[Endocrine surgery during and after the COVID-19 epidemic: Guidelines from AFCE]

La pandémie de COVID-19 impose une réorganisation majeure de l’ensemble de notre système de soins. En France, des règles générales ont été diffusées au niveau national et sont déclinées par chaque établissement, public comme privé, sur l’ensemble du territoire. Ces recommandations, rédigées par un groupe d’experts sous l’égide de l’Association francophone de chirurgie endocrinienne (AFCE), ont pour objectif de proposer des principes spécifiques de prise en charge chirurgicale au cours et au décours de l’épidémie de COVID- 19, pour les pathologies chirurgicales de la thyroïde, des parathyroïdes, du pancréas endocrine, et des surrénales.

Current concepts in primary hyperparathyroidism

622 patients were operated on between 1966 and 1988. Urolithiasis was the most common presenting symptom (26%) but routine measurements of serum calcium led to detect 50% cases. At present, the disease is three times more frequent in women than in men. Estrogenic deprivation, neck irradiation (3.4%) and lithium therapy favor the occurrence of hyperparathyroidism (HPT); frequent association with goiter (19.8%), diabetes (8.3%) and multiple endocrine neoplasia (3.5%) has been noticed. Bone Gla protein concentrations correlate with calcium and HPT blood concentrations but do not reflect the severity of bone damage. Dual photon absorptiometry is now available for quantification and follow-up of bone demineralization, especially in asymptomatic forms of HPT.

Prevention of hypocalcemia and hypoparathyroidism after total thyroidectomy. Recommendations of the Francophone Association of Endocrine Surgery (AFCE) with the French Society of Endocrinology (SFE) and the French Society of Nuclear Medicine (SFMN)

Postoperative hypoparathyroidism, resulting from removal and/or devascularization of one or more parathyroid glands, is a feared complication of total thyroidectomy. Two forms, which are distinguished by their frequency, their time to onset and their duration as well as by their presentation, must be individualized: early postoperative hypocalcemia, often secondary to early hypoparathyroidism is a frequent and often transient situation occurring within the first days after surgery; permanent hypoparathyroidism, which is rarer, manifests when parathyroid function remains impaired for more than six months after surgery. Because of their severity, these conditions must be known and ideally prevented during total thyroidectomy. The objective of this article is to provide surgeons with practical recommendations for the prevention, diagnosis, and treatment of hypoparathyroidism after total thyroidectomy. These recommendations, which are the fruit of a medico-surgical consensus, were developed by the Francophone Association of Endocrine Surgery (AFCE), the French Society of Endocrinology (SFE) and the French Society of Nuclear Medicine and Molecular Imaging. (SFMN). The content, grade and level of evidence for each recommendation was decided after consultation within a panel of experts, based on an analysis of recent literature.

Multiglandular disease in seemingly sporadic primary hyperparathyroidism revisited: where are we in the early 1990s? A plea against unilateral parathyroid exploration

BACKGROUND

Most of the available data on multiglandular disease (MGD) originate from long-term series. The spectrum of the disease has changed now because of earlier diagnosis. We decided to assess the current frequency of MGD in seemingly sporadic primary hyperparathyroidism.

METHODS

MGD was defined as the finding that more than one grossly enlarged gland weighed more than 50 mg and the rim of normal parathyroid tissue was diagnostic of adenoma. Nine hundred eight consecutive neck explorations for hyperparathyroidism were performed, 624 before 1989 and 284 between 1989 and 1991, and studied retrospectively. Since 1989, oil Red O staining has been done to assess hyperfunction.

RESULTS

When multiple endocrine neoplasia and non-multiple endocrine neoplasia familial cases of hyperparathyroidism are excluded, the frequency of MGD in seemingly sporadic primary hyperparathyroidism, 17.7% before 1989, is still 14% since then, including a 3% frequency of true multiple adenomas. With more restrictive criteria, which exclude the second enlarged gland if it weighed less than 100 mg, if it had no rim, and if oil Red O staining was negative, the frequency of MGD in sporadic hyperparathyroidism has remained 11% since 1989. Unilateral exploration had missed 78% of second enlarged glands, and preoperative imaging studies, when performed, showed more than one gland in only two of 22 cases.

CONCLUSIONS

Routine bilateral neck exploration is recommended in primary hyperparathyroidism because of a current frequency of MGD of at least 11%.

Primary hyperparathyroidism due to solitary adenoma. A comparative multicentre study of early and long-term results of different surgical regimens

Surgical regimens for treatment of solitary parathyroid adenoma were compared in a multicentre study in five departments of surgery in the United States and Europe. Three hundred and twenty-five patients fulfilled the inclusion criteria. Eight years after the operation 272 patients (84%) were available for follow-up investigation. Severe postoperative hypocalcaemia (less than 2.00 mmol) was significantly more common after bilateral than unilateral exploration (p less than 0.001), and in women (p less than 0.01). Neither age nor preoperative serum calcium concentration was related to the severity of postoperative hypocalcaemia. At follow-up, 96% of the patients who had had unilateral, and 89% of those who had had Bilateral exploration had remained normocalcaemic without further treatment. Of the patients who had had incisional biopsies of normal glands 8% had hypercalcaemia and 8% had hypocalcaemia. Of patients operated on without a biopsy being taken or who had had one whole normal gland removed 1% were hypercalcaemic and 4% were hypocalcaemic. Early and late hypocalcaemia are reduced by atraumatic handling of the normal parathyroid gland without increasing the risk of persistent or recurrent hypercalcaemia.