Outcomes of Total Parathyroidectomy with Autotransplantation versus Subtotal Parathyroidectomy with Routine Addition of Thymectomy to both Groups: Single Center Experience of Secondary Hyperparathyroidism

Yıl 2014, , 77 - 82, 07.08.2014

Cem Kaan Parsak Gökhan Sarıtaş Gülşah Seydaoglu Gürhan Sakman İsmail Cem Eray Mustafa Balal Orhan Demircan

https://doi.org/10.5152/balkanmedj.2014.9544

Öz

Background: Secondary hyperparathyroidism is a common acquired disorder seen in chronic renal failure. It may result in potentially serious complications including metabolic bone diseases, severe atherosclerosis and undesirable cardiovascular events. Parathyroidectomy is required in about 20% of patients after 3-10 years of dialysis and in up to 40% after 20 years. Aims: The aim of the current study was to evaluate the short-term and long-term outcomes of patients with secondary hyperparathyroidism who had undergone total parathyroidectomy with autotransplantation and thymectomy or subtotal parathyroidectomy with thymectomy by the same surgical team during the study period. Study Design: Retrospective comparative study. Methods: Clinical data of 50 patients who underwent parathyroid surgery for secondary hyperparathyroidism between 2003 and 2011 were reviewed retrospectively. Patients were divided into two subgroups of total parathyroidectomy with autotransplantation or subtotal parathyroidectomy. Thymectomy was routinely performed for both groups. Short term outcome parameters included intact parathyroid hormone, ionized calcium and alkaline phosphatase levels. Bone pain, bone fractures, persistent or recurrent disease were included in long term outcome parameters. Results: The mean duration of dialysis was eight years. The mean ionized calcium levels dropped significantly in the total parathyroidectomy with autotransplantation group (p=0.016). No serious postoperative complications were observed. Postoperative intravenous calcium supplementation was required in four patients in the total parathyroidectomy with autotransplantation group (total PTX+AT) and in three patients in the subtotal parathyroidectomy group (subtotal PTX). Postoperatively, all patients received oral calcium carbonate and calcitriol. The length of average hospital stay was 5 (3-10) days. Including nine patients who underwent successful renal transplantation pre-operative bone symptoms, hypercalcemia, hyperphosphatemia, and an increased alkaline phosphatase levels were improved or resolved in all patients. After a mean follow-up of 65 months, three patients (6%) had persistent and one (2%) had recurrent disease. Conclusion: Total parathroidectomy with autotransplantation is a beneficial and safe surgical procedure for patients on chronic dialysis with otherwise uncontrollable secondary hyperparathroidism and even in patients who have undergone renal transplantation after parathyroidectomy. Careful cervical exploration and routine thymectomy should be considered as a routine part of the surgical approach regardless of the preferred technique.

Anahtar Kelimeler

Autotransplantation, chronic renal failure, secondary hyperparathyroidism, parathyroidectomy, thymectomy

Outcomes of Total Parathyroidectomy with Autotransplantation versus Subtotal Parathyroidectomy with Routine Addition of Thymectomy to both Groups: Single Center Experience of Secondary Hyperparathyroidism

