Cryopreservation of Parathyroid Tissue after Parathyroid Surgery for Renal Hyperparathyroidism: Does it Really Make Sense?

Background

Metachronous autotransplantation of cryopreserved parathyroid tissue is a technique for treating postoperative hypoparathyroidism after parathyroid surgery for renal hyperparathyroidism (rHPT). The aim of the present study was to evaluate our institution’s experience with metachronous autotransplantation to analyze the role of cryopreservation in the treatment of rHPT and to determine for whom and when cryopreservation of parathyroid tissue should be deemed necessary.

Methods

A prospective database of patients with rHPT who underwent surgery between 1976 and 2011 was screened for patients with hypoparathyroidism who received a metachronous autotransplantation. Data were analyzed regarding clinical data, histopathological findings of the cryopreserved parathyroid tissues, and patient outcome after metachronous replantation of parathyroid tissue.

Results

Fifteen of 883 patients with rHPT underwent a metachronous autotransplantation under local anesthesia at a mean time of 23?months following the last cervical surgery. Histopathology of the parathyroid tissue chosen for transplantation revealed a necrosis rate of 0?% in 14 and 70?% in one patient. Mean preoperative serum calcium and parathyroid hormone (PTH) levels were 2.0?mmol/l and 3.7?pg/ml, respectively. Autotransplantation raised mean serum calcium and PTH levels to 2.2?mmol/l and 97.5?pg/ml, respectively, after a mean follow-up of 78?months.

Conclusions

Metachronous autotransplantation following parathyroid surgery in patients with rHPT effectively normalizes PTH and calcium levels. The success rate is high if an adequate cryopreservation procedure is applied. However, it is rarely necessary, and therefore the cryopreservation of parathyroid tissue in all patients has to be questioned, at least from an economic point of view.     

Does Intraoperative Quick Parathyroid Hormone Assay Improve the Results of Parathyroidectomy?

Preoperative sestamibi (MIBI) and ultrasonography (US) are used to localize parathyroid tumors in patients with primary hyperparathyroidism (pHPT). The intraoperative quick PTH assay (qPTH) has been recommended to determine whether all hyperfunctioning parathyroid tissue has been removed. We questioned whether qPTH improves the results of parathyroidectomy in patients with pHPT. We analyzed 115 unselected patients with pHPT without a family history or multiple endocrine neoplasia but who had undergone parathyroidectomy. All 115 patients had successful operations without complications. Of these patients, 88 (77%) had solitary adenomas, 13 had double adenomas, 1 had triple adenomas, 12 had hyperplasia, and 1 had carcinoma. Overall, MIBI was correct in 72% (76/106), US in 49% (49/99), and qPTH in 80% (92/115). For preoperative studies showing a single tumor, MIBI was correct in 83% (73/88), US was correct in 71% (45/63), and combined MIBI and US were correct in 95% (37/39). Adding qPTH in this subgroup did not improve the successful focused approach: 70% for MIBI, 65% for US, and 87% for combined MIBI and US. However, adding qPTH improved the overall success of parathyroidectomy (MIBI 92%, US 86%, combined MIBI and US 97%), but at the cost of unnecessary further exploration (MIBI 13%, US 6%, combined MIBI and US 8%). We conclude that when the same solitary tumor is identified by both MIBI and US, a focused exploration can be done with a 95% success rate. Adding qPTH to MIBI or US can improve the success rate but at a significant cost. General exploration of all parathyroid glands, however, has the highest success rate (100%).     

Is It Worthwhile to Hire a Practice Management Consultant?

This article discusses the decisions involved with hiring a consultant for the medical practice: when to hire one, how to locate the best one for a particular practice, finding a consultant and analyzing their skills in terms of the needs of the practice, and other essential advice to provide the medical practitioner with a basis for making a decision on consultants. The Achilles heel of doctors is the tendency to think they should be able to fix all problems on their own, thus often delay in seeking help for their practice that can alleviate existing problems or keep a practice on track with success. This often leads to excessively long work hours or compounding of problems, when a simple fix could be the solution when analyzed by an outside consultant. Approaches to determining the appropriateness of a particular consultant are presented, along with questions to ask when determining the expertise and the "fit" of a consultant.     

Endoscopic Parathyroidectomy: Why and When?

