Surgical Treatment Of Secondary Hyperparathyroidism Research Articles

Surgical treatment of secondary hyperparathyroidism in children with chronic kidney disease. Experience in 19 patients.

Secondary hyperparathyroidism (sHPT) is an important contributor to bone disease and cardiovascular calcifications in children with chronic kidney disease (CKD). When conservative measures are ineffective, parathyroidectomy is indicated. The aim of our study was to evaluate the efficacy and safety of subtotal parathyroidectomy (sPTX) in pediatric and adolescent patients, and to provide a rationale for considering this aggressive treatment in CKD patients with uncontrolled sHPT. We retrospectively analyzed the medical records of 19 pediatric CKD patients on dialysis with refractory sHPT who underwent sPTX at our institution between 2010 and 2020. All patients had clinical, radiological, and biochemical signs of renal osteodystrophy. One year after sPTX, parathyroid hormone (PTH) levels (median and interquartile range (IQR)) dropped from 2073 (1339-2484) to 164 (93-252) pg/mL (p=0.0001), alkaline phosphatase (ALP) levels from 1166 (764-2373) to 410 (126-421) IU/L (p=0.002), and the mean (±SDS) calcium-phosphate (Ca*P) product from 51±11 to 41±13mg2/dL2 (p=0.07). Postoperatively, all patients presented with severe hungry bone syndrome (HBS) and required intravenous and oral calcium and calcitriol supplementation. None of them had other postoperative complication. Histological findings had a good correlation with preoperative parathyroid ultrasound imaging (n: 15) in 100 % and with technetium-99m (99mTc) sestamibi scintigraphy (n: 15) in 86.6 %. Clinical and radiological signs of bone disease improved in all patients. Pediatric sPTX is effective and safe to control sHPT and calcium-phosphate metabolism in children with CKD on dialysis and may mitigate irreversible bone deformities and progression of cardiovascular disease.

#3724 CHANGES IN CARDIOVASCULAR CALCIFICATION AFTER PARATHYROIDECTOMY IN DIALYSIS-DEPENDENT PATIENTS

Abstract Background and Aims Vascular calcification (VC) is common in patients with end stage kidney disease on dialysis and with secondary hyperparathyroidism (SHPT). There is a lack of knowledge regarding dynamics of VC after surgical treatment of SHPT. We aimed to evaluate evolution of coronary artery calcification (CAC) and abdominal aortic calcification (AAC) after parathyroidectomy (PTx) in dialysis patients with SHPT. Method The prospective cohort study included 33 dialysis-dependent patients (mean age of 50±13 years) with severe SHPT who underwent subtotal (n = 16) or total PTx with autotransplantation of parathyroid tissue (n = 17). Cardiac computed tomography scan (quantification of coronary calcium by Agatston method) and lateral lumbar X-ray (semi-quantitative Kauppila score) were used to assess prevalence of VC before and 18 months after surgery. Levels of serum total calcium, phosphorus, parathyroid hormone (PTH), and alkaline phosphatase (AP) before and 18 months after surgery were also evaluated. Results In our cohort median dialysis vintage before surgery was 71 [Q1-Q3: 29; 136] months, total serum Ca was 2.47±0.23 mmol/l, median PTH was 139 [Q1-Q3: 90; 161] pg/ml. Prevalence of CAC before PTx was 79% (n = 26), and 61% (n = 20) of patients had AAC. Of note, 54.5% of the patients had severe coronary calcification (>400 AU), while only 12% were considered to have severe calcification using Kauppila score (>12). We observed moderate positive correlation between CAC and AAC scores (Spearman's ρ = 0.699 [95% CI: 0.48; 0.84], р<0.0001). Both CAC and AAC scores correlated moderately with age of the patients (ρ = 0.57 [95% CI: 0.3; 0.76], р = 0.0002, and ρ = 0.64 [95% CI: 0.39; 0.8], р<0.0001, respectively), AAC had weak correlation with their dialysis vintage (ρ = 0.45 [95% CI: 0.14; 0.68], р = 0.005. Median of baseline CAC was 458 [Q1-Q3: 23; 1585] AU, after 18 months - 491 [Q1-Q3: 58; 1956] AU, no statistically significant differences were observed (p = 0.91, Wilcoxon test). We did not find statistically significant differences between median of Kauppila scores before and after PTx as well: 3 [Q1-Q3: 0; 10] and 2 [Q1-Q3: 0; 10], correspondingly, p = 0.17 (Wilcoxon test) – Fig. 1. As it can be seen from Fig. 1, dynamics of both CAC and AAC values before and after PTx varied markedly across subjects. To investigate the factors that can promote VC we divided patients into 2 groups based on dynamics of САС (as the most accurate assessment method) 18 months after surgery: group 1 with CAC progression of more than 50 AU (n = 9) and group 2 with regression or progression less than 50 AU (n = 24). Patients who had progression of coronary calcification by the end of the follow-up had higher age (59±11 vs 46±12 years in 2nd group, p = 0.0128) higher serum calcium levels (2.57±0.24 vs 2.29±0.32 mmol/l in 2nd group, p = 0.0267), and higher AP levels at follow-up (69.8 [Q1-Q3: 62.8, 96.0] vs 51.7 [Q1-Q3: 41.4; 57.1] U/ml in 2nd group, p = 0.003). Univariate analysis showed no significant differences between groups comparing dialysis vintage (p = 0.53), phosphate levels (p = 0.54), PTH levels (p = 0.32). In addition, CAC progression risk was not associated with type of surgery (total vs subtotal PTx RR = 1.11 [95% CI: 0.71; 1.8], OR = 1.48 [95% CI: 0.3; 5.7], p = 0.708). Conclusion Prevalence of vascular calcification in dialysis-dependent patients with severe SHPT is high. Progression of CAC by 18 months after PTx was associated with higher age of the patients, higher follow-up levels of serum total Ca and AP.

