarly low. These findings demonstrate a variable relationship between the preoperative serum calcium level or the iPTH level to the weight or volume of the enlarged hyperfunctioning parathyroid gland. Identification of the pathologic parathyroid gland(s) in primary hyperparathyroidism cannot be based on a perceived relation of preoperative calcium or iPTH levels to the size of the enlarged glands.     

Normocalcemia with elevated parathyroid hormone levels after surgical treatment of primary hyperparathyroidism

BACKGROUND: Thirty percent of patients who undergo successful parathyroidectomy for primary hyperparathyroidism show unexplained elevated postoperative serum parathyroid hormone (PTH) levels despite normocalcemia. METHODS: PTH levels were measured monthly in 97 patients for 6 months after parathyroidectomy. Renal function, 25-OH-vitamin D levels, serum alkaline phosphatase levels, osteocalcin, and bone densitometry were evaluated before and 6 months after surgery. PTH reactivity to calcium loading was tested at the sixth month. RESULTS: Thirty patients had elevated PTH levels despite normocalcemia after parathyroidectomy. Before surgery, these 30 patients had higher PTH and creatinine levels, lower vitamin D levels, and more extensive bone involvement than those with normal postoperative PTH levels. In patients with normal renal function and normal vitamin D levels, postoperative PTH values correlated with preoperative PTH levels but not with bone disease. CONCLUSION: In most cases, elevated PTH levels after surgery is an adaptive reaction to renal dysfunction or vitamin D deficiency. If no adaptive cause can be found, persistent hyperparathyroidism must be suspected.     

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。     

Limited role for intraoperative intact PTH measurement in parathyroid surgery.

Primary hyperparathyroidism may be cured surgically by complete excision of abnormal parathyroid tissue. Reoperation for persistent hypercalcaemia due to residual abnormal parathyroid tissue may be associated with a high complication rate. It is possible to assay intact parathormone (iPTH) intraoperatively and as iPTH has a relatively short half-life, its measurement intraoperatively may be used to predict successful parathyroidectomy. We have studied intraoperative iPTH levels in a consecutive series of 33 patients undergoing surgery for primary hyperparathyroidism. We found that iPTH levels fell significantly (P < 0.05) from a median pre-excision level of 122 pg/ml to a median level of 36 pg/ml 20 min after excision. However, in 3/31 successful parathyroidectomies, the intraoperative iPTH levels either remained unchanged or had risen. Reliance on intraoperative iPTH levels in these patients may have resulted in unnecessary re-exploration. We conclude that intraoperative iPTH measurement has limited usefulness as a predictor of successful parathyroidectomy for primary hyperparathyroidism.     

Early biochemical response to parathyroidectomy for primary hyperparathyroidism and its predictive value for recurrent hypercalcemia and recurrent primary hyperparathyroidism

BackgroundThe traditional definition of cure after parathyroidectomy (PTX) for primary hyperparathyroidism is normocalcemia. Our hypothesis was that early postoperative levels of serum calcium and parathyroid hormone after PTX would have predictive value for later recurrence.MethodsWe performed a retrospective study of 1,146 patients with primary hyperparathyroidism who underwent PTX and had long-term biochemical follow-up. The first postoperative serum level of calcium and parathyroid hormone values were used to categorize patients into the following four early biochemical response groups: (1) complete response (normal calcium and normal parathyroid hormone), (2) partial response with hyperparathormonemia (normal calcium and increased parathyroid hormone), (3) partial response with hypercalcemia (increased calcium and normal parathyroid hormone), and (4) non-response (increases in both calcium and parathyroid hormone). Incidences of recurrent hypercalcemia and recurrent primary hyperparathyroidism >6 months after operation were then analyzed.ResultsThe overall rate of any elevated serum levels of calcium and any increase in serum levels of parathyroid hormone during >6-month follow-up was 9.8% (112 of 1146), with 6.6% (57 of 861) for group 1, 27% (35 of 129) for group 2, and 16% (20 of 127) for group 3 (P < .02). Partial biochemical responses with either increased serum calcium or increased parathyroid hormone levels were the strongest predictors of any episode of increased serum levels of calcium after 6 months and was associated with 2.7× to 4.3× the risk of recurrent primary hyperparathyroidism, respectively.ConclusionThis study demonstrates the importance of measuring parathyroid hormone in the early postoperative period to better predict later recurrent primary hyperparathyroidism.     

