Analysis of the role of thyroidectomy and thymectomy in the surgical treatment of secondary hyperparathyroidism

Purpose

Parathyroidectomy can be subtotal or total with an autograft for the treatment of renal hyperparathyroidism. In both cases, it may be extended with bilateral thymectomy and total or partial thyroidectomy. Thymectomy may be recommended in combination with parathyroidectomy in order to prevent mediastinal recurrence. Also, the occurrence of thyroid disease observed in patients with hyperparathyroidism is poorly understood and the incidence of cancer is controversial. The aim of the present study was to report the experience of a single center in the surgical treatment of renal hyperparathyroidism and to analyse the role of thyroid and thymus surgery in association with parathyroidectomy.

Significant Clinical Differences in Primary Hyperparathyroidism Between Patients with and Those Without Concomitant Thyroid Disease

Purpose We evaluated the differences in diagnosis and treatment for primary hyperparathyroidism (pHPT) in patients with and those without concomitant thyroid disease.Methods One hundred and ten patients with pHPT underwent parathyroid localization and thyroid examination by ultrasonography (US) and sestamibi scintigraphy (MIBI). The clinical and biochemical findings, parathyroid localization, and operations performed were compared in 49 patients without thyroid disease and 61 patients with thyroid disease.Results Asymptomatic hypercalcemia was significantly more prevalent in patients with concomitant thyroid disease (88.5%) than in those without thyroid disease (49.0%) (P < 0.01). The mean serum calcium was significantly higher and the inorganic phosphate level was significantly lower in patients without concomitant thyroid disease than in those with concomitant thyroid disease (P < 0.05, P < 0.01, respectively). The pathologic parathyroid gland was identified significantly more often in patients without concomitant thyroid disease than in those with concomitant thyroid disease both by US and MIBI (P < 0.05). Unilateral exploration was performed more often in patients without thyroid disease than in those with thyroid disease (P < 0.01).Conclusion Primary hyperparathyroidism was diagnosed at an earlier stage in patients with concomitant thyroid disease. Thyroid disease concomitant with pHPT influenced parathyroid localization as well as the indication for minimally invasive parathyroidectomy.     

Endoscopic repair of gastrostomy after inadvertent removal of percutaneous endoscopic gastrostomy tube

We report the first case of robot-assisted thoracoscopic resection of a mediastinal parathyroid adenoma in the aorto-pulmonary window. Intervention planning was based on preoperative CT-MIBI image fusion, a new imaging modality that enabled reliable and precise localization of the parathyroid. The technique consists of taking MIBI-SPECT and CT separately, using a fixation unit that provides reproducible positioning of the patients head and neck. The data sets are then superimposed upon each other using special software. After the localization process, a minimally invasive operation was performed using the DaVinci operating robot. The procedure proved not only to be feasible but also safe and not time-consuming. The postoperative course was uneventful, and the patient was discharged 4 days postoperatively. Compared to conventional thoracoscopic surgery, the robotic operating system provides better visualization of the operating field and facilitates the movement of the instruments. Precise preoperative imaging enables the careful planning of robot-assisted surgery for ectopic parathyroids located at relatively inaccessible regions such as the anterior mediastinum.     

Adrenal responses to subtotal parathyroidectomy for primary hyperparathyroidism

Summary Although it is well known that hypertension is often associated with primary hyperparathyroidism and that parathyroidectomy reverses or reduces this abnormality, the etiology of elevated blood pressure in hyperparathyroidism is still conjectural. We have analyzed serum calcium, blood pressure, and metabolites of adrenal cortical hormones before and after surgical therapy for hyperparathyroidism in 10 normotensive and six hypertensive patients with primary hyperparathyroidism. Successful parathyroidectomy lowered serum calcium (P<0.01) and diastolic blood pressure (P<0.05) in all subjects. Mean urinary aldosterone and Porter-Silber chromagens were within normal limits preoperatively in normotensive as well as hypertensive subjects. After parathyroidectomy, aldosterone levels as well as Porter-Silber chromagens decreased significantly in all patients (P<0.01). However, when normotensive and hypertensive subjects were analyzed separately, the decrease in aldosterone levels was significant only in the normotensive group (P<0.05) whereas the decrease in Porter-Silber chromagens reached significancy only in the hypertensive group (P<0.01). The results indicate that surgical therapy for hyperparathyroidism lowers serum calcium and blood pressure and is associated with a decrease in the excretion of adrenal steroid metabolites. It is suggested that the temporal relationship which exists between ionized calcium and steroidogenesis in hyperparathyroid patients contributes at least in part to the generalized decrease in blood pressure observed after successful parathyroidectomy.     