Комплексное хирургическое лечение вторичного гиперпаратиреоза в условиях многопрофильного стационара (клинический случай)

Комплексное хирургическое лечение вторичного гиперпаратиреоза в условиях многопрофильного стационара (клинический случай)

Ambulatory Parathyroidectomy for Secondary Hyperparathyroidism at a Large Dialysis Program in Toronto: A Program Report.

Operative wait times for non-oncology-related procedures continue to rise in Canada, and this was further exacerbated by the COVID-19 pandemic. These challenges will remain prevalent beyond the pandemic given the limited number of acute care beds and resources required to care for patients. As a result, the need for innovative approaches to optimize the utilization of health care resources while maintaining equitable and timely access is needed. In this report, we describe the development of a collaborative ambulatory parathyroidectomy program between two centers in Toronto, allowing for more expedient surgical treatment of secondary hyperparathyroidism among patients from a large dialysis program. The need for expanded access to surgical care for secondary hyperparathyroidism was identified through interdepartmental communication between referring nephrologists and surgeons at Sunnybrook Health Sciences Centre and Women's College Hospital, respectively. A multidisciplinary ambulatory parathyroidectomy planning team was formed that included nephrologists, endocrine surgeons, nurses, and patient care managers to conduct a needs assessment. It was identified that patients had long wait times, and to address that gap in care, a protocol was developed to identify suitable patients requiring treatment. The teams created a plan to coordinate patient care and transfers. A clinical tool and protocol for post-operative management of hypocalcemia was developed using a Delphi model, gathering input from many members of the care team. The Delphi process to finalize the protocol included a series of virtual meetings over a period of about 4 months with various stakeholders and included input from two departmental heads (medicine and surgery), three nephrologists, a nurse practitioner, a patient care manager, and two nurse educators. Meetings involved core members of the Nephrology Quality Improvement and Patient Safety at Sunnybrook Health Sciences Centre and finalized protocol was agreed upon by members of this group at a quarterly meeting. In this article, we describe the development, initial deployment, and planned assessment of the ambulatory parathyroidectomy program at the Women's College Hospital and Sunnybrook Health Sciences Centre. The primary aim of the program is to increase accessibility to parathyroidectomy for secondary hyperparathyroidism. A secondary aim was to allow patients to have streamlined care with a team that is well versed with maintenance dialysis needs and optimizing treatment of post operative hypocalcemia through standardized protocols. Ambulatory parathyroidectomy relies on effective communication, flow, and availability of acute care beds. It is anticipated that occasionally, unexpected hospital demands, and health care disruptions may occur, which can limit efficiency of the program. We will also need to examine the cost-effectiveness of this program as it may improve access but increase costs related to the procedure. As the program is implemented, useful adaptations and policies to our protocol to help mitigate these limitations will be documented and published in our outcomes report. Ontario residents with chronic kidney disease with secondary hyperparathyroidism who have failed medical management will have increased and timely access to parathyroidectomy.