25-hydroxyvitamin D deficiency is a risk factor for symptoms of postoperative hypocalcemia and secondary hyperparathyroidism after minimally invasive parathyroidectomy

BACKGROUND: Patients with primary hyperparathyroidism who undergo minimally invasive parathyroidectomy (MIP) may have postoperative symptoms of hypocalcemia or secondary hyperparathyroidism. This study sought to identify factors predictive of these events. METHODS: Between 1998 and 2004, 190 patients with primary hyperparathyroidism underwent MIP with excision of a single adenoma. Age, gender, race, prior head and neck surgery, use of preoperative thyroid hormone or calcium-channel blockers, preoperative levels of calcium, 25-hydroxyvitamin D (25[OH]D) and intact parathyroid hormone (iPTH), the presence of osteopenia or osteoporosis, intraoperative iPTH levels, and adenoma weight were evaluated by univariate analysis as predictors of postoperative symptoms of hypocalcemia and secondary hyperparathyroidism. RESULTS: None of the following were predictors of postoperative symptoms of hypocalcemia: age, gender, race, prior head and neck surgery, preoperative medications, preoperative calcium and iPTH levels, osteopenia or osteoporosis, intraoperative iPTH levels, or adenoma weight. However, patients with postoperative symptoms of hypocalcemia had significantly lower preoperative 25[OH]D levels (P = .01). Further, higher preoperative iPTH levels (P < .01) and lower preoperative 25[OH]D levels (P = .05) were associated with secondary hyperparathyroidism postoperatively. CONCLUSIONS: A low preoperative 25[OH]D level is associated with postoperative symptoms of hypocalcemia and secondary hyperparathyroidism in patients undergoing MIP. One might consider instituting empiric calcium supplementation postoperatively in patients with low 25[OH]D levels.     

Parathyroid exploration for primary hyperparathyroidism

Parathyroidectomy was studied retrospectively in 107 patients with primary hyperparathyroidism. This condition was diagnosed by measuring both the total serum calcium and ultrafilterable calcium (non-protein-bound) levels. The identification of ultrafilterable calcium is an important adjunct to parathyroid surgery as it allows the diagnosis of hyperparathyroidism when the total serum calcium level is normal. The surgical technique for selective parathyroidectomy and multiple biopsies was uniform. Parathyroid adenoma was discovered in 73 patients, diffuse hyperplasia in 26 and combined disease in 8. Postoperatively, two patients suffered from permanent hypocalcemia and three had hypercalcemia.     

Hyperparathyroidism associated with the enlargement of two or three parathyroid glands.

Eighty-five (23%) of 375 patients undergoing surgery for primary hyperparathyroidism were found to have enlargement (greater than 50 mg) of two or three parathyroid glands. Of 76 patients followed from 12 to 140 months after surgery, eight (10.5%) developed hypercalcemia at 1, 4, 45, 64, 74, 79, 84, and 133 months. In a comparison of pertinent preoperative biochemical and pathologic data between 55 patients with two- or three-gland hyperparathyroidism and 55 age- and sex-matched patients with single-gland hyperparathyroidism, only the preoperative serum phosphate differed significantly, being lower in the patients with single-gland disease (2.4 +/- 0.1 vs. 2.6 +/- 0.1; p less than 0.04). In the eight patients with two- or three-gland hyperparathyroidism who developed postoperative hypercalcemia, the preoperative concentrations of serum calcium were lower (10.8 +/- 0.2 vs. 11.5 +/- 0.2; p less than 0.019), the preoperative concentrations of serum phosphate were higher (3.1 +/- 0.2 vs. 2.5 +/- 0.1; p less than 0.020), and the weights of the excised parathyroid tissues were less (356 +/- 72 mg vs. 1354 +/- 215 mg; p less than 0.02) than those of patients with two- or three-gland disease who did not develop postoperative hypercalcemia, indicating a milder form of hyperparathyroidism. In the 68 patients without recurrent hypercalcemia, there was no tendency for the serum calcium concentration to increase with time. Patients with primary hyperparathyroidism associated with two or three enlarged parathyroid glands have an appreciable incidence of persistent or recurrent hypercalcemia, which may increase even further with longer observation.     

Hyperparathyroidism and gastroenteropancreatic hormone levels

The diagnosis of multiple endocrine neoplasia (MEN) in patients with presumed hyperparathyroidism has important ramifications for patient management especially since as many as 20% of patients with hyperparathyroidism may have associated MEN. Gut hormone levels were measured before and after surgery in 28 patients who underwent resection of a single parathyroid adenoma for biochemical or clinical evidence of hyperparathyroidism. The mean serum calcium level was 11.9 +/- 0.2 mg/dl before surgery and 9.3 +/- 0.3 mg/dl after surgery (p less than 0.001). Two or more hormone levels were elevated in 32% of patients before surgery and 21% after surgery. The same hormone abnormalities (pancreatic polypeptide [PP] and gastrin) occurred 56% of the time. Of elevated preoperative levels of PP, 91% were in the normal range after surgery. In patients with elevated preoperative PP levels, the postoperative level of PP decreased by an average of 64% of the preoperative level. In 27% of patients the level increased more than double the preoperative value. In two of four patients with high levels of PP after surgery the serum calcium level failed to fall. Of 18 patients whose PP levels fell, 17 had a fall in serum calcium levels. Of six patients whose PP levels rose, four had a significant fall in calcium levels. There was no correlation between the absolute levels or the decremental change of calcium and the change in PP. Several abnormalities in gut hormone secretion occur in patients with primary hyperparathyroidism and a parathyroid adenoma. An elevated serum level of PP does not signify MEN syndrome and must be reevaluated after resection of the parathyroid adenoma. Failure of adequate tumor resection is attended by persistent elevation of serum calcium and PP levels.     

