Parathyroid Surgery Research Articles

AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck.

AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck.

Abstract #1406181: Complications in the Management of Hypercalcemia in a Patient with Systemic Lupus Erythematous and Lupus Nephritis During Pregnancy

Hypercalcemia can present with a multitude of symptoms including anorexia, nausea and vomiting, constipation and neuropsychiatric disturbances. There is an overlap in these symptoms with those experienced during both pregnancy and in systemic lupus erythematosus. This case report highlights the difficulties in the diagnostic evaluation and management of hypercalcemia during pregnancy. A 26-year-old female with history of Systemic lupus erythematosus (SLE) complicated by Class V lupus nephritis and antiphospholipid syndrome presented August 2022 with symptomatic hypercalcemia at 8-weeks gestation. The patient reported fatigue, nausea and vomiting and new onset severe constipation, polydipsia and polyuria. Lab work was notable for hypercalcemia with calcium 13.2 mg/dl (corrected 13.7 mg/dl for Albumin 3.4g/dl) and parathyroid hormone (PTH) 153pg/ml. No parathyroid nodules were seen on ultrasound and 1st trimester ultrasound demonstrated a single live intra-uterine pregnancy. The patient was diagnosed with primary hyperparathyroidism and started on 0.9% normal saline intravenous fluid at 200cc/hr and Furosemide 20mg/Q6H IV to promote diuresis. Despite this, calcium could not be lowered to less than 12.4 mg/dl (13.0 mg/dl albumin corrected). The patient was discharged with instructions to drink 3-4L water per day and take Furosemide 20mg daily. On follow up at 14 weeks, Calcium was still elevated at 11.9 mg/dl and reported intermittent vomiting and constipation. ENT was consulted to consider parathyroidectomy however opted for conservative management of hypercalcemia prior to delivery due to inability to localize an adenoma and exclude ectopic parathyroid on imaging. The patient was followed closely for the remainder of her pregnancy with improvement in her symptoms, however continued to have persistent hypercalcemia posing risk of materno-fetal complications. Treatment for hypercalcemia is based upon the severity and symptoms, but it is important to consider gestational age. Exceeding the upper normal limit of calcium during pregnancy of 9.5 mg/dL increases the risk of fetal complications including spontaneous abortion, still birth and neonatal tetany. There is added difficulty in determining true symptomatic hypercalcemia given the overlap in symptomatology with pregnancy. In pregnant patients undergoing parathyroid surgery, localization can be done with ultrasound rather than Sestamibi but risks missing ectopic parathyroid glands. If surgery is not recommended, there are limited therapeutic options during pregnancy for hypercalcemia. Notably, IV fluids and diuretics provide modest temporary benefit. Total serum calcium is reported to decline across gestation, likely due to plasma volume expansion, and this may temporize the harmful effects of hypercalcemia to defer surgery until after birth. There is inadequate data on the safe use of Cinacalcet during pregnancy with no known risk of teratogenicity reported in case reports. There is however an increased risk of neonatal hypocalcemia due to gestational suppression of the fetal parathyroid glands.

Surgery for Sporadic Primary Hyperparathyroidism: Evolution over the Last Twenty Years in a Monocentric Setting.

The sporadic parathyroid pathology of surgical interest is primarily limited to lesions that are the cause of hormonal hyperfunction (primary hyperparathyroidism). In recent years, parathyroid surgery has evolved significantly, and numerous minimally invasive parathyroidectomy techniques have been developed. In this study, we describe a single-center and well-documented case series of sporadic primary hyperparathyroidism, surgically treated by a single operator in the Endocrine Surgery Unit of the Surgical Clinic of the University of Florence-Careggi University Hospital, recorded and updated in a dedicated database that embraces the entire evolutionary timeframe of parathyroid surgery. From January 2000 to May 2020, 504 patients with a clinical and instrumental diagnosis of hyperparathyroidism were included in the study. The patients were divided into two groups, based on the application of intraoperative parathyroid hormone (ioPTH). The analysis shows that the use of ioPTH with the rapid method could be ineffective in helping surgeons in primary operations, especially when ultrasound and scintiscan are concordant. The advantages obtained by not using intraoperative PTH are not only economic. In fact, our data shows shorter operating and general anesthesia times and hospital stays, having an important impact on patient biological commitment. Furthermore, the significant reduction in operating time makes it possible to almost triple the volume of activity in the same unit of time available, with an undeniable advantage for the reduction of waiting lists. In recent years, minimally invasive approaches have allowed surgeons to reach the best compromise between invasiveness and aesthetic results.