ИЗМЕНЕНИЕ КАЧЕСТВА ЖИЗНИ ПОСЛЕ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ВТОРИЧНОГО ГИПЕРПАРАТИРЕОЗА У ПАЦИЕНТОВ, ПОЛУЧАЮЩИХ ЗАМЕСТИТЕЛЬНУЮ ПОЧЕЧНУЮ ТЕРАПИЮ ГЕМОДИАЛИЗОМ

Objective. To assess quality of life (QoL) using the Short Form Medical Outcomes Study (SF-36) questionnaire before and after surgical treatment of secondary hyperparathyroidism (SHPT) in patients undergoing renal replacement therapy. Methods. QoL was assessed before surgery and in the period from 4 to 30 months after surgical treatment of SHPT. Twenty patients were questioned according to SF-36 questionnaire in a longitudinal study and in comparison, with the population indicators of the Irkutsk region residents. The median age before surgery was 53 years, the median level of PTH before surgery was 1715 pg/ml. After surgical treatment, the median of PTH was 12.9 pg/ml, calcium - 1.99 mmol/l; phosphorus - 1.72 mmol/l within 6-12 months. Results. An unfavorable effect of SHPT on QoL of patients receiving hemodialysis was shown in comparison with population indicators. Evaluation of the effectiveness of surgical treatment of SHPT in relation to changes in the quality of life of patients is given. A statistically significant increase in QoL indicators after surgical treatment was proved for all the studied scales (pW<0.05). In the long term after the operation, QoL of patients receiving hemodialysis exceeds the population indicators on the scales of the psychological component of health, pain intensity, social and role functioning. Conclusion. The SHPT in patients receiving hemodialysis is the cause of a decrease in QoL in comparison with population indicators was shown for the first time. Surgical remission of the disease leads to a statistically significant improvement in QoL, and on the scales of the psychological component of health, intensity of pain, social and role functioning, the quality of life of patients exceeds population indicators in a similar age group. The data obtained allow us to consider postoperative hypoparathyroidism as one of the favorable factors in course of postoperative period and criterion for remission of the disease. What this paper adds It has been shown that the secondary hyperparathyroidism in patients undergoing hemodialysis is the cause of a decrease in life of quality in comparison with population indicators. Surgical remission of the disease leads to a statistically significant improvement the quality of life. The data obtained allow considering postoperative hypoparathyroidism as one of the favorable factors in the course of the postoperative period and criteria for remission of the disease.

Surgical Treatment of Secondary Hyperparathyroidism at Ectopic Parathyroid Gland in Anterior-Superior Mediastinum (Literature Review and Clinical Case)

