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Management of Secondary and Tertiary Hyperparathyroidism- Joint Hospital Grandround 20.12.2003
Henry JoengDepartment of SurgeryUnited Christian Hospital, HKSAR
Overview
Pathophysiology Medical treatment Surgical treatment
Indication Pre-op localization study Different types of parathyroidectomies Rapid PTH assay
Experience in UCH
Secondary Hyperparathyroidism
Chronic extrinsic overstimulation of otherwise normal parathyroid gland
Diffuse hyperplasia of all 4 PTH glands
A negative calcium balance is the key stimulus
Chronic renal insufficiency is the commonest cause
Tertiary hyperparathyroidism
Autonomous hypersecretion of PTH in long lasting secondary hyperPTH despite correction of the underlying cause
Commonly seen in post-renal transplantion patient with long history of dialysis beforehand
Complications of 2o/3o HyperPTH
Skeletal Progressive bone demineralization Osteitis fibrosa cystitca Bone pain, pathological fracture
Soft tissue calcification Involve different organs or tissues Calciphylaxis
Complications of 2o/3o HyperPTH
Pruritus
Other Myopathy Peptic ulcer disease Neuropathy Cardiotoxicity
Biochemical changes Elevated “intact” PTH key
feature Elevated phosphate Elevated ALP Normal serum calcium level.
Elevated in 3o hyperPTH
Radiological changes Plain X ray
Subperiosteal bone resorption “Pepper pot” appearance of skull
Bone density Progressive decline
Surgical treatment 5-10 % patients on long term dialysis
need parathyroidectomy
Indication When complications of 2o/3o hyperPTH arise.
E.g. skeletal cx Medical treatments fail Biochemical parameter
E.g. [Ca][PO4] product > 70
PTX - Optimization Correct biochemical disturbance due
to underlying renal disease
Hemodialysis before operation
Aggressive pre-op calcium replacement
Anatomy of parathyroid gland Upper glands position more constant
77% around the intersection of RLN and inferior thyroid artery
Lower glands more variable Lower pole of thyroid, thyrothymic ligament 9% in thymus gland
Supernumerary gland in up to 8% cases Butterworth. J R Coll Surg Edinburg 1998
PTX - Localization Different from 1o HyperPTH Multi-gland disease Bilateral neck exploration Locate ectopic or supernumerary PTH
glands Sestamibi scan, USG
Types of parathyroidectomies
Subtotal parathyoidectomy
Total parathyroidectomy with autotransplantation
Subtotal parathyroidectomy
Stanbury, 1960 3 ½ PTH glands resected 50 mg of one viable gland left behind Advantage
Less post-op hypoparathyroidism Disadvantage
Second neck exploration if persistent or recurrent hyperparathyroidism
Total parathyroidectomy with autotransplantation
Wells, 1975 Remove all 4 PTH glands Autotransplant one PTH gland, usu
into brachioradialis muscle 20 pieces of 1 mm size fragment Separate pockets and marked with
non-absorbale suture
Total parathyroidiectomy with autotransplantation
Advantage Easier to differentiate between
hyperfunctioning graft or residual gland in neck
Easier to remove hyperfunctioning graft
Disadvantage Higher risk of post-op
hypoparathyroidism
Choice of operation Controversy
Persistant/ recurrent hyperPTH Symptom improvement HypoPTH/ Hypocalcemia
Literature search Database: Medline, EBM review, EMBase Keywords: 2o/ 3o hyperparathyroidism,
parathyroidectomy, compar$
Evidence … 1 RCT comparing subtotal PTX vs
Total PTX with autotransplantation Rothmund. Word J Surg 1991
Rothmund, 1991SPTX PTX+AT
No. of patient 20 20
Persistent hyperPTH 4/20 0/20 p<0.03
Symptom improvement
Bone pain 61% 87%
Radiological sign of renal osteodystrophy
33% 69% p<0.05
Muscle weakness 20% 83% p<0.04
Pruritus 45% 100% p<0.005
Hypocalcemia 1/20 1/20
Total parathyroidectomy alone
Remove all 4 PTH glands Not widely practiced, due to post-op
hypoparathyroidism and risk of adynamic bone disease
Recent case series and non-randomized comparative studies feasible method
Role of rapid PTH assay Short ½ life of intact PTH Immunochemiluminometric assay Confirm adequate resection and alert
the possibility of supernumerary gland
At 10min after resection, decrease iPTH of >60% is predictive of cure
Chou. Archives of Surgery. 2002 Mar
UCH experience From 5.2002 till 12.2003 15 patients with renal failure and
2o/3o hyperPTH Total PTX + AT in all patients Transcervical thymectomy in 4
patients Hemithyroidectomies in 3 patients
UCH experience
Mean FU 7.7 months (0.5 – 20) Mean Duration of dialysis 7.3 yrs (2 – 17) Persistent/ recurrent hyperPTH 4/15
(26.7%) iPTH > 7.7 pmol/l Asymptomatic No need of re-exploration
Improvement in bone pain 7/7 (100%) 2/15 patients had undetectable iPTH