Does 18F-Fluorocholine PET/CT add value to positive parathyroid scintigraphy in the presurgical assessment of primary hyperparathyroidism?

To investigate the value of presurgical 18F-FCH PET/CT in detecting additional hyperfunctioning parathyroids despite a positive 99mTc-sestamibi parathyroid scintigraphy in patients with primary hyperparathyroidism (pHPT). This is a retrospective study involving patients with pHPT, positive parathyroid scintigraphy performed before 18F-FCH PET/CT, and parathyroid surgery achieved after PET/CT. Imaging procedures were performed according to the EANM practice guidelines. Images were qualitatively interpreted as positive or negative. The number of pathological findings, their topography, and ectopic location were recorded. Histopathology, Miami criterion, and biological follow-up were considered to ensure effective parathyroidectomy confirming the complete excision of all hyperfunctioning glands. The impact of 18F-FCH PET/CT on therapeutic strategy was recorded. 64/632 scanned pHPT patients (10%) were included in the analysis. According to a per lesion-based analysis, sensitivity, specificity, positive predictive value, and negative predictive value of 99mTc-sestamibi scintigraphy were 82, 95, 87, and 93%, respectively. The same values for 18F-FCH PET/CT were 93, 99, 99, and 97%, respectively. 18F-FCH PET/CT showed a significantly higher global accuracy than 99mTc-sestamibi scintigraphy: 98% (CI: 95-99) vs. 91% (CI: 87-94%). Youden Index was 0.79 and 0.92 for 99mTc-sestamibi scintigraphy and 18F-FCH PET/CT, respectively. Scintigraphy and PET/CT were discordant in 13/64 (20%) patients (49 glands). 18F-FCH PET/CT identified nine pathologic parathyroids not detected by 99mTc-sestamibi scintigraphy in 8 patients (12.5%). Moreover, 18F-FCH PET/CT allowed the reconsideration of false-positive scintigraphic diagnosis (scinti+/PET-) for 8 parathyroids in 7 patients (11%). The 18F-FCH PET/CT influenced the surgical strategy in 7 cases (11% of the study population). In a preoperative setting, 18F-FCH PET/CT seems more accurate and useful than 99mTc-sestamibi scan in pHPT patients with positive scintigraphic results. Positive parathyroid scintigraphy could be not satisfactory before neck surgery particularly in patients with multiglandular disease, suggesting a need to evolve the practice and define new preoperative imaging algorithms including 18F-FCH PET/CT at the fore-front in pHPT patients.

Risk factors for recurrent disease in small papillary thyroid cancers – a Swedish register-based study

AimsTo study the correlation between clinicopathological risk factors and the risk for intervention-requiring cancer recurrence in patients with small papillary thyroid cancers (sPTCs).Materials and methodsRecords for 397 patients with sPTC (T1 ≤ 20mm) were obtained from the Scandinavian Quality Register for Thyroid, Parathyroid and Adrenal Surgery (SQRTPA) between 2010 and 2016. Follow-up time was at least 5 years. Data regarding intervention-requiring cancer recurrence were obtained from patient medical records and analysed regarding lymph node (LN) status (N0, N1a and N1b) and recurrence.ResultsAge was significantly lower in the N1a and N1b groups compared to N0 (45 vs. 40.5 vs. 49 years, respectively; p = 0.002). Tumour size was smaller in the N1a group compared to N1b group (9 vs. 11.8 mm; p <0.01). The mean number of metastatic LNs at initial surgery was higher in the N1b compared to N1a group (6.6 vs. 3; p = 0.001), and in the recurrent compared to the non-recurrent group (7 versus 3.9; p <0.01). The recurrence rate was higher in the N1b group than the N1a and N0 groups (25% vs. 2.4% vs. 1.4%, respectively; p = 0.001).ConclusionsLymph node stage N1b at diagnosis, and having five or more metastatic nodes, are strong risk factors for cancer recurrence and decreased disease-free survival in sPTC. The management of patients with sPTC should include thorough lymph node mapping for optimal treatment and individual risk stratification.

