Assessment of ultrasound guided percutaneous ethanol injection and parathyroidectomy in patients with tertiary hyperparathyroidism

Background. Tertiary hyperparathyroidism continues tocause significant morbidity in patients with chronic renal failure. This isfrequently resistant to medical management and may ultimately require asurgical parathyroidectomy. Recent studies have reported upon the techniqueof percutaneous ethanol ablation for both primary and tertiaryhyperparathyroidism. In this study we report on a 5 year experience usingethanol injection and compare the results with surgical parathyroidectomy.Methods. A prospective study in 39 patients withtertiary hyperparathyroidism, 25 were dialysis dependent and 14 had afunctioning renal allograft. Twenty-two patients underwent percutaneousfine needle ethanol injection (PFNEI) and 17 underwent surgicalparathyroidectomy. Results. A >30% reduction inintact parathyroid hormone (iPTH) was achieved in 11 of 22 patientsundergoing PFNEI after a mean of 1.8±1.4 injections per gland.In four patients, symptomatic hyperparathyroidism recurred and theyrequired further PFNEI or surgical parathyroidectomy at 17, 28, 46, and 48months later. There was no significant reduction in iPTH in 11 patientsfollowing PFNEI after a mean of 2.5±1.3 injections per gland.They all required a subsequent surgical parathyroidectomy for symptomatichyperparathyroidism. Four patients developed a laryngeal nerve palsyfollowing PFNEI, two of which were permanent. Seventeen patients underwentsuccessful surgical parathyroidectomy as a primary procedure.Conclusion. Whilst PFNEI is successful in primaryhyperparathyroidism, when typically only one adenoma is present, theeffectiveness of PFNEI is unpredictable and the long term results are poorcompared with those of surgical parathyroidectomy in tertiaryhyperparathyroidism. The procedure is not without complications and makessubsequent surgery more difficult. Therefore it can only be recommended forpatients with a known single parathyroid gland such as patients in whomhyperparathyroidism has recurred following a previous surgical subtotalparathyroidectomy and who are unsuitable for further surgery.