BACKGROUND: In recent years, several new minimally invasive techniques for parathyroidectomy (MIP) have been developed. There was a rapid worldwide acceptance of mini-open procedures by most surgeons. However, the use of an endoscope remains debatable. This study was designed to determine the role of preoperative imaging studies in the decision-making for using an endoscope during MIP. METHODS: All patients with sporadic primary hyperparathyroidism (PHPT) and candidate for MIP underwent localizing studies. MIP was proposed only for patients in whom a single adenoma was localized by both ultrasonography and sestamibi scanning. Three locations were described: (1) posterior to the two superior thirds of the thyroid lobe; (2) at the level of or below the inferior pole of the thyroid lobe but in a plane posterior to it; (3) at the level of or below the tip of the inferior pole of the thyroid lobe but in a superficial plane. In locations 1 and 2, the nerve was considered to be at risk and an endoscopic lateral approach was indicated. In location 3, a mini-open approach was indicated. RESULTS: Of the 165 patients operated on for PHPT in 2006, 86 underwent MIP. According to the results of imaging studies, 39 patients presented an adenoma in location 1, 21 in location 2, and 26 in location 3. In locations 1 and 2, 59 patients (1 false-positive) had an adenoma that was located posteriorly, in close proximity to the nerve; all were cured. In location 3, 25 patients (1 false-positive) presented an inferior parathyroid adenoma superficially located; all were cured. There was no transient or permanent laryngeal nerve palsy. CONCLUSIONS: In patients who are candidates for MIP, we recommend the use of the endoscope for the resection of parathyroid adenomas that are located deeply in the neck.     

Hypoparathyroidism after Total Parathyroidectomy plus Subcutaneous Autotransplantation for Secondary Hyperparathyroidism—Any Side Effects?

Background

This retrospective, case–control study was designed to find side effects of hypoparathyroidism after total parathyroidectomy plus autotransplantation.

Methods

After successful total parathyroidectomy plus autotransplantation for symptomatic secondary hyperparathyroidism, 19 patients who had intact parathyroid hormone (iPTH) levels <10 pg/ml during the follow-up period of 1 year and 38 patients, who had levels >10 pg/ml, were enrolled as the hypoparathyroid and nonhypoparathyroid groups. Data were collected on etiology, symptoms, serum levels of calcium, phosphate, alkaline phosphatase (Alk-ptase), iPTH, and bone mineral density (BMD) at different sites. Then, 1 week, 3 months, and 1 year after surgery, serum levels of calcium, phosphate, Alk-ptase, and iPTH were measured again. Three months later, symptoms were recorded. One year after surgery, the BMD at different sites was measured again. Patients’ daily requirements of calcium carbonate and vitamin D3 were recorded at the mean follow-up of 24 months.

Results

Calcium, phosphate, and iPTH levels decreased significantly 1 week, 3 months, and 1 year after surgery, and Alk-ptase levels increased at 1 week and then decreased significantly 3 months and 1 year after surgery. Symptoms improved significantly 3 months after surgery. The BMD of different sites increased significantly at 1 year. There were no differences between the two groups regarding changes of symptoms, BMD, and calcium, phosphate, and Alk-ptase levels. Hypoparathyroid patients required significantly more calcium carbonate and vitamin D3 than nonhypoparathyroid patients did (P = 0.002).

Conclusions

Even though hypoparathyroid patients require more calcium carbonate and vitamin D3 than nonhypoparathyroid patients do, they do not have any side effects.     

Parathyroid "double adenomas": fact of fiction?

It has been suggested that primary hyperparathyroidism (HPT) may occasionally be caused by "multiple adenomas." If this is true, then selective excision of the enlarged glands should be curative in such cases. To examine this proposition, we reviewed the records of 1,962 patients with surgically proved HPT and culled all those who met the following criteria: (1) identification and excision of two enlarged and histologically hypercellular parathyroid glands, each weighing more than 70 mg, and (2) identification and preservation of two other normal-sized parathyroid glands. There were 38 such patients (1.9% of the total group). Thirty-seven patients were euparathyroid at follow-up (an average of 4.6 years postoperatively). Only one individual, a member of a kindred with multiple endocrine neoplasia (MEN), type 1, had persistent HPT; but four other patients with MEN syndromes were among the group cured by surgery. The findings of this study support the notion that more than one adenoma may occasionally be found in primary HPT, and that selective excision of the enlarged glands with preservation of the normal parathyroid glands constitutes adequate treatment. One possible exception to this rule is the patient with either familial HPT or one of the MEN syndromes; subtotal parathyroidectomy is preferred in this situation.     