Therapeutic strategy for atypical ulnar fracture in long use of bisphosphonate: A systematic review

BackgroundAtypical fractures are caused by the combined effects of severe suppression of bone metabolism (SSBT) due to long-term bisphosphonate therapy and chronic repetitive bone microdamage. Atypical ulnar fractures (AUFs) due to SSBT are rare, and there is no standard treatment strategy for such fractures. The relevant literature was reviewed, and the treatment strategy for AUF is discussed. MethodsA systematic review was conducted. All studies on ulnar fractures in individuals with a history of bisphosphonate use were included, and the data were extracted and analyzed from the perspective of the therapeutic strategy. ResultsForty limbs of 35 patients were included. As for the treatment of AUF, 31 limbs were treated surgically, and conservative treatment with casting was performed for 9 limbs. The bone fusion rate was 22/40 (55.0%), and non-union was seen in all patients treated conservatively. There was a significant difference in the bone fusion rate between patients with surgical treatment and those with conservative treatment. The bone fusion rate of patients with parathyroid hormone (PTH) and surgery was 82.3% (14/17 limbs); the bone fusion rate with PTH and bone graft was 69.2% (9/13 limbs). However, there were no significant differences in the fusion rate in the groups with or without PTH, with or without bone grafting, or the combination of the two treatments. There was also no significant difference in the bone fusion rate in the groups with or without low-intensity pulsed ultrasound (LIPUS) treatment. ConclusionsBased on the literature review, surgery is necessary to achieve bone union, but surgery alone is not adequate to achieve bony union. Bone grafting and the administration of PTH and LIPUS may promote early bone fusion, but the present study did not show significant advantages of these additional treatments for bone union.

Primary Hyperparathyroidism in Multiple Endocrine Neoplasia Type 2A in Denmark 1930–2021: A Nationwide Population-Based Retrospective Study

Studies of primary hyperparathyroidism (PHPT) in multiple endocrine neoplasia type 2A (MEN 2A) shows divergence in frequency, disease definition, reporting of clinical characteristics and traces of selection bias. This is a nationwide population-based retrospective study of PHPT in MEN 2A, suggesting a representative frequency, with complete reporting and a strict PHPT definition. The Danish MEN 2A cohort 1930-2021 was used. Of 204 MEN 2A cases, 16 had PHPT, resulting in a frequency of 8% (CI, 5-12). Age-related penetrance at 50 years was 8% (CI, 4-15). PHPT was seen in the American Thyroid Association moderate (ATA-MOD) and high (ATA-H) risk groups in 62% and 38% of carriers, respectively. Median age at PHPT diagnosis was 45 years (range, 21-79). A total of 75% were asymptomatic and 25% were symptomatic. Thirteen underwent parathyroid surgery, resulting in a cure of 69%, persistence in 8% and recurrence in 23%. In this first study with a clear PHPT definition and no selection bias, we found a lower frequency of PHPT and age-related penetrance, but a higher age at PHPT diagnosis than often cited. This might be affected by the Danish RET p.Cys611Tyr founder effect. Our study corroborates that PHPT in MEN 2A is often mild, asymptomatic and is associated with both ATA-MOD and ATA-H variants. Likelihood of cure is high, but recurrence is not infrequent and can occur decades after surgery.

Nonrecurrent Laryngeal Nerve

The nonrecurrent laryngeal nerve (NRLN) is a rare anatomical variation of the recurrent laryngeal nerve (RLN), in which the nerve enters the larynx directly from the cervical vagus nerve without descending to the thoracic cavity. Knowledge of the anatomy of the RLN and its variations, as well as its identification and careful dissection, is essential to avoid injury to the nerve during thyroid surgery. If not predicted intraoperatively, this anatomical variation can put the nerve at risk with subsequent vocal fold palsy. We report this rare case to highlight the importance of anatomical knowledge to identify NRLN during thyroid and parathyroid surgery.

