Postoperative Serum Calcium Levels Research Articles

Success of cervical exploration for patients with asymptomatic primary hyperparathyroidism

Background: This study examined the success and safety of cervical exploration in patients with asymptomatic primary hyperparathyroidism compared with those with symptomatic disease. Methods: Records of patients undergoing cervical exploration for primary hyperparathyroidism from June 1990 to October 1996 were reviewed. Patients were divided into three groups: (1) asymptomatic, (2) symptomatic, and (3) afflicted (those with associated complications). Information collected consisted of preoperative and postoperative symptoms, serum calcium and parathyroid hormone levels (PTH), and descriptions of pathologic and operative findings. Results: Sixty-one patients were identified. Nineteen (31%) had no symptoms, 21 (34%) had subjective symptoms, and 21 had associated conditions, as described. Average preoperative and postoperative calcium levels were 11.5 mg% and 8.5 mg%, respectively. Average PTH levels also fell from 142 pg/mL to 49 pg/mL after surgery. Preoperative and postoperative calcium and PTH levels for the three groups showed no significant differences. The success of surgery in identifying pathology ranged from 90.5% to 95%, and again showed no difference among the three groups. Long-term morbidity (>6 months) in all groups was 0%. Conclusions: Cervical exploration and parathyroidectomy for asymptomatic primary hyperparathryoidism is safe and has similar success rates in identifying pathology and correcting biochemical abnormalities compared with patients with symptomatic disease.

Morbidity of thyroid surgery

Background: Morbidity is today’s concern in thyroid surgery. The purpose of this paper was to quantify risk factors’ contribution to morbidity rates. Methods: During 50 months, 1,163 patients undergoing 1,192 thyroidectomies at one hospital were reviewed at follow-up of 8 to 58 months. Results: There was 1 death (0.08%). Wound morbidity included 19 hematomas (1.6%), 3 chyle leaks (0.2%), and 6 abscesses (0.5%). Mean hospital stay was 4.3 days after surgery without drain and 5.3 days with drain ( P <0.01). Temporary and permanent hypoparathyroidism (TH; PH) rates were 20% and 4%. Parathyroid autografting and excision rates were 19% and 9%. TH rates were higher after parathyroid autografting or accidental excision ( P <0.01). There was no correlation between the severity of TH and the number of lymph nodes at neck dissection nor between postoperative serum calcium levels and the number of parathyroids identified at bilateral surgery. Temporary and permanent recurrent laryngeal nerve (RLN) palsy (TRLNP; PRLNP) rates were 2.9% and 0.5% (0.3% of 2,010 RLNs at risk). PH and TRLNP (not PRLNP) rates were higher after completion or total thyroidectomy with node dissection ( P <0.01). TRLNP and PRLNP rates after RLN exposure and after nonexposure were not statistically different. Surgical volume had no bearing on hematoma, abscess, TH, PH, TRLNP, and PRLNP rates. Conclusions: High surgical volume, identifying parathyroids and RLNs, failed to reduce morbidity. Completion and total thyroidectomy with node dissection increased PH and TRLNP (not PRLNP) rates.

Use of a rapid intraoperative parathyroid hormone assay in the surgical management of parathyroid disease.

To evaluate the utility of a rapid intraoperative parathyroid hormone (PTH) immunoradiometric assay in the surgical management of parathyroid disease, particularly with reference to limiting extent of cervical exploration. Nonrandomized prospective study. Academic tertiary care center. Forty-three consecutive patients undergoing parathyroid exploration for adenoma or hyperplasia had rapid PTH assays performed from blood drawn at induction and 7 minutes after resection of all hyperfunctioning parathyroid tissue. Excision of all hyperfunctioning parathyroid tissue as assessed by bilateral neck exploration, postoperative normalization of serum calcium and PTH levels, and resolution of clinical symptoms. The intraoperative rapid PTH assay accurately reflected whether all hyperfunctioning parathyroid tissue was excised in every patient. In 41 patients, all hyperfunctioning parathyroid tissue was resected at the time of surgery and confirmed by a corresponding decrease in the intraoperative postexcision rapid PTH determination as well as by subsequent normalization of postoperative serum calcium and PTH levels and resolution of clinical symptoms. In 2 patients, the postexcision rapid PTH assay determination was not consistent with removal of all hyperfunctioning parathyroid disease and both patients demonstrated persistent hyperparathyroidism postoperatively. The intraoperative rapid PTH assay may be of significant benefit in permitting directed unilateral parathyroid explorations for adenoma when combined with preoperative localization with a technetium-99m sestamibi scan. Additionally, the rapid PTH assay has proved to be of benefit in confirming excision of all hyperfunctioning parathyroid tissue in patients with multiple gland hyperplasia, particularly those who may harbor ectopic parathyroid tissue.