Parathyroidectomy is the leading treatment for drug-refractory secondary and tertiary hyperparathyroidism in patients with chronic kidney disease. Difficulties in performing this surgery are mainly associated with the anatomical features of the parathyroid glands, in particular with the variability of their number and topographic anatomy. Ectopic parathyroid glands are one of the most common causes of persistence or recurrence of secondary hyperparathyroidism after surgery. One of the common variants of ectopia is the localization of the parathyroid gland in the anterior-superior mediastinum. The article discusses the features of surgical treatment of secondary hyperparathyroidism in patients with end-stage chronic kidney disease with this ectopia. A new method of treating hyperparathyroidism in patients with an atypical location of the parathyroid gland in the anterior-superior mediastinum is presented. This method is characterized by low invasiveness of access, ease of implementation without using special equipment and instruments. The proposed method was used in the treatment of a patient with secondary hyperparathyroidism due to chronic renal failure as a result of chronic glomerulonephritis. The duration of hemodialysis at the time of the surgery was more than 17 years. In the presented clinical case, ectopia of one of the pathologically altered parathyroid glands in the anterior-superior mediastinum was found at the preoperative stage. As a method of surgical treatment, we carried out total parathyroidectomy with autotransplantation of a fragment of parathyroid tissue into the brachioradialis muscle. Thanks to this method, it was possible to remove the atypically located parathyroid gland from the cervicotomy access and to discharge the patient within the standard terms for a given volume of surgery.

Indications of surgical treatment of secondary hyperparathyroidism in hemodialysis patients

Indications of surgical treatment of secondary hyperparathyroidism in hemodialysis patients

Surgical treatment for secondary hyperparathyroidism in the new therapeutic era

Surgical treatment for secondary hyperparathyroidism in the new therapeutic era

Network meta-analysis of surgical treatment for secondary hyperparathyroidism.

Main surgical treatments for secondary hyperparathyroidism (SHPT) include subtotal parathyroidectomy (sPTX), total parathyroidectomy with autotransplantation (tPTX+AT), and total parathyroidectomy (tPTX); however, determining the best treatment is debatable. We conducted a network meta-analysis (NMA) comparing three treatments in terms of postoperative hypocalcemia (or hypoparathyroidism), postoperative recurrence, and reoperation. We searched PubMed, Medline, the Cochrane Library, and Embase for relevant research from inception to July 30, 2019. We performed our Bayesian NMA using R 3.51 software to assess odds ratios (OR) and 95% confidence intervals (CI). Network and forest plots displayed study outputs. Potential publication bias was assessed with funnel plots using software Stata/MP 13.0. Twenty-six articles comprising 5063 patients were included in our NMA, which showed that postoperative hypocalcemia (or hypoparathyroidism) occurred more frequently in tPTX than in sPTX (OR=3.50, 95% CI 1.10-11.0) or tPTX+AT patients (OR=1.80, 95% CI 0.66-5.20). Regarding postoperative hypocalcemia (or hypoparathyroidism), there was no significant difference between sPTX and tPTX+AT (OR=0.53, 95% CI 0.24-1.10). As for recurrence rates, statistically significant differences were observed between sPTX and tPTX (OR=25.0, 95% CI 5.1-260), tPTX+AT and tPTX (OR=20.0, 95% CI 4.2-200), and sPTX and tPTX+AT (OR=1.30, 95% CI 0.65-2.50). Regarding reoperation rates, sPTX experienced higher incidence compared with tPTX+AT (OR=1.20, 95% CI 0.53-2.70) or tPTX patients (OR=2.70, 95% CI 1.20-14.00). TPTX+AT is recommended as the most efficient and safe surgical SHPT treatment with minimal adverse effects. Large-scale randomized controlled trials are recommended to confirm the NMA results.

Surgical treatment of uremic secondary hyperparathyroidism complicated with thyroid nodules

Objective:To investigate the surgical treatment of secondary hyperparathyroidism(SHPT) with thyroid nodule(TN) in uremic patients.Method:The clinical data of 26 patients diagnosed as SHPT combined with TN were retrospectively analyzed.Result:The patients underwent total parathyroidectomy and parathyroid granuless were transplanted subcutaneously into the forearm. The levels of parathyroid hormone,alkaline phosphatase,serum calcium,serum phosphorus and calcium-phosphorus product in 6 months and 12 months after operation were significantly lower than those before operation(P<0.01).The quality of life assessed by KDQOL-SF scale was significantly higher than that before operation(P<0.01). Concomtiant TN was operated simultaneously, and gravel calcification was significantly associated with papillary thyroid carcinoma(P<0.01).Conclusion:Total parathyroidectomy plus subcutaneous minimal forearm autograft and concurrent surgery with TN are feasible, and can not only properly treat TN, but also significantly improve SHPT-related prognosis and quality of life. We should be alert to the possibility of malignant TN in SHPT background, especially those with grit calcification.

