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Guo MY, Pillar M, Manhas N, Melck A. Role of thymectomy in surgical treatment of renal hyperparathyroidism. Am J Surg 2024; 237:115864. [PMID: 39147637 DOI: 10.1016/j.amjsurg.2024.115864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/15/2024] [Accepted: 07/24/2024] [Indexed: 08/17/2024]
Abstract
INTRODUCTION The role for routine thymectomy in patients with secondary or tertiary hyperparathyroidism (SHPT, THPT) is unclear. We aim to compare rates of recurrence and complications in patients who underwent subtotal parathyroidectomy with and without thymectomy. METHODS Patients who underwent surgery for renal HPT at a tertiary endocrine surgery center between 2010 and 2022 were reviewed. Presence of parathyroid tissue in resected tissue was identified through pathology reports. A multivariate logistic regression was used to compare baseline characteristics, recurrence rates and complications between those who did and did not undergo thymectomy. RESULTS Of 107 patients who underwent subtotal parathyroidectomy, 29 (27.1 %) underwent concomitant thymectomy. Recurrence occurred in 15 patients (14 %). Thymectomy did not affect recurrence (OR: 0.33, 95%CI: 0.06-1.28, p = 0.14), but was associated with permanent hypoparathyroidism (OR: 4.62, 95%CI: 1.67-13.18, p = 0.003). Fewer parathyroid specimens increased the odds of thymectomy (p = 0.04). Parathyroid glands were found in 6 thymectomy samples (20.7 %). CONCLUSION Thymectomy at the time of subtotal parathyroidectomy for renal HPT was not associated with disease recurrence, but increased likelihood of permanent hypoparathyroidism.
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Affiliation(s)
- Michael Y Guo
- Department of General Surgery, University of British Columbia, Canada
| | - Michal Pillar
- Faculty of Medicine, University of British Columbia, Canada
| | - Neraj Manhas
- Department of General Surgery, University of British Columbia, Canada
| | - Adrienne Melck
- Department of Surgery, St. Paul's Hospital, Vancouver, British Columbia, Canada.
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Done JZ, Gabrielson A, Stemme R, Foote DC, Weller J, Villavicencio J, Charles I, Morris-Wiseman LF, Mathur A. Is thymectomy necessary during parathyroidectomy for secondary hyperparathyroidism in patients with end-stage kidney disease? Surgery 2024:S0039-6060(24)00711-6. [PMID: 39389821 DOI: 10.1016/j.surg.2024.06.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/31/2024] [Accepted: 06/02/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND Guidelines recommend thymectomy at the time of parathyroidectomy for secondary hyperparathyroidism to reduce the likelihood of persistent or recurrent disease. We sought to determine the frequency of thymectomy and explore its impact on recurrence of secondary hyperparathyroidism. METHODS Using TriNetX, a multi-institutional electronic health record and insurance claims network, we conducted a retrospective cohort study of adults with secondary hyperparathyroidism who underwent parathyroidectomy with or without thymectomy from 2005 to 2023. Rates of thymectomy, repeat parathyroidectomy, and calcimimetic use were compared between cohorts. Recurrence was defined by parathyroid hormone ≥600 pg/mL, reoperation, or calcimimetic use. Current Procedural Terminology and SNOMED codes for parathyroidectomy did not distinguish between subtotal compared with total parathyroidectomy. RESULTS Among 2,564 patients underwent surgery for secondary hyperparathyroidism, 2,272 (88.8%) underwent parathyroidectomy and 287 (11.2%) underwent parathyroidectomy + thymectomy. Rates of parathyroidectomy + thymectomydecreased over time, from 25.5% in 2005 to 10.1% in 2023. Preoperatively, there was no difference in mean preoperative parathyroid hormone levels, serum calcium or calcidiol, or cinacalcet use. Postoperatively, there was no difference in the mean parathyroid hormone level (183 pg/mL vs 180 pg/mL, P = .88), odds of calcimimetic use (odds ratio, 0.94, 95% confidence interval, 0.64-1.39), reoperation within 5 years postoperatively (odds ratio 0.72, 95% confidence interval 0.39-1.36), or rates of kidney transplantation (odds ratio 1.03, 95% confidence interval 0.67-1.60) between parathyroidectomy and parathyroidectomy + thymectomy groups. CONCLUSION Thymectomy is infrequently performed during parathyroidectomy for secondary hyperparathyroidism, and rates continue to decline. Although thymectomy at time of parathyroidectomy did not appear to decrease recurrence, future studies should include extent of parathyroidectomy to determine impact of thymectomy on recurrence in secondary hyperparathyroidism.