Application of a Self-developed, Low-budget Indocyanine Green Camera in Surgical Imaging – a Single Institution’s Experiences

Introduction: Indocyanine green is a fluorescent dye, the use of which is becoming more and more widespread in different areas of surgery. Several international studies deal with the dye’s usefulness in intraoperative angiography, the localization of tumors, the more precise identification of anatomical structures, the detection of lymph nodes and lymph ducts, etc. The application of the dye is safe, but a suitable equipment park is required for its use, which entails relatively high costs.Objectives: The aim of our research is to create a detector system on a low budget, to be used safely in everyday practice and to illustrate its operation with practical examples at our own institute.Methods: By modifying a web camera, using filter lenses and special LEDs, we created a device suitable for exciting and detecting indocyanine green fluorescence. We prove its excellent versatility during the following procedures at our institute: breast tumor surgery, kidney transplantation, bowel resection, parathyroid surgery and liver tumor resection.Results: The finished camera has an LED light source with a peak wavelength of 780 nm, and the incoming light is filtered by a bandpass filter with a center wavelength of 832 nm. A low budget ($112), easy-to-use tool was created, which is suitable for taking advantage of the opportunities provided by indocyanine green.

Revision Parathyroid Surgery - Challenges and Considerations in Comparison to Primary Surgery.

Revision parathyroidectomy is made necessary by recurrent or persistent parathyroid disease. This study aimed to identify challenges in revision surgery compared to primary parathyroid surgery. All revision parathyroidectomies performed by one surgeon over a 17-year period were assessed for demographics, imaging, histology, biochemistry, cure rate, gland weight, gland location and gland ectopia, and compared to a series of 100 primary parathyroidectomies. Twenty-eight revision surgical procedures were identified. Sestamibi scanning for gland localisation was superior to ultrasound in both primary and revision surgery. Pre-operative calcium and gland weight were significantly higher in revision cases. There were no significant differences in post-operative calcium levels, pre- or post-operative parathyroid hormone levels, or gland location. 36 per cent of glands excised in revision surgery were ectopic, compared to 25 per cent in primary procedures. The cure rate was significantly lower in revision surgery. Revision parathyroidectomy patients present with higher pre-operative calcium and larger adenomas; the cure rate is significantly lower in these patients.

Ultrasound Guided Cervical Plexus Block for Parathyroidectomy-Out First Experiences

Ultrasound guided Cervical Plexus Block (CPB) is a technique that has been applied in parathyroid surgery. Main advantages of ultrasound technique include a direct view of nerves; local anaesthetic (LA) spreading during injection; reduced volume of LA; blood vessels and other structures injury is significantly reduced. It is especially useful in patients with serious comorbidities, in which possible peri-operative consequences and risks of general anaesthesia can be avoided. Based on our first results of the presented cases, we can say that superficial CPB is a safe and simple procedure in order to provide perioperative analgesia in parathyroid surgery.

Outpatient parathyroid gland operations in the German system-Feasible and useful?

In 2019 approximately 7500 procedures were carried out for parathyroid diseases in Germany (Statistisches Bundesamt 2020, https://www.destatis.de/DE/ ). All operations were performed as inpatient procedures. The catalogue of outpatient procedures for 2023 does not include operations on the parathyroid glands. Which conditions are prerequisites for parathyroid surgery on an outpatient basis? Published data on outpatient parathyroid surgery were analyzed with respect to the underlying disease, procedures performed and patient-specific circumstances. Initial operations for localized sporadic primary hyperparathyroidism (pHPT) seem to be suitable for outpatient surgery, provided that affected patients fulfil the general prerequisites for an outpatient operation. The procedures focused parathyroidectomy and unilateral exploration can be carried out using local or general anesthesia and have avery low risk for postoperative complications. The organization of the day of the operation and the postoperative treatment of the patient should be organized within a detailed standard of procedure. The remuneration for an outpatient parathyroidectomy is not included in the German outpatient surgery catalogue and is therefore currently not adequately financially reimbursed. In selected patients a limited initial intervention for primary hyperparathyroidism can be safely performed on an outpatient basis; however, the present German reimbursement modalities have to be revised so that the cost of these outpatient operations can be adequately covered.

