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Endoscopic total parathyroidectomy and partial parathyroid tissue autotransplantation for patients with secondary hyperparathyroidism: a new surgical approach.

Sun Y, Cai H, Bai J, Zhao H, Miao Y - World J Surg (2009)

Bottom Line: Hypoparathyroidism was not found after the operation.The clinical data were compared between ETP+AT and TP+AT.ETP+AT is a safe option for the treatment of SHPT with low morbidity and mortality, shorter hospital stay and low recurrence rate.

View Article: PubMed Central - PubMed

Affiliation: Department of Minimally Invasive Surgery, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China. jssym@vip.sina.com

ABSTRACT

Background: Secondary hyperparathyroidism (SHPT) (i.e., renal hyperparathyroidism) is one of the most serious complications in long-term hemodialysis patients. The purpose of this retrospective study was to explore the feasibility of a new surgical approach--endoscopic total parathyroidectomy with autotransplantation (ETP+AT)--and evaluate its practical application for patients with SHPT.

Methods: The study included 34 SHPT patients who underwent ETP+AT from among 67 cases at the Department of Minimally Invasive Surgery, the First Affiliated Hospital of Nanjing Medical University over a 3-year period. The other 33 patients underwent traditional total parathyroidectomy with autotransplantation (TP+AT). Two criteria were used as indications to perform ETP+AT in SHPT patients. The first was a high serum parathyroid hormone level (PTH >800 pg/ml) associated with hypercalcemia and/or hyperphosphatemia that which were refractory to medical treatment. The second criterion was the presence of clinical symptoms including pruritus, bone and joint pain, muscle weakness, progression of soft tissue calcification, and spontaneous fractures. Ultrasonography, (99m)Tc sestamibi scans, and computed tomography were used to evaluate the thyroid and parathyroid glands.

Results: There was no surgery-related mortality among any of the patients with ETP+AT. One patient underwent conventional neck exploration because of bleeding and injury of a unilateral recurrent laryngeal nerve after the operation. Preoperative symptoms were alleviated, and the serum PTH and alkaline phosphatase levels, hyperphosphatemia, and hypercalcemia were improved or normalized in most patients. Recurrence was observed in one patient with a sixth parathyroid gland behind his thyroid, and the patient required a second operation. Hypoparathyroidism was not found after the operation. The clinical data were compared between ETP+AT and TP+AT.

Conclusions: ETP+AT is a safe option for the treatment of SHPT with low morbidity and mortality, shorter hospital stay and low recurrence rate. It is important to avoid intraoperative bleeding, identify all parathyroid glands during the surgery, and choose adequate parathyroid tissues for autografting.

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a, b Autotransplantation. Sliced hyperplastic parathyroid tissues were implanted in forearm muscles
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Fig4: a, b Autotransplantation. Sliced hyperplastic parathyroid tissues were implanted in forearm muscles

Mentions: The procedure of ETP+AT is follows. Under general anesthesia, the patient was placed in the lithotomy position with the neck elevated by a sandbag. The surgery operator stood between the legs of the patient and an assistant stood at the right side of the patient. Three incisions were made at the crossing point of the bilateral medioclavicular lines, parasternal line, and the second intercostal level with the length of each incisions being 0.5, 0.5, and 1 cm, respectively (Fig. 1). We created a subcutaneous space by injecting 1% epinephrine solution, an expanding dilator, and carbon dioxide (CO2) with a pressure of 8 mmHg; we then placed three trocars according to the size of the incisions. Hypodermic porous connectivum of the thorax and cervical area was dissociated by an ultrasonic scalpel; the edge was on the lateral border of both sternocleidomastoid muscles and the inferior margin of thyroid cartilage. A longitudinal incision of the linea alba cervicalis was made, and the bilateral infrahyoid muscle groups were transected to expose the thyroid gland. Th posterior surface of the thyroid was explored to find the parathyroid glands (Fig. 2) according to the surgical anatomy of the parathyroids and the preoperative image diagnosis. The hyperplastic parathyroids were dissected, removed (Fig. 3), and preserved in ice. A portion of each parathyroid was examined and confirmed by pathological analysis. The cervical muscle that had been cut was sutured with 3-0 absorbable intermittent stitches after two drainage tubes were placed. For autotransplantation, 30 pieces of the sliced hyperplastic glands (1 × 1 × 1 mm3) were implanted into muscles in the forearm without formation of an arteriovenous (A-V) fistula for hemodialysis (Fig. 4a, b).Fig. 1


Endoscopic total parathyroidectomy and partial parathyroid tissue autotransplantation for patients with secondary hyperparathyroidism: a new surgical approach.

