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      Endoscopic Total Parathyroidectomy and Partial Parathyroid Tissue Autotransplantation for Patients with Secondary Hyperparathyroidism: A New Surgical Approach

      , , , ,

      World Journal of Surgery

      Springer-Verlag

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          Abstract

          Background

          Secondary hyperparathyroidism (SHPT) (i.e., renal hyperparathyroidism) is one of the most serious complications in long-term hemodialysis patients. The purpose of this retrospective study was to explore the feasibility of a new surgical approach—endoscopic total parathyroidectomy with autotransplantation (ETP+AT)—and evaluate its practical application for patients with SHPT.

          Methods

          The study included 34 SHPT patients who underwent ETP+AT from among 67 cases at the Department of Minimally Invasive Surgery, the First Affiliated Hospital of Nanjing Medical University over a 3-year period. The other 33 patients underwent traditional total parathyroidectomy with autotransplantation (TP+AT). Two criteria were used as indications to perform ETP+AT in SHPT patients. The first was a high serum parathyroid hormone level (PTH >800 pg/ml) associated with hypercalcemia and/or hyperphosphatemia that which were refractory to medical treatment. The second criterion was the presence of clinical symptoms including pruritus, bone and joint pain, muscle weakness, progression of soft tissue calcification, and spontaneous fractures. Ultrasonography, 99mTc sestamibi scans, and computed tomography were used to evaluate the thyroid and parathyroid glands.

          Results

          There was no surgery-related mortality among any of the patients with ETP+AT. One patient underwent conventional neck exploration because of bleeding and injury of a unilateral recurrent laryngeal nerve after the operation. Preoperative symptoms were alleviated, and the serum PTH and alkaline phosphatase levels, hyperphosphatemia, and hypercalcemia were improved or normalized in most patients. Recurrence was observed in one patient with a sixth parathyroid gland behind his thyroid, and the patient required a second operation. Hypoparathyroidism was not found after the operation. The clinical data were compared between ETP+AT and TP+AT.

          Conclusions

          ETP+AT is a safe option for the treatment of SHPT with low morbidity and mortality, shorter hospital stay and low recurrence rate. It is important to avoid intraoperative bleeding, identify all parathyroid glands during the surgery, and choose adequate parathyroid tissues for autografting.

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          Most cited references 21

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          Cardiac calcification in adult hemodialysis patients. A link between end-stage renal disease and cardiovascular disease?

          We sought to determine clinical and laboratory correlates of calcification of the coronary arteries (CAs), aorta and mitral and aortic valves in adult subjects with end-stage renal disease (ESRD) receiving hemodialysis. Vascular calcification is known to be a risk factor for ischemic heart disease in non-uremic individuals. Patients with ESRD experience accelerated vascular calcification, due at least in part to dysregulation of mineral metabolism. Clinical correlates of the extent of calcification in ESRD have not been identified. Moreover, the clinical relevance of calcification as measured by electron-beam tomography (EBT) has not been determined in the ESRD population. We conducted a cross-sectional analysis of 205 maintenance hemodialysis patients who received baseline EBT for evaluation of vascular and valvular calcification. We compared subjects with and without clinical evidence of atherosclerotic vascular disease and determined correlates of the extent of vascular and valvular calcification using multivariable linear regression and proportional odds logistic regression analyses. The median coronary artery calcium score was 595 (interquartile range, 76 to 1,600), values consistent with a high risk of obstructive coronary artery disease in the general population. The CA calcium scores were directly related to the prevalence of myocardial infarction (p < 0.0001) and angina (p < 0.0001), and the aortic calcium scores were directly related to the prevalence of claudication (p = 0.001) and aortic aneurysm (p = 0.02). The extent of coronary calcification was more pronounced with older age, male gender, white race, diabetes, longer dialysis vintage and higher serum concentrations of calcium and phosphorus. Total cholesterol (and high-density lipoprotein and low-density lipoprotein subfractions), triglycerides, hemoglobin and albumin were not significantly related to the extent of CA calcification. Only dialysis vintage was significantly associated with the prevalence of valvular calcification. Coronary artery calcification is common, severe and significantly associated with ischemic cardiovascular disease in adult ESRD patients. The dysregulation of mineral metabolism in ESRD may influence vascular calcification risk.
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            The anatomic basis of parathyroid surgery.

             C. Wang (1976)
            A study of 645 normal adult parathyroid glands in 160 cadavers revealed that there is a definite pattern of anatomic distribution on the basis of the embryologic development of the parathyroid, thyroid, and thymic glands. The sites of predilection of the upper gland (Parathyroid IV) are, in order of frequency, the cricothyroid junction; the dorsum of the upper pole of the thyroid; and the retropharyngeal space. Those of the lower gland (Parathyroid III) are at the lower pole of the thyroid and the thymic tongue; rarely in the upper, the lateral neck, or the mediastinum. An understanding of the developmental relationship of the parathyroid glands to the thyroid and the thymus is fundamental in the delineation of the embryologic origin of the parathyroid glands. The parathyroid gland, located within the surgical capsule of the thyroid (subcapsular), when diseased, remains in place locally. A gland outside of the capsule (extracapsular) is often displaced into the posterior or anterior mediastinum. A collective assessment of the size, weight, color, shape, and consistency of the parathyroid gland is mandatory in the determination of its normalcy. Frozen section examination for stromal and intracellular fatty content is an added assurance of normalcy. That parathyroid glands sink in saline solution, and fat globules float, may aid in differentiating the two types of tissue. Supernumerary, fused, and intrathyroidal parathyroids, albeit rare, are of surgical importance.
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              Surgical anatomy of human parathyroid glands.

              In an autopsy study of 503 cases the parathyroid glands were dissected, and the number of glands in each case and the anatomic distribution of the glands were recorded. In 18 cases (3%) only three glands were found. In these cases the lower combined weight suggested that a fourth gland had been missed. In 421 cases (84%) there were four glands and in 64 cases (13%) there were supernumerary glands. Most often the supernumerary gland was a fifth gland, usually in the thymus. The anatomic distribution of the glands showed considerable constancy. The positions of the glands on the one side were symmetrical with those on the other side in approximately 80% of cases. The superior parathyroids were frequently found just above the intersection between the recurrent laryngeal nerve and the inferior thyroid artery. The inferior parathyroids most often lay somewhat more ventrally, close to the lower thyroid pole or in the upper thymus or thyrothymic ligament. In a few cases the lower parathyroids were situated higher up in the neck, obviously because of a failure of descent during the embryologic development. In view of the number of supernumerary glands and their location, it is concluded that wide excision of fat tissue surrounding the parathyroids and thymectomy should be performed during operation in patients with hyperparathyroidism secondary to uremia or those with multiple endocrine neoplasia syndromes.
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                Author and article information

                Contributors
                jssym@vip.sina.com
                chh1168@163.com
                Journal
                World J Surg
                World Journal of Surgery
                Springer-Verlag (New York )
                0364-2313
                1432-2323
                17 June 2009
                August 2009
                : 33
                : 8
                : 1674-1679
                Affiliations
                Department of Minimally Invasive Surgery, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu 210029 China
                Article
                86
                10.1007/s00268-009-0086-3
                2712635
                19533223
                © The Author(s) 2009
                Categories
                Article
                Custom metadata
                © Société Internationale de Chirurgie 2009

                Surgery

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