Rocuronium with sugammadex as a rescue reversal agent to solve conflicting recommendations for thyroid or parathyroid surgery. A prospective study

IntroductionFor thyroid or parathyroid surgery, there is a challenge to select a muscle relaxant agent allowing a good quality for tracheal intubation without any residual effect at the time of intraoperative neural monitoring. Patients and methodsIn this monocentric study, non-morbidly obese adult patients without risk factors for difficult tracheal intubation who underwent thyroid or parathyroid surgery with intraoperative neural monitoring were prospectively included. After rocuronium injection (0.5 mg.kg−1) during propofol-sufentanil induction, intubation conditions were evaluated using the Copenhagen score. The surgeon positioned the electrodes NIM® and tested the vagal nerve before recurrent nerve dissection. The signal was considered positive when the wave amplitude exceeded 100 μV. If not, sugammadex (2 mg.kg−1) was administered. The dissection began when the signal was positive. ResultsFrom January 2022 to June 2022, 48 out of 50 patients, 39 (81%) female, met inclusion criteria and were prospectively recruited in the study (two patients had predictable difficult intubation criteria). Intubation conditions were clinically acceptable for 46/48 (96%) of patients. The time delay from rocuronium injection to vagal stimulation was 43 min (mean) +/− 11 (SD). The vagal stimulation was positive in 45 patients (94%). In the 3 remaining patients, sugammadex successfully reversed residual curarization and allowed positive vagal stimulation. DiscussionThis prospective study shows that the use of 0.5 mg.kg−1 rocuronium with sugammadex as a rescue reversal agent allows good quality and safety for intubation conditions and intraoperative neural monitoring in patients scheduled for thyroid or parathyroid surgery.

Transoral Thyroidectomy: Initial Results of the European TOETVA Study Group

BackgroundThe aim of this study was to evaluate a new surgical technique by the European Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) Study Group.MethodsThis study included 391 patients (47 [(12%]) male and 344 [(88%)] female) who had undergone endoscopic thyroid or parathyroid surgery via the vestibular approach between February 2016 and May 2022 at nine centers. The data were analyzed with regard to complications, surgery time and specimen retrieval.ResultsOverall, 376 (96.2%) TOETVA and 15 (3.8%) transoral endoscopic parathyroidectomy vestibular approach interventions were performed with an average surgery time of 145 (± 61.2) minutes and 509 nerves at risk. The specimens were retrieved via a transoral vestibular and retroauricular approach in 66 (16.9%) patients and via a transaxillary approach in 8 (2%). Benign histology including Grave’s disease was identified in 272 (69.6%) patients, 1 (0.3%) presented noninvasive follicular thyroid neoplasms with papillary-like nuclear features, and 103 (26.3%) showed differentiated thyroid carcinoma. Solitary parathyroid adenoma were removed in 15 (3.8%) patients. Conversion to open surgery was necessary in 13 (3.3%) and revision had to be performed in 2 (0.5%) patients. Transient recurrent laryngeal nerve palsy (RLNP) was present in 18 (4.6%) and permanent RLNP in 2 (0.5%) patients. Fifteen (3.8%) patients experienced transient hypoparathyroidism after thyroidectomy. No case of permanent hypoparathyroidism was observed. Postoperative surgical site infection occurred in 1 (0.3%) patient. Despite a higher rate of sensory and motor disorders and skin discoloration at discharge, permanent disorders were present in only 3 (0.8%) and 16 (4.1%) patients, respectively.ConclusionOur results show that transoral endoscopic surgery, performed by experienced endocrine surgeons, is a safe alternative to conventional thyroid surgery.

The Role of Primary Repair of the Recurrent Laryngeal Nerve during Thyroid/Parathyroid Surgery in Vocal Outcomes-A Systematic Review.

