Intramuscular Injection of Parathyroid Autografts is a Viable Option After Total Parathyroidectomy

Efficacy and safety of total parathyroidectomy with autotransplantation vs. subtotal parathyroidectomy for secondary hyperparathyroidism: A retrospective study

Background

No consensus has been reached on the best surgical approach for secondary hyperparathyroidism (SHPT). We evaluated the short-term and long-term efficacy and safety of total parathyroidectomy with autotransplantation (TPTX + AT) and subtotal parathyroidectomy (SPTX).

Methods

We retrospectively analyzed the data of 140 patients undergoing TPTX + AT and 64 undergoing SPTX between 2010 and 2021 in Second Affiliated Hospital of Soochow University, and carried out follow-up. We compared the differences in symptoms, serological examinations, complications and mortality between the two methods, and explored the independent risk factors of secondary hyperparathyroidism recurrence.

Results

In short time after surgery, serum intact parathyroid hormone and calcium level was lower in TPTX + AT group than that in SPTX group (both P < 0.05). Severe hypocalcemia was more common in TPTX group (P = 0.003). The recurrent rate was 17.1% for TPTX + AT and 34.4% for SPTX (P = 0.006). There was no statistical difference in all-cause mortality, cardiovascular events, cardiovascular mortality between the two methods. Higher preoperative serum phosphorus level (HR: 1.929 95% CI 1.045-3.563, P = 0.011) and the SPTX surgical method (HR: 2.309, 95% CI 1.276-4.176, P = 0.006) were found to be independent risk factors for SHPT recurrence.

Conclusions

Compared with SPTX, TPTX + AT is more effective in reducing the recurrent risk of SHPT without increasing the risk of all-cause mortality and cardiovascular events.

Autotransplantation of parathyroid tissue into subcutaneous subclavicular area following total parathyroidectomy in secondary hyperparathyroidism

BACKGROUND

Total parathyroidectomy with autotransplantation is still an excellent treatment option for secondary hyperparathyroidism. Intramuscular or subcutaneous parathyroid autotransplantation has been previously reported; however, there have been no studies to date regarding the implantation of the parathyroid tissue in the subclavian area of the neck.

METHODS

This was a prospective cross-sectional study between 2018 and 2019. Patients who underwent total parathyroidectomy with autotransplantation of parathyroid tissue into subcutaneous subclavicular area due to secondary hyperparathyroidism were included. The patients' demographic information, including age and gender, was gathered, and the length of the dialysis period was asked from the patients. To evaluate the outcome of the study, parathyroid hormone (PTH) was measured and recorded before and after the operation. SPSS software, version 26, was used for data analysis.

RESULTS

Forty-two patients with a mean age of 41.05 ± 9.41 years were included. The mean length of the dialysis period was 8.07 ± 2.68 years. The mean primary PTH was 1770.61 ± 482.97 pg/ml (range: 656-2500 <). After 6 weeks of operation, 19 patients (45.2%) had functional autotransplanted tissue, and the median PTH was 28 pg/ml (IQR: 33.55, range: 0.1-221.8). However, the results showed that after 10 weeks, the patients with functional tissue were increased to 22 (52.4%), and the median PTH was 35 pg/ml (IQR: 48, range: 5.0-602.9). The functionality of autotransplanted tissue in the 6th and 10th weeks after surgery had no significant association with age, gender, and length of the dialysis period (p value > 0.05).

CONCLUSION

Subcutaneous implantation is recommended in the treatment of secondary hyperparathyroidism based on its high success rate and ease of use, suitable vascularization, easy accessibility to the surgery location in case of the need for autographtectomy.

The application of subcapsular saline injection during bilateral axillo-breast approach robotic thyroidectomy: a preliminary report

PURPOSE

Saving the parathyroid gland during robotic thyroidectomy is challenging. This study evaluated the application of a novel method, subcapsular saline injection (SCASI), to save the parathyroid gland during bilateral axillo-breast approach (BABA) robotic total thyroidectomy.

METHODS

Of the 81 included patients operated on from 2014 to 2016, 31 and 50 underwent BABA robotic total thyroidectomy with and without SCASI, respectively. Serum concentrations of parathyroid hormone (PTH), calcium, and ionized calcium were measured at 1 day and 9 months postoperatively. Transient hypoparathyroidism was defined as PTH < 10.0 pg/mL after 1 day and permanent hypoparathyroidism as PTH < 15.0 pg/mL at 9 months.