Surgical treatment of secondary hyperparathyroidism in patients with chronic kidney disease

Surgery of patients with secondary hyperparathyroidism in the era of calcimimetics continues to play an important role in selected patients and achieves an efficient control of hyperparathyroidism. Taken together, the results of literature review suggest a clinically significant beneficial effect of surgical parathyroidectomy to decrease the overall and cardiovascular mortality in patients with secondary hyperparathyroidism due to chronic kidney disease. However, the independent randomized controlled trial comparing surgery with medical therapy to clarify the outcome and to improve the quality of life is in need.

Surgical Treatment of Secondary Hyperparathyroidism in Surgery B of Chu of Point G

Purpose: To describe the epidemiological, clinical and therapeutic aspects of secondary hyperparathyroidism inrenal failure chronic. Patients and methods: We collected 11 cases of hyperparathyroidism secondary to renal failure terminal operated in the Service of surgery B of the Central Hospital University of Point G between December 2016 and November 2018. Results: The sex ratio was 0.22 in favor of women. The average age of the patients was 43 or 27 years with extremes of 63 and 25 years. Secondary hyperparathyroidism in renal failure chronic represented 1.9% of interventions to cold in the Service of surgery B. 100% of patients (11/11) were haemodialysis. 100% of the patients had clinical and biological signs. 45.5% (5/11) had radiological signs. The average rate of parathyroid hormone was 2413.51 pg/ml with extremes of 1264 pg/ml and 3616 pg/ml. The reference value was 15 - 65 pg/ml. The surgical technique of choice was the 7/8th parathyroidectomy in 100% of cases. The postoperative were simple in 81.8%, and complicated in 18.2%. There were no death. The average duration of postoperative follow-up was 6 months. After surgery, 50% of patients (5/10) had normal levels of parathyroid hormone and 50% (5/10) made a persistent hyperparathyroidism. Conclusion: Secondary hyperparathyroidism is a frequent complication in renal insufficient chronic in hemodialysis. Surgery is indicated in the resistant cases of medical treatment. The 7/8th parathyroidectomy is the surgical technique of choice. The rate of post operative complications is higher in our context.

Surgical treatment of secondary hyperparathyroidism

Aim: Initial treatment of secondary hyperparathyroidism (sHPT), often seen as a result of end-stage renal failure, is medical treatment. Treatment-resistant patients require surgery. The aim of this study is to evaluate the diagnosis and treatment of patients who underwent sHPT. Material and Methods: Twenty-one patients who were operated for sHPT were included in the study. The demographic data of the patients and correlation of imaging results with correct localization and pathological diagnosis were evaluated. Results: The mean age of the patients was 45.80±1.10. While the number of patients with growth in a parathyroid gland was 7 (32%), the number of patients with multiple glands was 8 (39%). According to scintigraphy evaluation, the same values were 4 (19%) and 12 (57%) patients. 7 (34%) patients were underwent adenoma excision, 11 (52%) patients were underwent subtotal parathyroidectomy and 3 (14%) patients were underwent total parathyroidectomy + parathyroid auto-implantation. Persistent hyperparathyroidism was seen in 2 patients who underwent subtotal parathyroidectomy and 1 patient who underwent adenoma excision. Conclusion: Today, the treatment of sHPT is still the best treatment option, and as a treatment, subtotal parathyroidectomy and total parathyroidectomy + parathyroid autoimplantation surgery should be preferred.