Recurrent laryngeal nerve (RLN) injury is a well and long-known complication of thyroid and parathyroid surgery that significantly affects the quality of life of patients. Despite the advances in surgical techniques and technology, it still occurs in clinical practice either as temporary paresis or as permanent paralysis of the corresponding vocal cord. The purpose of the current systematic review is to examine the value of intraoperative repair of the RLN in voice restoration. A systematic review of the existing literature was conducted using PubMed, Scopus, Cochrane Library, and Google Scholar databases according to the PRISMA guidelines. The systematic review resulted in 18 studies, which met the inclusion criteria. An improvement in phonatory function and voice quality was observed in all these studies after immediate RLN reconstruction (not always statistically significant). This improvement appears to be comparable to or even higher than that achieved with other methods of repair, and in some cases, the improvement approaches levels found in normal subjects. Intraoperative RLN reconstruction is not widely used in clinical practice, but the evidence so far makes it a viable and safe alternative to traditional techniques with better long-term results, as it prevents the occurrence of atrophy of the vocal cord and should be considered in the operating room if possible.

Patterns of Prescribing Postoperative Analgesic Medication After Thyroid Surgery: A Retrospective Cohort Study.

Mild-to-moderate postoperative pain is common after surgical procedures of the thyroid. Opioid analgesics have been commonly prescribed in such cases, but their use has been debated owing to concerns regarding the addictive nature of opioids. Recently, experts from the Endocrine Surgery Section of the American Head and Neck Society released a consensus document to limit the use of opioids as the first-line pain control medication after head and neck or endocrine procedures. However, differences in pain management prescriptions have been noted in many settings. This study aims to assess the post-thyroid surgery pain control medication prescription practices of head and neck and endocrine surgeons. This study retrospectively reviewed the charts of 105 adult patients who underwent thyroid surgery (total thyroidectomy, thyroid lobectomy, or subtotal thyroidectomy) by head and neck or endocrine surgeons. The type of prescribed pain medication at hospital discharge postoperatively was then retrieved from each patient's discharge medication list. Descriptive statistics mean, standard deviations, frequencies, and percentages were computed, while the Chi-square test was applied to measure the significant differences among variables at a 5.00% significant level. An outpatient oral opioid, in the form combining paracetamol and codeine, was prescribed for 62 (59%) patients, whereas 43 (41%) were discharged on paracetamol only. The use of opioids is the practice pattern for pain management among some head and neck or endocrine surgeons despite emerging evidence that supports the use of non-opioid and other alternative analgesic strategies in outpatient thyroid and parathyroid surgery. Further research and quality improvement interventions should be geared towards leading all health professionals to appropriate prescription practices to improve patient safety and reduce unnecessary opioid prescriptions.

Detection, resection and cure: a systematic review and meta-analysis of 18F-choline PET in primary hyperparathyroidism.

Primary hyperparathyroidism (pHPT) is a common endocrine disorder caused by an autonomous overproduction of parathyroid hormone (PTH) by a parathyroid gland. Over the last decade, 18F-choline (FCH) PET has emerged as a highly performant imaging technique for guiding parathyroidectomy. As cure is the goal of surgery, the main aims of this study were to summarize patient-based sensitivity, positive predictive value (PPV), and cure rate of FCH PET guided surgery in the surgical management of pHPT. We conducted a systematic review and metaanalysis according to the PRISMA Guidelines. A literature search was performed in the PubMed, Web of Science and Cochrane databases, last updated November 2022. Original articles on choline PET in patients with pHPT mentioning patient-based sensitivity, PPV and cure rate were retained. Quality of included studies was assessed using the QUADAS-2 Tool. Patient-based sensitivity, PPV and cure rate were pooled by using a random-effects model. Twenty-three studies including 1716 patients were included for quantitative assessment. FCH PET showed a pooled patient-based sensitivity of 93.8% (95% CI: 89.8-96.3) and PPV of 97% (95% CI: 92.8-98.8) in patients with pHPT. Parathyroid surgery was performed in 1129 patients. The pooled cure rate of PET-guided surgery was 92.8% (95% CI: 87.4-96.0). Heterogeneity was shown to be moderate for all effect sizes. FCH PET showed a high patient-based sensitivity, PPV and cure rate of PET guided surgery in patients with pHPT.

