Multiglandular Parathyroid Disease: the Results of Surgical Treatment

Background. Sporadic multiple gland disease in primary hyperparathyroidism occurs in 7 to 33 % of cases. The absence of specific risk factors, low sensitivity of imaging methods, and low efficiency of bilateral neck exploration and intraoperative monitoring of parathyroid hormone indicate the complexity of the diagnosis and treatment of this disease’s form. Aim of the research. To analyze the results of surgical treatment of multiple lesions of the parathyroid gland in primary and secondary hyperparathyroidism. Methods. There was retrospective study, which included 100 observations of surgical treatment for primary and secondary hyperparathyroidism in the thoracic department of Irkutsk Regional Clinical Hospital from May 2018 to September 2019. The main point was to identify the frequency of surgical treatment outcomes in patients with multiple parathyroid lesions. As part of the study, potential predictors of multiple gland disease in primary hyperparathyroidism were analyzed. Results. Multiple gland disease in primary hyperparathyroidism occurs in 29 % of cases and causes persistence of the disease (p ≤ 0.01). Signs of multiple gland disease in primary hyperparathyroidism include the level of ionized calcium, parathyroid hormone (p ≤ 0.05), creatinine level and glomerular filtration rate (p ≤ 0.01). A negative result of intraoperative monitoring correlates with persistence of primary hyperparathyroidism in multiple lesions (χ2, p ≤ 0.05). Selective parathyroidectomy is associated with persistence of hyperparathyroidism in multiple lesions (χ2, p ≤ 0.05), while total parathyroidectomy is associated with remission of the disease (χ2, p ≤ 0.05). We did not find a statistically significant relationship between the results of surgical treatment for morphology of the parathyroid glands (χ2, p > 0.1). Conclusion. Multiple gland disease is the main cause of persistence of primary hyperparathyroidism. This form of the disease corresponds to lower levels of calcium, parathyroid hormone, and kidney function. Persistence factors have been established: removal of less than four parathyroid glands and a negative result of intraoperative monitoring of parathyroid hormone. Bilateral neck exploration does not reduce the incidence of disease persistence

Surgical Treatment of Secondary Hyperparathyroidism at Ectopic Parathyroid Gland in Anterior-Superior Mediastinum (Literature Review and Clinical Case)

Parathyroidectomy is the leading treatment for drug-refractory secondary and tertiary hyperparathyroidism in patients with chronic kidney disease. Difficulties in performing this surgery are mainly associated with the anatomical features of the parathyroid glands, in particular with the variability of their number and topographic anatomy. Ectopic parathyroid glands are one of the most common causes of persistence or recurrence of secondary hyperparathyroidism after surgery. One of the common variants of ectopia is the localization of the parathyroid gland in the anterior-superior mediastinum. The article discusses the features of surgical treatment of secondary hyperparathyroidism in patients with end-stage chronic kidney disease with this ectopia. A new method of treating hyperparathyroidism in patients with an atypical location of the parathyroid gland in the anterior-superior mediastinum is presented. This method is characterized by low invasiveness of access, ease of implementation without using special equipment and instruments. The proposed method was used in the treatment of a patient with secondary hyperparathyroidism due to chronic renal failure as a result of chronic glomerulonephritis. The duration of hemodialysis at the time of the surgery was more than 17 years. In the presented clinical case, ectopia of one of the pathologically altered parathyroid glands in the anterior-superior mediastinum was found at the preoperative stage. As a method of surgical treatment, we carried out total parathyroidectomy with autotransplantation of a fragment of parathyroid tissue into the brachioradialis muscle. Thanks to this method, it was possible to remove the atypically located parathyroid gland from the cervicotomy access and to discharge the patient within the standard terms for a given volume of surgery

Experience of surgical treatment of secondary hyperparathyroidism

Surgical treatment of secondary hyperparathyroidism (HPT) in patients having renal replacement therapy (RRT) is a current problem. The aim of our study was to optimize the treatment of secondary HPT based on the comparative analysis of effectiveness of the surgeries with different extents. We conducted a retrospective analysis of the results of surgical treatment of uremic HPT in 34 patients. 36 surgeries were performed including 34 primary (16 subtotal parathyroidecomies (PTE), 13 total parathyroidecomies (total PTE 1), 5 total parathyroidecomies with central neck dissection and resection of superior mediastinum and superior thymus horns (total PTE II)) and 2 repeated surgeries (total PTE 11 and parathyroidadenomectomy). Gross examination of 134 surgical specimens revealed dyssynchronous pathological changes in parathyroid glands (PTG), normal PTG structure was found in 2 cases. Recurrent HPT was found in 3 cases, persistent HPT - in 9 cases, hypoparathyroidism - in 5 cases after subtotal PTE and in 9 cases after total PTE with autotransplantation (p = 0,267). Target values of parathyroid hormone were registered in 8 patients, including 4 patients after subtotal PTE and 4 patients after total PTE (p > 0,95). Morbidity was similar in all types of surgeries (p > 0,5). Analysis of morbidity determined that simultaneous surgery of thyroid gland increased the risk of laryngeal paralysis (р = 0,028). The decrease in occurrence of secondary HPT persistence (with the source accessible for removal through cervical approach) at total PTE based on the removal of parathyroid glands of all localizations accessible through cervical approach (including thyroid gland lobes with diagnosed ectopia, central cervical fat pad, superior mediastinum and superior thymus horns) was registered (NNT = 4)