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

PurposeParathyroidectomy 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. Materials and methodsWe analysed parathyroid surgery data, considering patient demographics, such as age and gender, and surgical procedure data, such as type of hyperparathyroidism, associated thyroid or thymus surgery, surgical duration and mediastinal recurrence. Histopathological results of thyroid and thymus samples were also analysed. ResultsMedical records of 109 patients who underwent parathyroidectomy for secondary hyperparathyroidism were reviewed. On average, thymectomy did not have impact on time of parathyroidectomy (p = 0.62) even when thyroidectomy was included (p = 0.91). Intrathymic parathyroids were detected in 7.5% of the thymuses removed and papillary carcinoma was detected in 20,8% of thyroid tissue samples. Two patients showed recurrence of supernumerary intrathymic parathyroids and a single case of mediastinitis was observed. ConclusionsParathyroidectomy with thymectomy and/or thyroidectomy has an important role in the treatment of renal hyperparathyroidism since thyroid cancer can frequently occur and require surgery. Thymectomy should be considered to avoid recurrence and a risky re-operation.

Спорные вопросы хирургического лечения вторичного гиперпаратиреоза. Обзор литературы

Спорные вопросы хирургического лечения вторичного гиперпаратиреоза. Обзор литературы

ОПЫТ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ВТОРИЧНОГО ГИПЕРПАРАТИРЕОЗА

Surgical treatment of secondary hyperparathyroidism (HPT) in patients having renal replacement therapy (RRT) is a current problem. The aim of our study was to optimize the treatment of secondary HPT based on the comparative analysis of effectiveness of the surgeries with different extents. We conducted a retrospective analysis of the results of surgical treatment of uremic HPT in 34 patients. 36 surgeries were performed including 34primary (16subtotal parathyroidecomies (PTE), 13total parathyroidecomies (total PTEI), 5total parathyroidecomies with central neck dissection and resection of superior mediastinum and superior thymus horns (total PTEII)) and 2repeated surgeries (total PTEII and parathyroidadenomectomy). Gross examination of 134 surgical specimens revealed dyssynchronous pathological changes in parathyroid glands (PTG), normal PTG structure was found in 2cases. Recurrent HPT was found in 3 cases, persistent HPT – in 9cases, hypoparathyroidism – in 5cases after subtotal PTE and in 9 cases after total PTE with autotransplantation (p=0,267). Target values of parathyroid hormone were registered in 8patients, including 4 patients after subtotal PTE and 4 patients after total PTE (p&amp;#62;0,95). Morbidity was similar in all types of surgeries (p&amp;#62;0,5). Analysis of morbidity determined that simultaneous surgery of thyroid gland increased the risk of laryngeal paralysis (р=0,028). The decrease in occurrence of secondary HPT persistence (with the source accessible for removal through cervical approach) at total PTE based on the removal of parathyroid glands of all localizations accessible through cervical approach (including thyroid gland lobes with diagnosed ectopia, central cervical fat pad, superior mediastinum and superior thymus horns) was registered (NNT=4).

Surgical treatment of secondary hyperparathyroidism in elderly patients: an institutional experience.

Secondary hyperparathyroidism in elderly fragile patients presents clinical difficulties due to severity of symptoms and related comorbidity. The optimal surgical approach for this group of patients is still debated. The aim of the study was to define the optimal technique of parathyroidectomy in elderly patients with secondary hyperparathyroidism. Retrospective analysis in a series of 253 patients including 35 elderly individuals at a single institution was carried out. Postoperative parathyroid hormone decrease, surgical complications and symptoms control were analyzed for all patients in relation to the types of parathyroidectomy performed. In elderly patients, total parathyroidectomy was the most used approach. Subtotal parathyroidectomy was mostly reserved for younger patients suitable for kidney transplantation. No elderly patients treated with total parathyroidectomy were autotransplanted. No significant difference in surgical complications was observed between younger and elderly patients and considering the different procedures. Adequate symptom control after surgery was achieved in almost 90% of patients. A limited rate of recurrence requiring repeat surgery was observed only after subtotal parathyroidectomy. Considering the features of all types of parathyroidectomy, very low recurrence rate, contained postoperative hypocalcemia and limited complications following total parathyroidectomy, might represent specific advantages for elderly patients. Total parathyroidectomy without parathyroid transplantation is safe for elderly patients with secondary hyperparathyroidism and a good alternative to the well-established total parathyroidectomy with autografting.