Parathyroidectomy in secondary hyperparathyroidism: Is there an optimal operative management?

BACKGROUND: Subtotal parathyroidectomy (SPTX) and total PTX with autotransplantation (TPTX + AT) are both accepted operations for secondary hyperparathyroidism (2HPT). Studies have shown the 2 procedures to have similar rates of recurrent or persistent HPT (0% to 10%). The majority of these reports are small case series and despite apparently similar outcomes; the optimal operative management for 2HPT remains controversial. The purpose of this study was to determine whether there were any clinical outcome differences between these apparently comparable operations. METHODS: A meta-analysis of 53 publications on reoperative operation for 2HPT from 1983 to 2004 identified 501 patients who had undergone an operation for recurrent or persistent 2HPT. The data evaluated included the type of initial operation, the need for reoperative operation as it related to the type of initial operation, and the intraoperative findings. RESULTS: The initial operation had been a SPTX in 36% and a TPTX + AT in 64% of patients. Reoperative operation was for persistent 2HPT in 82 of 485 (17%) and for recurrent 2HPT in 403 of 485 (83%) patients. Findings at reoperation included: autograft hyperplasia (49%), supernumerary glands (20%), remnant hyperplasia (17%), a missed in situ gland (7%), and a negative exploration (5%). Supernumerary glands, missed in situ glands, and negative explorations occurred at equal rates for both operations. Reoperation determined that inadequate cervical explorations occurred in 42% of patients who had undergone a SPTX and in 34% of patients who had undergone a TPTX + AT. CONCLUSIONS: Operative failures occur because of the limitations in preoperative localization, inadequate exploration, and the natural history of hyperplastic parathyroid tissue. The initial operation should include an attempt to localize supernumerary glands both pre- and intra-operatively.     

Parathyroid autotransplantation during thyroidectomy: is frozen section necessary?

OBJECTIVE: To evaluate the accuracy of parathyroid gland identification and the need for routine frozen section examination before parathyroid autotransplantation during thyroidectomy. DESIGN: A prospective case series. SETTING: An endocrine surgical unit. PATIENTS: From January 1, 1995, to December 31, 1997, parathyroid autotransplantation was attempted for devascularized or inadvertently removed glands in 152 (33.7%) of 450 patients during thyroidectomy. Before autotransplantation, a biopsy specimen of the transplanted tissue was sent for histological examination without frozen section confirmation. MAIN OUTCOME MEASURES: Positive identification of parathyroid tissue in microscopic examination. RESULTS: Of 179 attempted autotransplantations of parathyroid glands, parathyroid tissue was confirmed in 167 biopsy specimens (93.3%). Incorrect identification of parathyroid gland occurred in 12 instances. The tissue mistaken as parathyroid gland included fat in 6 cases, thyroid tissue in 4 cases, lymph node in 1 case, and thymus in 1 case. Transplantation of at least 1 parathyroid gland (range, 1-3) was confirmed in 144 patients. For patients with confirmed parathyroid autotransplantation at risk of hypoparathyroidism (n = 112), postoperative transient hypocalcemia occurred in 22 (19.6%), while no patient developed any permanent hypocalcemia during a median follow-up of 6 months. CONCLUSIONS: Devascularized or inadvertently removed parathyroid glands can be identified expeditiously without routine frozen section during thyroid surgery. Immediate autotransplantation should be performed and permanent hypoparathyroidism can be avoided with this measure.     

Hepatic Resection for Metastatic Renal Tumors: Is It Worthwhile?