RESULTS

There were no significant clinicopathologic differences between the two groups. The rate of transient hypoparathyroidism was significantly lower in the SCASI group than in the non-SCASI group [16.1% (5/31) vs. 44% (22/50), p < 0.01]. However, the rates of permanent hypoparathyroidism [0% (0/31) vs. 4% (2/50), p = 0.699] did not differ significantly.

CONCLUSIONS

SCASI is a feasible and safe method of saving the parathyroid gland during BABA robotic total thyroidectomy.

Patients' views about parathyroid transplantation for post-thyroidectomy hypoparathyroidism

BACKGROUND

Permanent hypoparathyroidism (hypoPT) represents the most common postoperative complication associated with total thyroidectomy. Current treatment relies on high-dose calcium and/or vitamin D supplementation, but often this is insufficient and some patients remain symptomatic. Parathyroid allotransplantation is a new therapeutic option described recently in the literature. This study aims to investigate the patients' acceptability of parathyroid transplantation as a potential new treatment for hypoPT.

METHOD

Online survey of members of HypoParaUK, a support group for individuals affected by hypoPT.

RESULTS

Responses were received from 252 hypoPT patients. Majority declared to experience severe symptoms despite regular medical treatment. On a severity scale of 0-5, symptoms that were most troublesome were fatigue (3.8), low sense of well-being (3.5), and numbness/tingling (2.9). On a scale of 0-10, on average, their current quality of life (QoL) was 5 ± 3 and they expected this would improve to 7 ± 2 with correction of their hypoPT. Forty-four percent of patients were extremely interested in a potential technique involving intramuscular injection of parathyroid cell suspension compared to just 14% who were interested in the more invasive procedure of implantation of a parathyroid allograft into the forearm. The main concerns expressed were related to the possible need for immunosuppressive therapy.

CONCLUSION

Patients with severe symptomatic hypoPT seem interested to consider participation in a clinical trial exploring the feasibility and success rate of parathyroid transplantation.

Parathyroid Autotransplantation During Thyroid Surgery: A Novel Technique Using a Cell Culture Nutrient Solution

INTRODUCTION

Parathyroid autotransplantation is an easy procedure with a low complication rate. We adopted the transplantation into the sternocleidomastoid muscle, which allows an easier and time-saving surgical procedure using the same surgical incision.

METHODS

In this study, we retrospectively reviewed the records of 396 consecutive patients, who underwent total thyroidectomy for benign thyroid disease. In all cases in which a parathyroid was damaged or inadvertently removed, the gland was transplanted; before the autotransplantation, the parathyroid tissue was put in a cell culture nutrient solution for 5 min, afterward fragmented, and then was transplanted in the sternocleidomastoid muscle. To demonstrate a beneficial effect of the cell nutrient solution step, we compared data of transplanted patients with a control group of cases (n = 190) undergoing a standard immediate autotransplantation.

RESULTS

We divided patients in two main groups: group A (n = 160) including subjects that underwent one or more parathyroid gland autotransplantation using the cell nutrient solution, and group B (n = 236) concerning those who were not transplanted. Among patients, 62 hypocalcemias occurred, 40 in the group A and 22 in the group B (P < 0.001): 91.9 % were transient and 8.1 % (5 patients) definitive, all pertaining to the group B. Among controls (group C), 42 hypocalcemias occurred (P = 0.616 vs. group A and P = 0.002 vs. group B) and 3/42 became definitive (P = 0.096 vs. group A and P = 0.121 vs. group B). All differences concerning pre- and postoperative calcium values were statistically significant (P < 0.001).

CONCLUSIONS

We recommend the routine parathyroid autotransplantation, when a vascular damage is certain or suspected, in order to reduce the rate of permanent hypoparathyroidism, using a cell culture nutrient solution before gland transplantation.