Aspects of the surgical treatment of secondary hyperparathyroidism in patients with chronic renal failure are on dialysis replacement therapy program

Aspects of the surgical treatment of secondary hyperparathyroidism in patients with chronic renal failure are on dialysis replacement therapy program

Radioactive probe-guided parathyroidectomy for secondary hyperparathyroidism

Background The value of gamma probes in the surgical treatment of secondary hyperparathyroidism (sHPT) was determined. The aim of this study was to enhance the rate of successful total parathyroidectomy in patients with sHPT using intraoperative gamma probe investigations. Methods We retrospectively analyzed the clinical data of 48 sHPT patients between May 2007 and September 2011. Preoperative 99Tcm- methoxyisobutyl isonitrile (MIBI) scintigraphy and high-frequency ultrasonography were used for parathyroid localization. Thirty-five patients (group I) underwent conventional neck exploration and open parathyroidectomy. Thirteen patients (group II) underwent gamma probe-guided total parathyroidectomy and parathyroid transplantation. The two groups were compared in terms of the number of parathyroid resections, operative time, and postoperative changes in the blood levels of parathyroid hormone (PTH), calcium, and phosphate. Results The clinical manifestations, PTH and calcium levels, age distribution, and clinical characteristics did not differ between the two groups. The accuracy of preoperative 99Tcm-MIBI scintigraphy (89.74%) for the diagnosis of hyperparathyroidism did not differ from that of ultrasonography (81.25%). However, the accuracy of 99Tcm-MIBI scintigraphy (66.67%) for localizing hyperfunctioning parathyroids was significantly lower than that of ultrasonography (76.86%). The operation time was significantly longer in group I ((120±25) minutes) than in group II ((90±30) minutes). The accuracy of parathyroid identification was significantly higher in group II (92.59%) than in group I (80.39%). On average, significantly fewer parathyroid specimens were obtained in group I (2.5±0.5) than in group II (3.5±0.5). Compared with group I, group II showed a significant increase (15.4%) in the number of parathyroid resections. The PTH, calcium, and phosphate levels significantly decreased postoperatively in all patients. Conclusions Intraoperative gamma probe examination confirmed that the excised specimen was parathyroid tissue and improved the accuracy of parathyroid resection. The parathyroidectomy rate was increased by 15.4% due to the use of these probes. However, the probes did not detect all ectopic parathyroids, and further research is required to clarify the underlying reasons.

Surgical treatment of secondary hyperparathyroidism: a systematic review of the literature

Secondary hyperparathyroidism (HPT) has a high prevalence in renal patients. Secondary HPT results from disturbances in mineral homeostasis, particularly calcium, which stimulates the parathyroid glands, increasing the secretion of parathyroid hormone (PTH). Prolonged stimulation can lead to autonomy in parathyroid function. Initial treatment is clinical, but parathyroidectomy (PTx) may be required. PTx can be subtotal or total followed or not followed by parathyroid tissue autograft. We compared the indications and results of these strategies as shown in the literature through a systematic literature review on surgical treatment of secondary HPT presented in MedLine and LILACS from January 2008 to March 2014. The search terms were: hyperparathyroidism; secondary hyperparathyroidism; parathyroidectomy and parathyroid glands, restricted to research only in humans, articles available in electronic media, published in Portuguese, Spanish, English or French. We selected 49 articles. Subtotal and total PTx followed by parathyroid tissue autograft were the most used techniques, without consensus on the most effective surgical procedure, although there was a preference for the latter. The choice depends on surgeon's experience. There was consensus on the need to identify all parathyroid glands and cryopreservation of parathyroid tissue whenever possible to graft if hypoparathyroidism arise. Imaging studies may be useful, especially in recurrences. Alternative treatments of secondary HPT, both interventional and conservative, require further study.