Öz

Kaynakça

• Malberti F, Marcelli D, Conte F, Limido A, Spotti D, Locatelli F. Parathyroidectomy in patients on renal replacement therapy: an epidemiologic study. J Am Soc Nephrol 2001;12:1242-8.
• Tominaga Y, Uchida K, Haba T, Katayama A, Sato T, Hibi Y, et al. More than 1,000 cases of total parathyroidectomy with forearm autograft for renal hyperparathyroidism. Am J Kidney Dis 2001;38:168-71. [CrossRef]
• Fassbinder W, Brunner FP, Brynger H, Ehrich JH, Geerlings W, Raine AE, et al. Combined report on regular dialysis and transplantation in Europe, XX, 1989. Nephrol Dial Transplant 1991;Suppl 1:5-35.
• Shih ML, Duh QY, Hsieh CB, Lin SH, Wu HS, Chu PL, et al. Total parathyroidectomy without autotransplantation for secondary hyperparathyroidism. World J Surg 2009;33:248-54. [CrossRef]
• Hargrove GM, Pasieka JL, Hanley DA, Murphy MB. Short- and longterm outcome of total parathyroidectomy with immediate autografting versus subtotal parathyroidectomy in patients with end-stage renal disease. Am J Nephrol 1999;19:559-64. [CrossRef]
• Gasparri G, Camandona M, Abbona GC, Papotti M, Jeantet A, Radice E, et al. Secondary and tertiary hyperparathyroidism: causes of recurrent disease after 446 parathyroidectomies. Ann Surg 2001;233:65-9. [CrossRef]
• Naranda J, Ekart R, Pecovnik-Balon B. Total parathyroidectomy with forearm autotransplantation as the treatment of choice for secondary hyperparathyroidism. J Int Med Res 2011;39:978-87. [CrossRef]
• Lorenz K, Ukkat J, Sekulla C, Gimm O, Brauckhoff M, Dralle H. Total parathyroidectomy without autotransplantation for renal hyperparathyroidism: experience with a qPTH-controlled protocol. World J Surg 2006;30:743-51. [CrossRef]
• National Kidney Foundation K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 2003;42:1-140. [CrossRef]
• Santos RO, Ohe MN, Carvalho AB, Neves MC, Kunii I, Lazaretti- Castro M, et al. Total parathyroidectomy with presternal intramuscular autotransplantation in renal patients: A prospective study of 66 patients. J Osteoporos 2012;2012:631243.
• Pitt SC, Sippel RS, Chen H. Secondary and tertiary HPT, state of the art surgical management. Surg Clin North Am 2009;89:1227-39. [CrossRef]
• Riss P, Asari R, Scheuba C, Niederle B. Current trends in surgery for renal hyperparathyroidism (RHPT) an international survey. Langenbecks Arch Surg 2013;398:121-30. [CrossRef]
• Mittendorf EA, Merlino JI, McHenry CR. Post-parathyroidectomy hypocalcemia: incidence, risk factors, and management. Am Surg 2004;70:114-19.
• Drueke TB, Ritz E. Treatment of secondary hyperparathyroidism in CKD patients with cinacalcet and/or vitamin D derivatives [Review]. Clin J Am Soc Nephrol 2009;4:234-41.[CrossRef]
• Wallfelt CH, Larsson R, Gylfe E, Ljunghall S, Rastad J, Akerström G. Secretory disturbance in hyperplastic parathyroid nodules of uremic hyperparathyroidism: implication for parathyroid autotransplantation. World J Surg 1988;12:431-8.[CrossRef]
• Riss P, Kaczirek K, Heinz G, Bieglmayer C, Niederle B. A “defined baseline” in PTH monitoring increases surgical success in patients with multiple gland disease. Surgery 2007;142:398-404. [CrossRef]
• Bieglmayer C, Kaczirek K, Prager G, Niederle B. Parathyroid hormone monitoring during total parathyroidectomy for renal hyperparathyroidism: pilot study of the impact of renal function and assay specificity. Clin Chem 2006;52:1112-9. [CrossRef]
• Pitt SC, Panneerselvan R, Chen H, Sippel RS. Secondary and tertiary hyperparathyroidism: the utility of ioPTH monitoring. World J Surgery 2010;34:1343-9. [CrossRef]
• Riss P, Asari R, Scheuba C, Niederle B. Current trends in surgery for renal hyperparathyroidism (RHPT) -an international survey. Langenbecks Arch Surg 2013;398:121-30. [CrossRef]
• Agha A, Loss M, Schlitt HJ, Scherer MN. Recurrence of secondary hyperparathyroidism in patients after total parathyroidectomy with autotransplantation: technical and therapeutic aspects. Eur Arch Otorhinolaryngol 2012;269:1519-25. [CrossRef]
• Kinnaert P, Salmon I, Decoster-Gervy C, Vienne A, De Pauw L, Hooghe L, et al. Long-term results of subcutaneous parathyroid grafts in uremic patients. Arch Surg 2000;135:186-90. [CrossRef]
• Stracke S, Keller F, Steinbach G, Henne-Bruns D, Wuerl P. Long-term outcome after total parathyroidectomy for the management of secondary hyperparathyroidism. Nephron Clin Pract 2009;111:c102-9. [CrossRef]
• Triponez F, Dosseh D, Hazzan M, Noel C, Soudan B, Lokey J, et al. Accuracy of intra-operative PTH measurement during subtotal parathyroidectomy for tertiary hyperparathyroidism after renal transplantation. Langenbecks Arch Surg 2006;391:561-5. [CrossRef]
• Pattou FN, Pellissier LC, Noël C, Wambergue F, Huglo DG, Proye CA. Supernumerary parathyroid glands: frequency and surgical significance in treatment of renal hyperparathyroidism. World J Surg 2000;24:1330-4. [CrossRef]
• Schneider R, Waldmann J, Ramaswamy A, Fernández ED, Bartsch DK, Schlosser K. Frequency of ectopic and supernumerary intrathymic parathyroid glands in patients with renal hyperparathyroidism: analysis of 461 patients undergoing initial parathyroidectomy with bilateral cervical thymectomy. World J Surg 2011;35:1260-5. [CrossRef]
• Rayes N, Seehofer D, Schindler R, Reinke P, Kahl A, Ulrich F, et al. Long-term results of subtotal vs total parathyroidectomy without autotransplantation in kidney transplant recipients. Arch Surg 2008;143:756-61. [CrossRef]
• Richards ML, Wormuth J, Bingener J, Sirinek K. Parathyroidectomy in secondary hyperparathyroidism: Is there an optimal operative management? Surgery 2006;139:174-80. [CrossRef]