Surgical and medical management of patients with pulmonary metastasis from parathyroid carcinoma.

The aim of this study was to characterize patients with pulmonary metastasis of parathyroid carcinoma and to evaluate the long-term effect of surgical and medical therapy. Seven patients with pulmonary metastasis of parathyroid carcinoma were treated between 1980 and 1992. Six patients underwent resection of pulmonary metastases, and one patient has had long-term bisphosphonate therapy alone. Bisphosphonate was also given before or after operation to three patients. Two patients underwent a unilateral thoracotomy for a single pulmonary lesion, and four other patients with multiple lesions underwent staged bilateral thoracotomies. The postoperative serum calcium level returned to normal after each thoracotomy in three patients who were alive and well 3, 8, and 12 years after the first thoracotomy. Hypercalcemia persisted in the other three patients. In two of the patients, bisphosphonate therapy was also unable to control hypercalcemia. In one patient the serum calcium level has been maintained in the 13 mg/dl range by bimonthly bisphosphonate therapy alone for 3 years. The aggressive surgical approach to pulmonary metastasis of parathyroid carcinoma was shown to be effective for palliation in selected patients. Bisphosphonate therapy is an alternative to resection but has only a temporary calcium-lowering effect.

Clinical usefulness of an intraoperative "quick parathyroid hormone" assay.

Intraoperative assays of parathyroid hormone (PTH) in the surgical management of hyperparathyroidism have been limited by an extended "turnaround" time, making it impractical for the operating surgeon. With our modification of a standard immunoradiometric assay for intact PTH, results are reported in 12 minutes. The operative usefulness and the ability of this "quick PTH" assay to predict postoperative serum calcium levels are reported here. Quick PTH levels from whole blood samples taken 10 minutes after excision of hyperfunctioning parathyroid glands were compared with preoperative and preexcision samples in patients undergoing 63 parathyroidectomies. Patients were divided into two groups with assay incubation times of 10 and 6 minutes. The latter was clearly not sensitive enough and resulted in a 20% false-negative rate. However, with a 10-minute incubation time, a decrease of 54% or more in quick PTH levels resulted in postoperative normocalcemia in patients with primary hyperparathyroidism. With these criteria used to predict the postoperative return to normocalcemia in 29 patients with primary hyperparathyroidism, the quick PTH assay had a sensitivity of 96%, specificity of 100%, and overall accuracy of 97%. The quick PTH assay was especially helpful in predicting postoperative calcium levels when multiple excisions were necessary to remove all hyperfunctioning tissue or some normal parathyroid glands were not visualized.

Postoperative management of primary hyperparathyroidism.

Postoperative management of patients with primary hyperparathyroidism requires to determine whether the operation has succeeded or not in early postopera­ tive days as well as to deal with postoperative hypoparathyroidism. Twenty three surgically managed patients with primary hyperparathyroidism were studied. Attention was focused on the time course of postoperative serum calcium levels and postoperative hypocalcemic signs. The following conclusion were obtained. When the surgery was successful, the serum total calcium levels fell·to normal range within 48 hours, then below normal range and gradually returned to normal. It took about one to three months for the serum calcium levels to return to normal. Severe postoperative hypocalcemic signs were observed in those patients with extensive bone disease and high serum alkaline phosphatase activities, in those where initial hypocalcemic signs appeared within 24 hours after surgery, and in those where plasma total calcium levels continued to decrease after the fourth postoperative day. Calcium should be administered only to patients with severe hypocalcemic signs or to those with postoperative congestive heart failure. The second exploration should be performed without delay when the fluctuating hypercalcemia persists after the operation.