Effects of different treatment methods on renal anemia in maintenance hemodialysis patients with hyperparathyroidism secondary to uremia

Objective To observe the effects of three treatment methods on renal anemia in maintenance hemodialysis patients with hyperparathyroidism secondary to uremia and analyze the influencing factors of erythropoietin (EPO) dosage. Methods A total of 55 maintenance hemodialysis patients with secondary hyperparathyroidism at the hemodialysis center of Huashan Hospital affiliated to Fudan University from January 2015 to December 2016 were retrospectively divided into three groups according to different treatment methods, parathyroidectomy +forearm transplantation group (surgery group, n=16), cinacalcet treatment group (n=6), and calcitriol treatment group (n=33), respectively. The hemoglobin level and erythropoietin dosage were measured before treatment and in the 3rd month, the 6th month and the 12th month after treatment. The changes of hemoglobin and erythropoietin dosage in the three groups before and after treatment were observed, and the mixed effect model was used to analyze the difference of the change of hemoglobin and erythropoietin dosage among three groups. Multiple linear regression analysis was used to analyze the influencing factors of EPO dosage after one year. Results The levels of intact parathyroid hormone (iPTH) in the surgery group and the cinacalcet group before treatment were significantly higher than that in the calcitriol group (both P＜0.05). In the 12th month after treatment, the levels of iPTH decreased significantly in the patients of surgery group and the cinacalcet group compared with those before treatment (both P＜0.05). The levels of serum alkaline phosphatase, serum calcium and serum phosphorus in the surgery group also decreased significantly compared with those before treatment (all P＜0.05). The mixed effect model analysis showed that the hemoglobin level of surgery group was on an upward trend after the treatment, and the overall level was significantly higher than cinacalcet and calcitriol treatment group (P=0.007). There was no significant difference in the dosage change of erythropoietin (EPO) in the three groups over time. However, the intra-group comparison of the mixed effect model showed that the dosage of EPO in the 12th month was significantly lower than that of before the treatment in surgery group (P=0.007). Multiple linear regression analysis showed that dialysis vintage (B=-0.064, P=0.012) and ferritin ≥ 500 μg/L (B=0.645, P=0.032) were independent influencing factors of EPO dosage. The longer the dialysis vintage, the less EPO dosage, and more EPO dosage were observed in patients with ferritin ≥ 500 μg/L. Conclusions Parathyroidectomy and forearm transplantation is more effective in reducing EPO dosage and improving renal anemia in maintenance hemodialysis patients with secondary hyperparathyroidism. Dialysis vintage and ferritin are independent influencing factors for the dosage of EPO.     

甲状旁腺全切自体移植术的配合

甲状旁腺全切除后自体移植术是目前国际上治疗慢性肾功能衰竭继发甲状旁腺功能亢进症的较先进方法之一。我们在日本专家的指导下，进行了３例甲状旁旁腺全切除后部分腺体自体前臂移植术，取得了满意疗效。我们体会到，充分的术前准备和细致严密的术中观察、临床测和及时而正确的处理，对手术的成功起了很大的作用．     

Hungry bone syndrome after parathyroidectomy caused by an ectopic parathyroid adenoma

Hungry bone syndrome (HBS), i.e., persistent hypocalcemia and hypophosphatemia as a result of extensive remineralization, is rarely encountered in children after parathyroid surgery. Herein, we report a 12-year-old girl who was diagnosed to have an ectopic parathyroid adenoma, and HBS was observed in the postsurgical follow-up. The diagnosis and the risk factors are discussed in the light of the literature.     

