Outcomes of Total Parathyroidectomy with Autotransplantation versus Subtotal Parathyroidectomy with Routine Addition of Thymectomy to both Groups: Single Center Experience of Secondary Hyperparathyroidism

Abstract

Secondary hyperparathyroidism (sHPT) is a common acquired disorder seen in chronic renal failure. It may result in potentially serious complications including metabolic bone diseases, severe atherosclerosis and undesirable cardiovascular events (1). Parathyroidectomy (PTX) is required in about 20% of patients after 3-10 years of dialysis and in up to 40% after 20 years (2, 3).When medical treatment fails, subtotal parathyroidectomy (subtotal PTX) with a cervical remnant and total parathyroidectomy with autotransplantation (total PTX+AT) are the standard procedures, although both are associated with high recurrence rates (4-7). A considerable quantity of functioning parathyroid tissue is left after each of these operations in order to prevent possible hypoparathyroidism and the need for longBackground: Secondary hyperparathyroidism is a common acquired disorder seen in chronic renal failure. It may result in potentially serious complications including metabolic bone diseases, severe atherosclerosis and undesirable cardiovascular events. Parathyroidectomy is required in about 20% of patients after 3-10 years of dialysis and in up to 40% after 20 years. Aims: The aim of the current study was to evaluate the short-term and long-term outcomes of patients with secondary hyperparathyroidism who had undergone total parathyroidectomy with autotransplantation and thymectomy or subtotal parathyroidectomy with thymectomy by the same surgical team during the study period. Study Design: Retrospective comparative study. Methods: Clinical data of 50 patients who underwent parathyroid surgery for secondary hyperparathyroidism between 2003 and 2011 were reviewed retrospectively. Patients were divided into two subgroups of total parathyroidectomy with autotransplantation or subtotal parathyroidectomy. Thymectomy was routinely performed for both groups. Short term outcome parameters included intact parathyroid hormone, ionized calcium and alkaline phosphatase levels. Bone pain, bone fractures, persistent or recurrent disease were included in long term outcome parameters. Results: The mean duration of dialysis was eight years. The mean ionized calcium levels dropped significantly in the total parathyroidectomy with autotransplantation group (p=0.016). No serious postoperative complications were observed. Postoperative intravenous calcium supplementation was required in four patients in the total parathyroidectomy with autotransplantation group (total PTX+AT) and in three patients in the subtotal parathyroidectomy group (subtotal PTX). Postoperatively, all patients received oral calcium carbonate and calcitriol. The length of average hospital stay was 5 (3-10) days. Including nine patients who underwent successful renal transplantation pre-operative bone symptoms, hypercalcemia, hyperphosphatemia, and an increased alkaline phosphatase levels were improved or resolved in all patients. After a mean follow-up of 65 months, three patients (6%) had persistent and one (2%) had recurrent disease. Conclusion: Total parathroidectomy with auto...

Experience of surgical treatment of thyroid and parathyroid diseases

“…In 1 case (1.1 %), a tense mediastinal hematoma developed after sternotomy when an adenoma grown into the aortopulmonary window was removed, the complication was eliminated using a video-assisted mini-thoracotomy. The frequency of hemorrhagic complications in our study did not exceed the values reported by other authors -from 2 % to 4.3 % (bleeding, neck necrosis, requiring surgical drainage) [14,16].…”

Częściowe usunięcie przytarczyc versus całkowite usunięcie przytarczyc z autoprzeszczepem we wtórnej nadczynności przytarczyc — jednoośrodkowe, prospektywne badanie w grupie 43 pacjentów

“…Even if scintigraphy (99mTc-MIBI) is considered the best and most sensitive test [1,3,16], its role in locating all parathyroid glands before surgery is doubtful, being less important when compared with the surgeon's experience [16]. Scintigraphy becomes important in redo procedures for relapsing or persistent hyperparathyroidism, especially when associated with high-resolution cervical ultrasonography [1,16].…”

“…In spite of improved conventional medical therapy, the need for parathyroidectomy remains high, especially in the group of patients on long-term dialysis with medically refractory sHPT [2,3]. Among surgical indications in sHPT few are generally accepted, i.e.…”

“…The remnant-conserving techniques of parathyroidectomy consist of either subtotal parathyroidectomy (sPtx) -removing all parathyroid tissue but a small portion of a normal appearing gland which is left in the neck or total parathyroidectomy with autotransplant (tPtx + AT) -removing all parathyroid tissue and reimplanting at a distance small pieces of tissue in well-vascularised muscular structures. Even if both techniques are now under intense criticism, mainly due to their high recurrence rates of sHPT, they remain the most recommended and widely performed surgical procedures [1,3]. Recently another technique, total parathyroidectomy without autotransplant (tPtx), re-emerged as a trustworthy surgical solution in severe sHPT, especially in patients with low perspective for renal transplantation [1,3,6].…”

“…Even if both techniques are now under intense criticism, mainly due to their high recurrence rates of sHPT, they remain the most recommended and widely performed surgical procedures [1,3]. Recently another technique, total parathyroidectomy without autotransplant (tPtx), re-emerged as a trustworthy surgical solution in severe sHPT, especially in patients with low perspective for renal transplantation [1,3,6].…”