Sun Y, Cai H, Bai J, Zhao H, Miao Y - World J Surg (2009)

a, b Autotransplantation. Sliced hyperplastic parathyroid tissues were implanted in forearm muscles
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2712635&req=5

Fig4: a, b Autotransplantation. Sliced hyperplastic parathyroid tissues were implanted in forearm muscles
Mentions: The procedure of ETP+AT is follows. Under general anesthesia, the patient was placed in the lithotomy position with the neck elevated by a sandbag. The surgery operator stood between the legs of the patient and an assistant stood at the right side of the patient. Three incisions were made at the crossing point of the bilateral medioclavicular lines, parasternal line, and the second intercostal level with the length of each incisions being 0.5, 0.5, and 1 cm, respectively (Fig. 1). We created a subcutaneous space by injecting 1% epinephrine solution, an expanding dilator, and carbon dioxide (CO2) with a pressure of 8 mmHg; we then placed three trocars according to the size of the incisions. Hypodermic porous connectivum of the thorax and cervical area was dissociated by an ultrasonic scalpel; the edge was on the lateral border of both sternocleidomastoid muscles and the inferior margin of thyroid cartilage. A longitudinal incision of the linea alba cervicalis was made, and the bilateral infrahyoid muscle groups were transected to expose the thyroid gland. Th posterior surface of the thyroid was explored to find the parathyroid glands (Fig. 2) according to the surgical anatomy of the parathyroids and the preoperative image diagnosis. The hyperplastic parathyroids were dissected, removed (Fig. 3), and preserved in ice. A portion of each parathyroid was examined and confirmed by pathological analysis. The cervical muscle that had been cut was sutured with 3-0 absorbable intermittent stitches after two drainage tubes were placed. For autotransplantation, 30 pieces of the sliced hyperplastic glands (1 × 1 × 1 mm3) were implanted into muscles in the forearm without formation of an arteriovenous (A-V) fistula for hemodialysis (Fig. 4a, b).Fig. 1

Bottom Line: Hypoparathyroidism was not found after the operation.The clinical data were compared between ETP+AT and TP+AT.ETP+AT is a safe option for the treatment of SHPT with low morbidity and mortality, shorter hospital stay and low recurrence rate.

View Article: PubMed Central - PubMed

Affiliation: Department of Minimally Invasive Surgery, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China. jssym@vip.sina.com

ABSTRACT

Background: Secondary hyperparathyroidism (SHPT) (i.e., renal hyperparathyroidism) is one of the most serious complications in long-term hemodialysis patients. The purpose of this retrospective study was to explore the feasibility of a new surgical approach--endoscopic total parathyroidectomy with autotransplantation (ETP+AT)--and evaluate its practical application for patients with SHPT.

Methods: The study included 34 SHPT patients who underwent ETP+AT from among 67 cases at the Department of Minimally Invasive Surgery, the First Affiliated Hospital of Nanjing Medical University over a 3-year period. The other 33 patients underwent traditional total parathyroidectomy with autotransplantation (TP+AT). Two criteria were used as indications to perform ETP+AT in SHPT patients. The first was a high serum parathyroid hormone level (PTH >800 pg/ml) associated with hypercalcemia and/or hyperphosphatemia that which were refractory to medical treatment. The second criterion was the presence of clinical symptoms including pruritus, bone and joint pain, muscle weakness, progression of soft tissue calcification, and spontaneous fractures. Ultrasonography, (99m)Tc sestamibi scans, and computed tomography were used to evaluate the thyroid and parathyroid glands.

Results: There was no surgery-related mortality among any of the patients with ETP+AT. One patient underwent conventional neck exploration because of bleeding and injury of a unilateral recurrent laryngeal nerve after the operation. Preoperative symptoms were alleviated, and the serum PTH and alkaline phosphatase levels, hyperphosphatemia, and hypercalcemia were improved or normalized in most patients. Recurrence was observed in one patient with a sixth parathyroid gland behind his thyroid, and the patient required a second operation. Hypoparathyroidism was not found after the operation. The clinical data were compared between ETP+AT and TP+AT.

Conclusions: ETP+AT is a safe option for the treatment of SHPT with low morbidity and mortality, shorter hospital stay and low recurrence rate. It is important to avoid intraoperative bleeding, identify all parathyroid glands during the surgery, and choose adequate parathyroid tissues for autografting.

Show MeSH
Related in: MedlinePlus