EXPERIENCE OF SURGICAL TREATMENT OF THYROID AND PARATHYROID DISEASES

Background. In our country some aspects of thyroid and parathyroid surgery are still discussed. Aim. To present our experience in surgical treatment of benign diseases of the thyroid and parathyroid glands. Materials and methods. A retrospective analysis of the results of surgical treatment of 1511 patients with thyroid and parathyroid disease was performed. Results. Thyroidectomy was performed in 73.6 % of cases with thyroid diseases. The frequency of postoperative complications: laryngeal paresis -1.37 %, hypoparathyroidism - 0.84 %, hemorrhagic complications -1.2 %. Selective parathyroidectomy was performed in 99 % of cases with primary hyperparathyroidism. Persistent hypoparathyroidism and laryngeal paresis have not been identified. Total parathyroidectomy with central neck dissection, upper mediastinum and upper horn of the thymus gland was performed in 66.3 % of cases with secondary hyperparathyroidism. Persistent laryngeal paresis was established in 3.3 % of cases, hemorrhagic complications - in 3.3 %. Conclusions. Constant analysis of our own results gives us reasons for our own attitude to the controversial issues of thyroid and parathyroid surgery. Presently, we prefer thyroidectomy in the treatment of diffuse toxic goiter and multinodular goiter, hemithyroidectomy - for the single-node goiter. In the surgical treatment of primary and uremic hyperparathyroidism, we consider mandatory the use of intraoperative monitoring of intact parathyroid hormone. When performing total parathyroidectomy, we perform the autotransplantation of the fragment of the parathyroid gland

EXPERIENCE OF SURGICAL TREATMENT OF THYROID AND PARATHYROID DISEASES

Background. In our country some aspects of thyroid and parathyroid surgery are still discussed. Aim. To present our experience in surgical treatment of benign diseases of the thyroid and parathyroid glands. Materials and methods. A retrospective analysis of the results of surgical treatment of 1511 patients with thyroid and parathyroid disease was performed. Results. Thyroidectomy was performed in 73.6 % of cases with thyroid diseases. The frequency of postoperative complications: laryngeal paresis - 1.37 %, hypoparathyroidism - 0.84 %, hemorrhagic complications - 1.2 %. Selective parathyroidectomy was performed in 99 % of cases with primary hyperparathyroidism. Persistent hypoparathyroidism and laryngeal paresis have not been identified. Total parathyroidectomy with central neck dissection, upper mediastinum and upper horn of the thymus gland was performed in 66.3 % of cases with secondary hyperparathyroidism. Persistent laryngeal paresis was established in 3.3 % of cases, hemorrhagic complications - in 3.3 %. Conclusions. Constant analysis of our own results gives us reasons for our own attitude to the controversial issues of thyroid and parathyroid surgery. Presently, we prefer thyroidectomy in the treatment of diffuse toxic goiter and multinodular goiter, hemithyroidectomy - for the single-node goiter. In the surgical treatment of primary and uremic hyperparathyroidism, we consider mandatory the use of intraoperative monitoring of intact parathyroid hormone. When performing total parathyroidectomy, we perform the autotransplantation of the fragment of the parathyroid gland

Results of surgical treatment of uremic hyperparathyroidism (analysis 67 observations)

The analysis of the results of surgical treatment of hyperparathyroidism in 63 patients on dialysis replacement renal therapy is presented. A total of 63 primary and 4 secondary (for recurrence) surgical interventions were performed including 12 (17.9 %) - subtotal parathyroidectomy, 8 (11.9 %) - total parathyroidectomy with autotransplantation (type I), 43 (64.2 %) - total parathyroidectomy with removal of the central cellular tissue of the neck, the superior mediastinum and upper horns of the thymus gland with autotransplantation (type II); 3 (4.5 %) - secondary total parathyroidectomy type II and 1 (1.5 %) - secondary parathyroid adenomectomy. With the use of intraoperative monitoring of intact parathyroid hormone, 15 (22.4 %) operations were performed. In the postoperative period from 1 to 134 months, the patients had a decrease in blood levels of calcium, phosphorus and intact parathyroid hormone. Postoperative hypoparathyroidism was detected in 38 cases (56.7 %) of 67 observations: in 5 cases after subtotal parathyroidectomy, 5 - after total parathyroidectomy type I, and 28 - after total parathyroidectomy type II. The permissible level of parathyroid hormone was reached in 13 (19.4 %) cases: 1 - after subtotal parathyroidectomy, 11 - after total parathyroidectomy type II and 1 - after parathyroid adenomectomy. Persistence and relapse of the disease were revealed in 16 observations: 6 - after subtotal parathyroidectomy, 3 - after total parathyroidectomy type I and 7 - after total parathyroidectomy type II. When using intraoperative monitoring of intact parathyroid hormone, there are: 1 observation with the development of the persistence of the disease, 3 - with the permissible level of parathyroid hormone and in 13 cases - with the development of hypoparathyroidism. Based on the results of a comparative analysis of the results of surgical intervention, depending on the type of operation, total type II parathyroidectomy is justified for the prevention of the development of persistence and recurrent HTT (p = 0.01)