The use of indocyanine green in thyroid and parathyroid surgery. Our initial experience.

The use of indocyanine green in thyroid and parathyroid surgery. Our initial experience.

Hungry bone syndrome after parathyroid surgery.

Data on the incidence rates of hungry bone syndrome after parathyroidectomy in patients on dialysis are inconsistent, as the published rates vary from 15.8% to 92.9%. Between 2009 and 2019, 120 hemodialysis patients underwent parathyroidectomy for secondary hyperparathyroidism at the Chang Gung Memorial Hospital. The patients were stratified into two groups based on the presence (n=100) or absence (n=20) of hungry bone syndrome after parathyroidectomy. Subtotal parathyroidectomy was the most common surgery performed (76.7%), followed by total parathyroidectomy with autoimplantation (23.3%). Pathological examination revealed parathyroid hyperplasia. Hungry bone syndrome developed within 0.3 ± 0.3months and lasted for 11.1 ± 14.7months. After surgery, compared with patients without hungry bone syndrome, patients with hungry bone syndrome had lower levels of nadir corrected calcium (P < 0.001), as well as lower nadir (P < 0.001) and peak (P < 0.001) intact parathyroid hormone levels. During 59.3 ± 44.0months of follow-up, persistence and recurrence of hyperparathyroidism occurred in 25 (20.8%) and 30 (25.0%) patients, respectively. Furthermore, patients with hungry bone syndrome had a lower rate of persistent hyperparathyroidism than those without hungry bone syndrome (P < 0.001). Four patients (3.3%) underwent a second parathyroidectomy. Patients with hungry bone syndrome received fewer second parathyroidectomies than those without hungry bone syndrome (P < 0.001). Finally, a multivariate logistic regression model revealed that the preoperative blood ferritin level was a negative predictor of the development of hungry bone syndrome (P=0.038). Hungry bone syndrome is common (83.3%) after parathyroidectomy for secondary hyperparathyroidism in patients undergoing hemodialysis, and this complication should be monitored and managed appropriately.

Early Bone Pain Relief a Reliable Indicator of Successful Para Thyroidectomy - A Comparative Prospective Study

Aim: To evaluate early bone pain relief as anindicatorof successful Para thyroidectomy in hyperparathyroidism. Methodology: A prospective, comparative study was conducted at the Department of Surgery, Jinnah Postgraduate Medical Center, between March 2022 and August 2022. All patients with symptoms of hyperparathyroidism, confirmed with increased intact parathyroid hormone and elevated levels of calcium onpresentation were included in the study. Patients were classified as primaryhyperparathyroidism when the MIBI scan detected an adenoma with clinical features ofhypercalcemia and increased PTH whereas, patients were diagnosed with secondaryhyperparathyroidism if patient presented with renal failure, persistently high levels of PTH, as well as hypocalcemia. All patients with primary hyperparathyroidism underwentexcision for adenoma while patients with secondary hyperparathyroidism underwenttotal Para thyroidectomy and auto transplantation. Visual analogue scale was used toassess bone pain at presentation and 12 to 24 hours after procedure, and then six-weeks atfollow-up. Change in symptomatology was observed and compared between the twosets of patients. Results: A total of fourteen primary hyperparathyroidism cases were observed in ourcenter. 13 patients presented with bone pain and deformity, three of these patients were operated for renal stones, three patients had depressive symptoms. The calcium ranged from 12-15mg/dl with adenoma ranging from 1.0 cm to 4.0 cm.Three cases were diagnosed as secondary hyperparathyroidism, secondary to renal failure. Total Para thyroidectomy was done to remove all four parathyroid glands with subsequent auto transplant. All patients had hypo calcemic signs postoperative, which was relieved after calcium transfusion for two days followed by oral. Conclusion: In all patients, irrespective of the cause of the hyperparathyroidism, early pain reliefwas correlated with successful parathyroid surgery. Keywords: Parathyroid, hyperparathyroidism, primary, secondary, PTH, calcium, pain