Feasibility of injectable thermoreversible gels for use in intramuscular injection of parathyroid autotransplantation

Surgical transplantation of parathyroid tissue into the forearm muscle is one of the most commonly used surgical techniques. While simple, the procedure suffers from drawbacks. This study evaluated the feasibility of thermoreversible gel as an injectable carrier for parathyroid autotransplantation. Polyethyleneglycol-polyalanine-co-phenylalanine (PEG-PAF) thermoreversible gel (sol form at 4 °C, gel form at 37 °C) were manufactured. Thirty-eight Sprague-Dawley rats were divided into two groups (19 control, C group; 19 experimental, P group). The parathyroid glands of rats were excised. Parathyroid tissues were transplanted into the muscle pocket in sternocleidomastoid muscle in the C group. In the P group, the tissues were injected into the same muscle mixed with 0.3 ml thermoreversible gel. The serum levels of parathyroid hormone (PTH), ionized calcium, and phosphorous were measured before surgical procedure, on 7, 21, 56, and 70 days after surgery. Histology and immunohistochemistry were performed. Preoperative median PTH level of the C and the P group were 60.80 and 43.85 pg/ml, respectively (p = 0.641). Seventy days after surgery, median PTH level was 32.8 and 25.61 pg/ml, respectively. On day 70, the PTH level was restored by 54 % in the C group and 56 % in the P group compared to the preoperative value (p = 0.620). There were no significant intergroup differences in the ionized calcium/phosphorous level. Histology and immunohistochemistry revealed the successful transplantation of parathyroid tissues into the muscles in both groups. In conclusion, the PEG-PAF-based thermoreversible gel is a good candidate carrier material for intramuscular parathyroid autotransplantation.

Outcomes of parathyroidectomy in renal hyperparathyroidism in patients with No access to renal transplantation in Singapore

BACKGROUND

Total parathyroidectomy with autotransplantation (TPTX + AT) and subtotal parathyroidectomy (SPTX) are considered standard surgical treatments for refractory renal hyperparathyroidism. However, there is little data available comparing their outcomes in an area with poor access to renal transplant and calcimimetics.

METHODS

Patients with renal hyperparathyroidism who underwent TPTX + AT and SPTX in a tertiary institution from 2006 to 2013 were studied. Patient characteristics, pre- and post-operative biochemical marker levels, and outcomes including recurrence rates, post-operative morbidity and mortality were analysed.

RESULTS

87 patients underwent parathyroidectomy for renal hyperthyroidism. Transplant patients were excluded in this study. 81 patients were on long-term dialysis, with a median time of 7 years from initiation of haemodialysis to parathyroidectomy. 57 patients (70.4%) underwent TPTX + AT while 24 (29.6%) underwent SPTX. Post-operatively, there was significant decrease in parathyroid hormone (PTH), calcium and phosphate levels in both groups. PTH and phosphate levels were significantly lowered with TPTX compared to SPTX (p = 0.004, 0.003). Symptomatic hypocalcaemia was seen in both groups. In a median follow-up of 4 years, 11 patients developed biochemical recurrence, with a median time of 29 months to recurrence. Median PTH at recurrence was 67.1 pmol/L. Rate of recurrence was higher in patients who underwent SPTX (20.8% vs 10.5%), with a shorter median time to recurrence (median 62.1 vs 81.3 months). 2 patients required resection of the autograft. Cohort mortality was 11 patients (13.4%), with 3 deaths secondary to cardiovascular events.

CONCLUSION

Total parathyroidectomy with autoimplantation is superior to subtotal parathyroidectomy in the short to intermediate term.

Autotransplantation of parathyroid grafts into the tibialis anterior muscle after parathyroidectomy: a novel autotransplantation site

Background

Surgical management of renal secondary hyperparathyroidism (sHPT) is varying. Total parathyroidectomy with heterotopic autotransplantation (TPTX + AT) is one of the standard surgical procedures in sHPT, but there is no consensus about the optimal site for graft insertion. At the surgical department of the University Hospital of Heidelberg we prefer the autotransplantation into the tibialis anterior muscle. The aim of this study was to assess the long-term function of the auto-transplanted parathyroid tissue in this type of surgical procedure.

Methods

The function of the autograft of 42 patients was assessed 8.2 ± 2.5 years after surgery, using a modified Casanova-test of the leg bearing the parathyroid tissue. Ischemic blockage was induced by tourniquet and the levels of parathyroid hormone (PTH) were assessed during the test.

