Reoperation for persistent or recurrent secondary hyperparathyroidism

Alida Abruzzo, Maria Concetta Gioviale, Giuseppe Damiano, Vincenzo Davide Palumbo, Salvatore Buscemi, Giulia Lo Monte, Leonardo Gulotta, Giuseppe Buscemi, Attilio Ignazio Lo Monte, Alida Abruzzo, Maria Concetta Gioviale, Giuseppe Damiano, Vincenzo Davide Palumbo, Salvatore Buscemi, Giulia Lo Monte, Leonardo Gulotta, Giuseppe Buscemi, Attilio Ignazio Lo Monte

Abstract

Background: Secondary hyperparathyroidism is a common acquired disorder seen in chronic renal failure. Its pathophysiology is mainly due to hyperphosphatemia and vitamin D deficiency and resistance. When medical treatment fails, subtotal and total parathyroidectomy with autotransplantation are the standard procedures, although both are associated with high recurrence rates.

Methods and results: 4 patients experienced persistence and 9 relapse. The first 4 were subjected to reoperation after 6 months for the persistence of symptoms due to the finding of a supernumerary adenomatous gland while the remaining patients at the reoperation showed in 5 cases 2 more glands in over thymic position, and 4 an hyperplasia of the residual glandular tissue. A classic cervicotomy was sufficient to remove the residual parathyroid in patients with persistent hyperparathyroidism. For cases of recurrent hyperparathyroidism it was enough a medial approach and sometimes lateral for the complete excision of the hyperplastic tissue. The advent of the intraoperative technique of parathyroid hormone dosage allowed a better performance of the surgical technique for the last 3 patients undergoing reoperation. After reoperation all patients had immediate regression of clinical symptoms with normalization of serum calcium and PTH levels.

Conclusions: On the basis of these considerations, diagnostic imaging has a not negligible role because during the first intervention helps to have an idea of the possible location of the glands and thus to avoid the risk of recurrence and relapse due to ectopic or supernumerary tissue.

Keywords: intraoperative parathyroid hormone measurement; persistent hyperparathyroidism; recurrent hyperparathyroidism; subtotal parathyroidectomy.

References

    1. Cunningham J, Locatelli F, Rodriguez M. Secondary Hyperparathyroidism: Pathogenesis, Disease Progression, and Therapeutic Options. Clin J Am Soc Nephrol. 2011;6:913921.
    1. Fraser WD. Hyperparathyroidism. Lancet. 2009;374:14558.
    1. Lappas D, Noussios G, Anagnostis P, Adamidou F, Chatzigeorgiou A, Skandalakis P. Location, number and morphology of parathyroid glands: results from a large anatomical series. Anat Sci Int. 2012;87(3):160–4.
    1. Sakman G, Parsak CK, Balal M, et al. Outcomes of Total Parathyroidectomy with Autotransplantation versus Subtotal Parathyroidectomy with Routine Addition of Thymectomy to both Groups: Single Center Experience of Secondary Hyperparathyroidism. Balkan Med J. 2014;31:77–82.
    1. Yumita S. Intervention for recurrent secondary hyperparathyroidism from a residual parathyroid gland. Nephrol Dial Transplant. 2003;18:62–4.
    1. Chou FF, Lee CH, Chen HY, Chen JB, Hsu KT, SheenChen SM. Persistent and Recurrent Hyperparathyroidism After Total Parathyroidectomy With Autotransplantation. Annals Of Surgery. 2002;235(1):99–104.
    1. Lo Monte AI, Bellavia M, Damiano G, et al. A complex case of fatal calciphylaxis in a female patient with hyperparathyroidism secondary to end stage renal disease of graft and coexistence of haemolytic uremic syndrome. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2012;156(3):262–5.
    1. Lo Monte AI, Bellavia M, Maione C, et al. Systemic calciphylaxis and thrombotic microangiopathy in a kidney transplant patient:two mixing fatal syndromes? Med Hypotheses. 2012;79(1):74–5.
    1. Gioviale MC, Damiano G, Lombardo C, Maione C, Buscemi G, Lo Monte AI. Bone resorption in kidney transplant recipients. Transplant Proc. 2009;41(4):1170–4.
    1. Bellavia M, Gioviale MC, Damiano G, et al. Is secondary hyperparathyroidism-related myelofibrosis a negative prognostic factor for kidney transplant outcome? Med Hypotheses. 2011;77(4):557–9.
    1. Gioviale MC, Bellavia M, Damiano G, Lo Monte AI. Posttransplantation tertiary hyperparathyroidism. Ann Transplant. 2012;17(3):111–9.
    1. Gomes EM, Nunes RC, Lacativa PG, et al. Ectopic and extranumerary parathyroid glands location in patients with hyperparathyroidism secondary to end stage renal disease. Acta Cir Bras. 2007;22(2):105–9.
    1. Varga I, Pospisilova V, Gmitterova K, Galfiova P, Polak S, Galbavy S. The phylogenesis and ontogenesis of the human pharyngeal region focused on the thymus, parathyroid, and thyroid glands. Neuro Endocrinol Lett. 2008;29(6):837–45.
    1. Noussios G, Anagnostis P, Natsis K. Ectopic parathyroid glands and their anatomical, clinical and surgical implications. Exp Clin Endocrinol Diabetes. 2012;120(10):604–10.
    1. Phitayakorn R, McHenry CR. Incidence and location of ectopic abnormal parathyroid glands. Am J Surg. 2006;191:418–23.
    1. Andrade JS, Mangussi-Gomes JP, Rocha LA, et al. Localization of ectopic and supernumerary parathyroid glands in patients with secondary and tertiary hyperparathyroidism: surgical description and correlation with preoperative ultrasonography and Tc99m-Sestamibi scintigraphy. Braz J Otorhinolaryngol. 2014;80(1):29–34.
    1. Pitt SC, Panneerselvan R, Chen H, Sippel RS. Secondary and tertiary hyperparathyroidism: the utility of ioPTH monitoring. World J Surg. 2010;34(6):1343–9.
    1. Clary BM, Garner SC, Leight GS Jr. Intraoperative parathyroid hormone monitoring during parathyroidectomy for secondary hyperparathyroidism. Surgery. 1997;122(6):1034–8.
    1. Gioviale MC, Gambino G, Maione C, et al. Use of monitoring intraoperative parathyroid hormone during parathyroidectomy in patients on waiting list for renal transplantation. Transplant Proc. 2007;39(6):1775–8.
    1. Gioviale MC, Gambino G, Maione C, et al. Intraoperative parathyroid hormone monitoring during parathyroidectomy for hyperparathyroidism in waiting list and kidney transplant patients. Transplant Proc. 2006;38(4):1003–5.
    1. Rodriquez JM, Tezelman S, Siperstein AE, et al. Localization procedures in patients with persistent or recurrent hyperparathyroidism. Arch Surg. 1994;129(8):870–5.
    1. Wells SA Jr, Debenedetti MK, Doherty GM. Recurrent or persistent hyperparathyroidism. J Bone Miner Res. 2002;17(2):158–62.

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