Background: Liver metastases of malignant renal tumors are regarded as having an ominous prognosis because they are infrequently amenable to radical surgery and respond poorly to chemotherapy. Little is known of the outcome of isolated metastases to the liver for which resection is potentially curative.Methods: Data on 14 patients with liver metastases from renal tumors who underwent a liver resection in a single center between 1982 and 2001 were analyzed retrospectively.Results: There was no operative or postoperative mortality. The median survival was 26 months, with a survival rate of 69% at 1 year and 26% at 3 years. The curative pattern of hepatectomy (2-year survival, 69% vs. 0%; P = .001), an interval between the nephrectomy and the diagnosis of liver metastases in excess of 24 months (2-year survival, 71% vs. 25%; P = .05), tumor size <50 mm (2-year survival, 83% vs. 17%; P = .006), and the possibility of achieving a repeat hepatectomy in the case of recurrence (2-year survival, 100% vs. 21%; P = .02) were associated with a better outcome after the liver resection. Four patients were alive without evidence of disease at 6, 12, 26, and 96 months after the first hepatic resection, and one was alive with hepatic recurrence 18 months after resection.Conclusions: In patients with liver metastases of malignant renal tumors, an aggressive policy for achieving tumor eradication seems to offer a chance for long-term survival, especially after a long disease-free interval from the nephrectomy. However, despite an aggressive policy for achieving tumor eradication, recurrence frequently occurs after liver resection.     

Staging Laparoscopy for Hilar Cholangiocarcinoma: Is it Still Worthwhile?

Purpose  

This study was designed to evaluate the benefit of staging laparoscopy (SL) in patients with suspected hilar cholangiocarcinoma (HCCA) during the past 10 years. Only 50–60% of patients with HCCA who undergo laparotomy are ultimately amenable to a potentially curative resection. In a previous study, we recommended routine use of SL to prevent unnecessary laparotomies. The accuracy of imaging techniques, however, has significantly improved during the past decade, which is likely to impact the yield and accuracy of SL.     

Early pulmonary embolism after injury: A different clinical entity?

Background

We sought to characterize pulmonary embolism (PE) occurring early after injury. We hypothesized that early PE may represent a different clinical entity than those occurring later in the post-injury period.

Methods

All trauma patients diagnosed with PE from 2005 to 2010 were examined. PEs diagnosed within 72 h of admission were compared against those occurring later.

Results

19 out of 54 PEs were diagnosed early. Early PE patients had a higher rate of lower extremity fractures, a lower mean injury severity score, and a lower average length of stay. Early PE patients had a shorter average time to start of chemical prophylaxis, were less likely to have had a femoral line, and less likely to have operative intervention under general anaesthesia.

Conclusions

Early PE after trauma may occur with different underlying pathophysiology than previously thought. Further study is indicated as this has implications concerning the prevention of PE in trauma patients.     

Pancreatogastrostomy after Pancreatoduodenectomy: A Safe, Feasible Reconstruction Method?

Pancreatogastrostomy is a safe reconstructive technique after pancreatoduodenectomy, even when performed as an educational operation in the hands of relatively inexperienced surgeons in a high-volume hospital. Sixteen surgeons with various case volumes operated on 190 consecutive patients and performed pancreatogastrostomy after pancreatoduodenectomy within the last 15 years in a university teaching hospital. Resections were performed for tumors localized in the head of the pancreas, the ampulla of Vater, or the distal common bile duct or duodenum (n = 169); for chronic pancreatitis (n = 16); and for miscellaneous reasons in five cases. The main outcome measures were postoperative mortality and morbidity, particularly the pancreatic leakage rate with special regard to the case volume of the performing surgeon. The overall mortality rate was 4.2% (n = 8), the 30-day mortality rate was 3.2% (n = 6), and mortality directly related to surgery was 2.6% (n = 5). Morbidity occurred in 45%, including severe surgical complications, which required reoperation (9%), and minor surgical complications that could be managed conservatively (30%). There were no significant differences in overall surgical morbidity rates when the groups with varying patient volume per surgeon were compared. The incidence of pancreatic leakage was 7.4%, which did not contribute to mortality in any case and showed no statistical differences between the surgical volume groups. We concluded that pancreatogastrostomy is safe and feasible even in the hands of inexperienced but supervised surgeons. The leakage rate is similar to the data from other high-volume centers. Once a leak is established, it can easily be managed conservatively, so it rarely contributes to severe complications or causes subsequent mortality. We recommend pancreatogastrostomy as a beneficial alternative to pancreatojejunostomy, even in the case of low surgical volume.^* JS and MO contributed equally to this work.