Results

At the point of assessment, the ischemic blockage led to a significant reduction in the concentration of PTH (≥50 % of the baseline value) in 19 patients (45 %) indicating well-functioning autografts. In 11 patients (26 %), ischemic blockage did not cause any change in the concentration of PTH (≤20 % of the baseline value), indicating functioning residual parathyroid tissue from another site. The source of PTH production was classified as unidentifiable in five patients (12 %). Two patients had developed graft-dependent recurrent HPT (5 %) without therapeutic consequences and three patients suffered from persistent symptomatic hypoparathyroidism (7 %).

Conclusions

These results indicate that TPTX + AT into the tibialis anterior muscle is a successful surgical treatment for renal HPT and that the modified Casanova-test is a suitable diagnostic tool for autografts function.

Aetiology, Diagnosis and Surgical Treatment of Primary Hyperparathyroidism in Children: New Trends

Primary hyperparathyroidism (PHPT) in children is a rare disorder with sharp contrasts in its presentation and aetiology compared with the disease process in adults. This review outlines the current literature, which is limited to about 200 cases, with reference to the aetiology, clinical features, outcomes of investigations, and surgery in children affected by PHPT. Familial conditions account for almost half of all cases of PHPT in children, suggesting that routine genetic testing would be appropriate. Neonatal severe hyperparathyroidism requires urgent medical attention, and performing total parathyroidectomies offers cure, though conservative management is successful in selected cases. Familial hyperparathyroidism in older children can be caused by conditions such as multiple endocrine neoplasia types 1 and 2a, hyperparathyroidism-jaw tumour syndrome and familial hyperparathyroidism. The role of surgery for this group is discussed. The use of ultrasound and MIBI (99mTc-methoxyisobutylnitrile) scanning appears to accurately localise solitary adenomas in sporadic PHPT, thereby supporting the role of minimally invasive parathyroidectomy in children. © 2015 S. Karger AG, Basel.

A novel non-surgical, minimally invasive technique for parathyroid autotransplantation: a case report

We present a case report of intramuscular autotransplantation of the parathyroid cell suspension acquired after total parathyroidectomy. A 15-yr-old female patient who had been undergoing hemodialysis due to chronic renal failure for eight yr was diagnosed with secondary hyperthyroidism and subsequently underwent total parathyroidectomy. The parathyroid cells were acquired from the resected tissues, processed through isolation and cultivation phases, and counted using a cell counter. A total of two million cells were injected into the left deltoid muscle using a 22-gauge needle. After surgery, five and 10 million cells were injected in the fifth and 12 week, respectively. The desired serum levels of parathyroid hormones and calcium were not achieved after the first two transplantations. In addition, there was no regression in the patient's symptoms. However, at four wk after the third transplantation, serum parathyroid hormone level did not decrease to <3 pg/mL, the patient was asymptomatic, and the oral treatment was stopped. Our findings indicate that this new technique is applicable because it is minimally invasive, and it can be easily repeated.

Islet survival and function following intramuscular autotransplantation in the minipig

The liver may not be an optimal site for islet transplantation due to obstacles by an instant blood-mediated inflammatory response (IBMIR), and low revascularization of transplanted islets. Therefore, intramuscular islet transplantation (IMIT) offers an attractive alternative, based on its simplicity, enabling easier access for noninvasive graft imaging and cell explantation. In this study, we explored the outcome of autologous IMIT in the minipig (n = 30). Using the intramuscular injection technique, we demonstrated by direct histological evidence the rapid revascularization of islets autotransplanted into the gracilius muscle. Islet survival assessment was performed using immunohistochemistry staining for insulin and glucagon up to a period of 6 months. Furthermore, we showed the crucial role of minimizing mechanical trauma to the myofibers and limiting exocrine contamination. Intramuscular islet graft function after transplantation was confirmed by documenting the acute insulin response to intravenous glucose in 5/11 pancreatectomized animals. Graft function after IMIT remained however significantly lower than the function measured in 12 out of 18 minipigs who received a similar islet volume in the liver through intraportal infusion. Collectively, these results demonstrated in a clinically relevant preclinical model, suggest IMIT as a promising alternative to intraportal infusion for the transplantation of β cells in certain medical situations.