Mediastinal hyperfunctioning parathyroids: incidence, evolving treatment, and outcome

BACKGROUND: The evaluation and treatment of hyperfunctioning mediastinal parathyroid gland(s) (MPG) is evolving. This study reports our overall experience with MPG in a tertiary referral center. METHODS: A prospective database of 922 patients undergoing parathyroidectomy by 2 surgeons from 1982 to 2005 was reviewed. RESULTS: Thirty-two of 922 (3.5%) patients had MPG. Nine (28%) patients had a prior failed parathyroidectomy. Sestamibi and computed tomography scans were correctly positive in 24/28 (86%) and 6/7 (86%) patients, respectively. MPGs were removed via cervical approach in 22 (69%). Eleven of 22 patients had a focused cervical approach. Nine MPGs required a limited sternotomy (n = 3) or a successful radioguided video-assisted thoracoscopic approach (VATS, n = 4) for removal. Two VATS were converted to a full sternotomy. One patient refused surgery. All patients who required sternotomy/VATS had MPGs caudal to the innominate vein. Twenty-nine of 31 (94%) patients were cured. Two are stable on calcimimetics. One patient has permanent hypoparathyroidism. CONCLUSIONS: Most MPGs can be removed through a cervical approach. Preoperative Sestamibi and computed tomography scans can help the surgeon plan the best initial surgical approach. Those below the innominate vein require a thoracic procedure, preferably a radioguided probe-assisted thoracoscopic resection with intraoperative parathyroid hormone (ioPTH). An alternative to surgical removal is medical treatment.     

Surgery improves quality of life in patients with “mild” hyperparathyroidism

Background

Surgical treatment of patients with “classic” hyperparathyroidism improves quality of life, but these benefits to patients with “mild” disease remain unclear.

Methods

The SF-36 Health Survey was administered to 174 patients 1 week before, 1 week after, and 1 year after undergoing parathyroidectomy.

Results

One hundred fifty-one patients completed at least 2 surveys. There were 18 and 133 cases of “mild” and “classic” hyperparathyroidism, respectively. Preoperatively, the groups did not differ significantly in the 10 scales. One year after surgery, patients with “classic” and “mild” disease improved significantly in 9/10 and 10/10 scales, respectively (P < 0.05). Those with “mild” disease had a statistically larger improvement than those with “classic” disease in 4 scales.

Conclusions

Quality of life significantly improved in surgically treated patients with both “mild” and “classic” hyperparathyroidism, supporting surgical treatment of “mild” hyperparathyroidism. Moreover, quality of life may improve more in patients with “mild” rather than “classic” disease.     

Dementia as presenting symptom of primary hyperparathyroidism: favourable outcome after surgery

The case of a 76-year-old female patient is presented with a two-year history of progressive dementia, apathy and gait impairment. Initially, Alzheimer's disease was diagnosed and she was given donepezil for one year with no significant improvement. An extensive blood and biochemical control revealed high serum calcium and parathormone levels, and normal thyroid hormones and anti-thyroid antibodies. Ultrasound of thyroid and parathyroid glands revealed an adenoma of the right parathyroid. The detailed investigation for causes of secondary hyperparathyroidism was negative. Due to the absence of clinical hyperparathyroidism she was initially treated conservatively. At referral, the neurological picture consisted of: mild signs of parkinsonism, moderate dementia (MMSE=15) and severe behavioural disturbances. Because of the continuous aggravation of the cognitive deficit, parathyroidectomy was decided although there were no clinical or laboratory signs of involvement from other organs. Three weeks after the operation the neurological picture showed dramatical improvement. Parkinsonism and behavioural disorders were remarkably reduced and the MMSE score raised to 25. In summary we report an exceptional case of primary hyperparathyroidism (PHPT) presenting as dementia and treated successfully by parathyroidectomy.