A decade of change in the uptake of parathyroidectomy in England and Wales

Introduction

Since the late 1990s, a number of factors have reduced the threshold for parathyroidectomy in patients with primary hyperparathyroidism. This study examined whether this has translated into increased numbers of parathyroid operations over the last decade.

Methods

A retrospective analysis was performed of the Patient Episode Database for Wales and English Hospital Episode Statistics annual data from 2000 to 2010 for parathyroidectomy admissions per 100,000 population. Statistical analysis was by linear regression.

Results

Between 2000 and 2010 there were 24,247 parathyroid operations in England and Wales (0.005% of the population), with 3 times as many women treated as men. Overall, incidence of parathyroidectomy rose from 3.3/100,000 population in 2000 to 5.8/100,000 in 2010 (p<0.0001). In England, it increased from 3.3/100,000 population to 5.8/100,000 and in Wales, it increased from 2.4/100,000 population to 4.6/100,000. Despite similar population demographics, the difference in the rate of change between England and Wales was significant (p<0.05). Uptake also varied according to age; in those aged 0–14 years, incidence of parathyroidectomy remained static whereas in all other age groups, uptake of parathyroidectomy increased significantly from 2000 to 2010. Most notably, surgical intervention in those aged 60–74 and >75 years nearly doubled over the decade (p<0.0001).

Conclusions

The incidence of parathyroidectomy in adults has increased significantly in the last decade in England and Wales. This likely reflects changes in population demography, available guidelines, lower threshold for referral, changing surgical approach and the realisation that surgical morbidity is now infrequent.     

Lateral endoscopic parathyroidectomy in children

Endoscopic thyroid and parathyroid surgery was first described by Gagner in 1996, and Henry subsequently proposed a lateral endoscopic approach in 1999. Technical progress in the fields of optics, endoscopy, digital imaging and laparoscopy has gradually enhanced the feasibility and clinical utility of this technique for the treatment of benign and malignant lesions. To date, published paediatric cases have only concerned thyroid surgery. In the light of two clinical cases, this article describes our lateral endoscopic approach applied to paediatric parathyroid surgery.     

Historical Perspectives on Parathyroid Surgery

The field of parathyroid surgery is rich in history. It begins with an obscure publication by a Swedish medical student noting a distinct anatomic entity in the neck adjacent to the thyroid gland; these tiny glands would come to be known as the parathyroid glands. This was followed by the subsequent discovery of their role in calcium metabolism, once the devastating effects of hyperparathyroidism on the bones and kidneys were recognized. The first neck explorations with identification and removal of parathyroid adenomas took place in the early twentieth century. Following the initial parathyroid operations in the United States and Europe, the mid-twentieth century was dominated by extensive investigation into calcium metabolism and the effects of parathyroid hormone and by refinement of techniques in parathyroid surgery. In more recent years, the introduction of sophisticated localization studies and minimally invasive parathyroid operations continues to inspire progress in this unique and fascinating field. In this review, the sequence of events starting with the anatomic recognition of the parathyroid glands and ending with the most recent developments and advances in parathyroid surgery are described.     

Robotic transoral vestibular parathyroidectomy: Two case reports and review of literature

Advances in preoperative localization studies and demands for scarless surgery have promoted the investigation for remote techniques in parathyroid surgery. Transoral vestibular approach seems to provide the most comfortable and safest access to the neck. In this paper, we report our initial experience with robotic transoral vestibular parathyroidectomy (RTVP) in four patients with primary hyperparathyroidism. The surgery was performed with the Da Vinci system through three trocars introduced from the lower lip vestibule. The procedure was converted to open in two patients due to inappropriate preoperative localization. The mean operative time was 169 min. No postoperative complications were seen. Patients were discharged on postoperative day 1. RTVP is a feasible and safe technique, which allows better surgical exposure and manipulation of the instruments. The advantages of transoral vestibular approach can be enhanced by robotics. Further studies are needed to analyze complications and costs.     

Spectrum of renal dysfunction after curative parathyroidectomy in symptomatic primary hyperparathyroidism

ObjectiveThe long-term renal consequences of curative parathyroidectomy (PTX) in symptomatic primary hyperparathyroidism (sPHPT) are not well characterized. We aimed to assess renal glomerular and tubular functions in an sPHPT cohort at ≥ 1 year's follow-up.DesignRetrospective-prospective study.MethodssPHPT patients with preoperative eGFR ≥ 60 mL/min/1.73m² and in remission (normocalcemic) for ≥ 1 year after PTX underwent clinical and biochemical assessment (calcium profile, renal parameters). Ammonium chloride and bicarbonate loading tests were performed in patients with renal tubular dysfunction (RTD).ResultsForty-eight patients (31 females) with median plasma PTH 1,029 (338–1604) pg/mL and mean eGFR 109.2 ± 26.0 mL/min/1.73m² at diagnosis were evaluated at 5.62 ± 3.66 years after curative PTX. At follow-up, eGFR was < 60 mL/min/m² in 5 patients (10.4%). Patients with > 10% drop in eGFR (n = 31) had significantly higher pre-PTX plasma PTH (1,137 vs. 687 pg/mL), and longer time to post-PTX evaluation (6.8 vs. 3.4 years). RTD was seen in 11 patients (22.9%): urinary low molecular weight proteinuria (14.6%), distal renal tubular acidosis (12.5%), hypophosphatemia (8.3%), and hypokalemia (8.3%); RTD was associated with significantly lower post-PTX eGFR (72.7 vs. 95.4 mL/min/m²). Five of the 7 RTD patients undergoing loading test had impaired urinary acidification, whereas none had impaired bicarbonate resorption.ConclusionsReduction in eGFR and subclinical RTD were prevalent at long-term follow-up in the present Asian-Indian cohort with cured sPHPT. Further studies are warranted to understand the clinical implications of these various renal abnormalities.