原发性甲状旁腺功能亢进术后低钙血症相关因素分析

目的 探讨原发性甲状旁腺功能亢进术后出现低钙血症及其症状的相关因素。方法 收集2009年1月至2015年3月北京协和医院行手术治疗的原发性甲状旁腺功能亢进病人临床资料,分析与术后低钙血症及其症状相关的临床因素。 结果 641例原发性甲状旁腺功能亢进病人成功接受甲状旁腺切除术治疗,并得到术后病理学诊断及长期随访证实。118例（18.4%）术后第一日血清总钙低于正常值下限,210例（32.8%）出现低钙血症相关的临床症状。多因素相关分析发现：原发性甲状旁腺病人术后出现低钙血症相关症状,与病人年龄、术前血清无机磷及碱性磷酸酶（ALP）相关;术后第一日血清总钙水平低于正常与术前血清全片段甲状旁腺激素（iPTH）水平相关。 结论 青年病人、术前血清iPTH和ALP水平增高、血清无机磷水平低可能是原发性甲状旁腺功能亢进术后低钙的相关因素。     

Experienced radio-guided surgery teams can successfully perform minimally invasive radio-guided parathyroidectomy without intraoperative parathyroid hormone assays

Minimally invasive parathyroidectomy is an accepted treatment option for primary hyperparathyroidism. The need for intraoperative parathyroid hormone assays (iPTH) to confirm adenoma removal remains controversial. We studied minimally invasive radio-guided parathyroidectomy (MIRP) performed using preoperative sestamibi localization studies, intraoperative gamma detection probe, and the selective use of frozen section pathology without the use of iPTH. This is a single institution review of patients with primary hyperparathyroidism treated with MIRP by surgeons experienced in radio-guided surgery between October 1, 1998 and July 15, 2005. Information was obtained by reviewing computer medical records as well as contacting primary care physicians. Factors evaluated included laboratory values, pathology results, and evidence of recurrence. One hundred forty patients were included with a median preoperative calcium level of 11.3 mg/dL (range, 9.6-17) and a PTH level of 147 pg/mL (range, 19-5042). The median postoperative calcium level was 9.3 mg/dL. All patients were initially eucalcemic postoperatively except for one who had normal parathyroid levels. However, five (4%) patients required re-exploration for various reasons. Of the failures, one was secondary to the development of secondary hyperparathyroidism, and therefore would not have benefited from iPTH, one had thyroid tissue removed at the first operation, and three developed evidence of a second adenoma. One of these three patients had a drop in PTH level from 1558 pg/mL preoperatively to 64 pg/mL on postoperative Day 1, indicating that iPTH would not have prevented this failure. Thus, only three (2.1%) patients could have potentially benefited from the use of iPTH. MIRP was successful in 96 per cent of patients using a combination of preoperative sestamibi scans, intraoperative localization with a gamma probe, and the selective use of frozen pathology. This correlates with reported success rates of 95 per cent to 100 per cent using iPTH. We conclude that minimally invasive parathyroidectomy can be successfully performed without using iPTH assays.     

"Limited" parathyroidectomy in geriatric patients

OBJECTIVE: Elderly patients with primary hyperparathyroidism accompanied by other diseases are often denied referral for parathyroidectomy because of the associated risks of general anesthesia and bilateral neck exploration. However, marked symptomatic improvement is recognized after successful parathyroidectomy. The purpose of this report is to examine the postoperative outcome of geriatric patients undergoing "limited" parathyroidectomy. METHODS: Since 1993, 291 consecutive patients with primary hyperparathyroidism were treated with "limited" parathyroidectomy guided by preoperative localization and intraoperative parathyroid hormone assay. In 34 of the procedures (29 initial, 5 reoperations), the patient was 75 years or older; these patients are the subject of this report. Patients were followed up for serum calcium, parathyroid hormone levels, and symptomatology. RESULTS: Twenty-seven patients were followed up for 31 (range 6-84) months: all remained normocalcemic after single gland excision guided by intraoperative parathyroid hormone assay. Another six patients in the immediate postoperative period had normocalcemia. One patient had persistent hypercalcemia. Unilateral neck exploration was possible in 29 patients. The average operating time for initial parathyroidectomy was 50 (range 20-130) minutes. Nineteen patients were eligible for ambulatory surgery. Seven were discharged without an overnight stay, 11 had a 23-hour "social" admission, and one was kept overnight after a prolonged surgical procedure. Permanent hypoparathyroidism and laryngeal nerve injury were not observed. The mortality rate related to the procedure was 0%; there was one postoperative (do not resuscitate) death caused by colonic hemorrhage. With an average follow-up of 2 years, 64% of the patients had marked improvement of symptoms. CONCLUSION: Adjunctive use of preoperative localization and intraoperative parathyroid hormone assay has made "limited" parathyroidectomy a safe, effective treatment option in geriatric patients with primary hyperparathyroidism.