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Affiliation(s)
- Joy Z Done
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. https://twitter.com/JoyZhouDone
| | - Andrew Gabrielson
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rachel Stemme
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Darci C Foote
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennine Weller
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jennyfer Villavicencio
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Iyana Charles
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lilah F Morris-Wiseman
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. https://twitter.com/Lilahfran
| | - Aarti Mathur
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
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Mogl MT, Goretzki PE. [Special features of the diagnostics and treatment of hereditary primary hyperparathyroidism]. CHIRURGIE (HEIDELBERG, GERMANY) 2023:10.1007/s00104-023-01897-8. [PMID: 37291366 DOI: 10.1007/s00104-023-01897-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 06/10/2023]
Abstract
Between 2% and 10% of patients with primary hyperparathyroidism (pHPT) are diagnosed with hereditary forms of primary hyperparathyroidism (hpHPT). They are more prevalent in younger patients before the age of 40 years, in patients with persistence or recurrence of pHPT and pHPT patients with multi-glandular disease (MGD). The various forms of hpHPT diseases can be classified into four syndromes, i.e., hpHPT associated with diseases of other organ systems, and four diseases that are confined to the parathyroid glands. Approximately 40% of patients with hpHPT suffer from multiple endocrine neoplasia type 1 (MEN-1) or show germline mutations of the MEN‑1 gene. Currently, germline mutations that lead to a specific diagnosis in patients with hpHPT have currently been described in 13 different genes, which enables a clear diagnosis of the disease; however, a clear genotype-phenotype correlation does not exist, even though the complete loss of a coded protein (e.g. due to frame-shift mutations in the calcium sensing receptor, CASR) often leads to more severe clinical consequences than merely a reduced function of the protein (e.g. due to point mutation). As the various hpHPT diseases require different treatment approaches, which do not correspond to that of sporadic pHPT, a clear definition of the specific form of hpHPT must always be strived for. Therefore, before surgery of a pHPT with clinical, imaging or biochemical suspicion of hpHPT, genetic proof or exclusion of hpHPT is necessary. The differentiated treatment approach for hpHTP can only be defined by taking the clinical and diagnostic results of all the abovenamed findings into account.
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Affiliation(s)
- Martina T Mogl
- Chirurgische Klinik, Charité Campus Mitte/Campus Virchow-Klinikum, Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - Peter E Goretzki
- Chirurgische Klinik, Charité Campus Mitte/Campus Virchow-Klinikum, Berlin, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin und Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg 2022; 276:e141-e176. [PMID: 35848728 DOI: 10.1097/sla.0000000000005522] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.
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Yalçınkaya İ, Doğruyol MT. Prophylactic Chest Surgery Procedures. PROPHYLACTIC SURGERY 2021:371-378. [DOI: 10.1007/978-3-030-66853-2_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Li W, Liu B, Shan C, Liu Z, Wang Q, Rao W, Zha S, Zhang W, Qiu M. Application of carbon nanoparticles in localization of parathyroid glands during total parathyroidectomy for secondary hyperparathyroidism. Am J Surg 2020; 220:1586-1591. [PMID: 32423601 DOI: 10.1016/j.amjsurg.2020.04.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Intraoperative imaging is used to address the challenges of parathyroidectomy, but no standard modality has been established. This study aimed to assess whether carbon nanoparticle injection is useful in localizing parathyroid glands (PGs) during parathyroidectomy. METHODS Patients who underwent total parathyroidectomy (TPTX) between September 2015 and November 2018 were included. The operative duration and intact parathyroid hormones (iPTH) were analyzed. RESULTS A total of 61 patients were included; of these, 32 with carbon nanoparticle injection (TPTX + CN group) and 29 without (TPTX group). The operative duration in the TPTX + CN group was significantly shorter (90.6 ± 21.2 vs 101.4 ± 19.4 min, P = 0.042), which is more apparent in those with normal sized PGs. For those with four enlarged PGs, iPTH levels on 1 day and 1 year postoperatively were significantly lower in the TPTX + CN group (P = 0.032 and P = 0.036, respectively). CONCLUSION Carbon nanoparticles are useful in the identification normal sized PGs and complete resection of enlarged PGs.
