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Management of Secondary and Tertiary Hyperparathyroidism - Joint Hospital Grandround 20.12.2003 Henry Joeng Department of Surgery United Christian Hospital,

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Presentation on theme: "Management of Secondary and Tertiary Hyperparathyroidism - Joint Hospital Grandround 20.12.2003 Henry Joeng Department of Surgery United Christian Hospital,"— Presentation transcript:

1 Management of Secondary and Tertiary Hyperparathyroidism - Joint Hospital Grandround Henry Joeng Department of Surgery United Christian Hospital, HKSAR

2 Overview Pathophysiology Medical treatment Surgical treatment Indication Pre-op localization study Different types of parathyroidectomies Rapid PTH assay Experience in UCH

3 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

4 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

5 Complications of 2 o /3 o HyperPTH Skeletal Progressive bone demineralization Osteitis fibrosa cystitca Bone pain, pathological fracture Soft tissue calcification Involve different organs or tissues Calciphylaxis

6 Complications of 2 o /3 o HyperPTH Pruritus Other Myopathy Peptic ulcer disease Neuropathy Cardiotoxicity

7 Biochemical changes Elevated “intact” PTH  key feature Elevated phosphate Elevated ALP Normal serum calcium level. Elevated in 3 o hyperPTH

8 Radiological changes Plain X ray Subperiosteal bone resorption “Pepper pot” appearance of skull Bone density Progressive decline

9 Medical treatment Oral calcium supplement Oral 1,25 – D3 supplement Oral phosphate binder

10 Surgical treatment 5-10 % patients on long term dialysis need parathyroidectomy Indication When complications of 2 o /3 o hyperPTH arise. E.g. skeletal cx Medical treatments fail Biochemical parameter E.g. [Ca][PO4] product > 70

11 PTX - Optimization Correct biochemical disturbance due to underlying renal disease Hemodialysis before operation Aggressive pre-op calcium replacement

12 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

13 PTX - Localization Different from 1 o HyperPTH Multi-gland disease Bilateral neck exploration Locate ectopic or supernumerary PTH glands Sestamibi scan, USG

14 Types of parathyroidectomies Subtotal parathyoidectomy Total parathyroidectomy with autotransplantation

15 Subtotal parathyroidectomy Stanbury, 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

16 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

17 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

18 Choice of operation Controversy Persistant/ recurrent hyperPTH Symptom improvement HypoPTH/ Hypocalcemia Literature search Database: Medline, EBM review, EMBase Keywords: 2 o / 3 o hyperparathyroidism, parathyroidectomy, compar$

19 Evidence … 1 RCT comparing subtotal PTX vs Total PTX with autotransplantation Rothmund. Word J Surg 1991

20 Rothmund, 1991 SPTXPTX+AT No. of patient20 Persistent hyperPTH4/200/20p<0.03 Symptom improvement Bone pain61%87% Radiological sign of renal osteodystrophy 33%69%p<0.05 Muscle weakness20%83%p<0.04 Pruritus45%100%p<0.005 Hypocalcemia1/20

21 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

22 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 Mar

23 UCH experience From till patients with renal failure and 2 o /3 o hyperPTH Total PTX + AT in all patients Transcervical thymectomy in 4 patients Hemithyroidectomies in 3 patients

24 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

25 Summary 5-10% patients on dialysis need parathyroidectomy due to development of complication Total PTX + autotransplantation and subtotal PTX are the common surgical options Rapid PTH assay may be a useful adjunct

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