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Affiliation(s)
- Wei Li
- Department of General Surgery, Changzheng Hospital, Naval medical university, Shanghai, 200003, China
| | - Bingyang Liu
- Department of General Surgery, Changzheng Hospital, Naval medical university, Shanghai, 200003, China
| | - Chengxiang Shan
- Department of General Surgery, Changzheng Hospital, Naval medical university, Shanghai, 200003, China
| | - Zhiyong Liu
- Department of Laboratory Diagnostics, Changhai Hospital, Naval medical university, Shanghai, 200433, China
| | - Qiang Wang
- Department of General Surgery, Changzheng Hospital, Naval medical university, Shanghai, 200003, China
| | - Wensheng Rao
- Department of General Surgery, Changzheng Hospital, Naval medical university, Shanghai, 200003, China
| | - Siluo Zha
- Department of General Surgery, Changzheng Hospital, Naval medical university, Shanghai, 200003, China
| | - Wei Zhang
- Department of General Surgery, Changzheng Hospital, Naval medical university, Shanghai, 200003, China.
| | - Ming Qiu
- Department of General Surgery, Changzheng Hospital, Naval medical university, Shanghai, 200003, China.
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Zhang J, Dong MJ, Yang J, Tian D. Unusual recurrent renal secondary hyperparathyroidism caused by hyperplastic autograft with supernumerary parathyroid adenoma: A case report. Medicine (Baltimore) 2019; 98:e16077. [PMID: 31192970 PMCID: PMC6587644 DOI: 10.1097/md.0000000000016077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
RATIONALE Secondary hyperparathyroidism (SHPT) is often complicated with chronic renal failure. Though the total parathyroidectomy (TPTX) with forearm autotransplantation (FAT) has been commonly used to treatment refractory renal SHPT, the recurrence of SHPT is not infrequent, resulting from hyperplastic autograft, remnant parathyroid tissues, and supernumerary parathyroid gland (SPG). PATIENT CONCERNS A 67-year-old man undergoing TPTX+FAT 4 years previously for renal SHPT, who received regular hemodialysis with active vitamin D supplements of Rocaltrol treatment postoperatively, was admitted to our hospital with progressively elevated serum intact parathyroid hormone (iPTH) from 176 to 1266 pg/mL for 8 months and bilateral ankle joints pain for 1 month. Tc-sestamibi dual-phase imaging with single positron emission tomography (SPECT)/computed tomography (CT) revealed a nodule in suprasternal fossa, besides a nodule in autografted site, accompanied with intense radioactivity. DIAGNOSIS Recurrent SHPT was easily diagnosed based on previous medical history, painful joints, increased serum iPTH level and positive findings of Tc-sestamibi imaging. Routine postoperative pathology showed that the nodules were consistent with an adenomatoid hyperplasic autograft and a supernumerary parathyroid adenoma in suprasternal fossa, respectively. INTERVENTIONS Reoperation for removing nodules in suprasternal fossa and autografted site was performed 1 month later. Then regular hemodialysis 3 times a week with Rocaltrol was continued. OUTCOMES During 12 months of follow-up, the joints pain improved obviously and the serum iPTH level ranged from 30.1 to 442 pg/mL. LESSONS Although rare, recurrent renal SHPT may be caused by a coexistence of both hyperfunctional autograft and SPG after TPTX+FAT. The Tc-sestamibi parathyroid imaging with SPECT/CT is helpful to locate the culprits of recurrent renal SHPT before reoperation. To prevent recurrence of renal SHPT, the present initial surgical procedures should be further optimized in patient on permanent hemodialysis.
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Challenges and controversies in the surgical management of uremic hyperparathyroidism: A systematic review. Am J Surg 2018; 216:713-722. [DOI: 10.1016/j.amjsurg.2018.07.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 05/19/2018] [Accepted: 07/17/2018] [Indexed: 01/08/2023]
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