Tag Archives: Parathyroidectomy

Parathyroidectomy in the management of tertiary hyperparathyroidism

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Ferreira GF, et al. Parathyroidectomy after kidney transplantation: short-and long-term impact on renal function. Clinics (Sao Paulo). 2011;66(3):431-5. Free full-text.

Materials and methods: This was a retrospective case-controlled study. Nineteen patients with persistent hyperparathyroidism underwent parathyroidectomy due to hypercalcemia. The control group included 19 patients undergoing various general and urological operations.

Results: In the parathyroidectomy group, a significant increase in serum creatinine from 1.58 to 2.29 mg/dl (P < 0.05) was noted within the first 5 days after parathyroidectomy. In the control group, a statistically insignificant increase in serum creatinine from 1.49 to 1.65 mg/dl occurred over the same time period. The long-term mean serum creatinine level was not statistically different from baseline either in the parathyroidectomy group (final follow-up creatinine = 1.91 mg/dL) or in the non-parathyroidectomy group (final follow-up creatinine = 1.72 mg/dL).

Conclusion: Although renal function deteriorates in the acute period following parathyroidectomy, long-term stabilization occurs, with renal function similar to both preoperative function and to a control group of kidney-transplanted patients who underwent other general surgical operations by the final follow up.

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Postoperative calcium requirements in 6,000 patients undergoing outpatient parathyroidectomy: easily avoiding symptomatic hypocalcemia.

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Vasher M, Goodman A, Politz D, Norman J. Postoperative calcium requirements in 6,000 patients undergoing outpatient parathyroidectomy: easily avoiding symptomatic hypocalcemia. J Am Coll Surg. 2010 Jul;211(1):49-54. Full-text for Emory users.

Background: To determine the amount and duration of supplemental oral calcium for patients with varying clinical presentations discharged immediately after surgery for primary hyperparathyroidism.

Study design: A 4-year, prospective, single-institution study of 6,000 patients undergoing parathyroidectomy for primary hyperparathyroidism and discharged within 2.5 hours. Based on our previous studies, patients are started on a sliding scale of oral calcium determined by a number of preoperative measures (ie, serum calcium, body weight, osteoporosis) beginning 3 hours postoperation and decreasing to a maintenance dose by week 3. Patients reported all hypocalcemia symptoms daily for 2 weeks.

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Readmission rates following parathyroidectomy for renal disease

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One discussion this week included readmission rates following parathyroidectomy.

References: Ferrandino R, et al. Unplanned 30-day readmissions after parathyroidectomy in patients with chronic kidney disease: a nationwide analysis. Otolaryngology – Head and Neck Surgery. 2017 Dec;157(6):955-965. doi:10.1177/0194599817721154.

Summary: A retrospective cohort study was performed using the 2013 Nationwide Readmissions Database (NRD) of the Healthcare Cost and Utilization Project (HCUP) from the Agency for Healthcare Research and Quality (AHRQ). In a total of 2756 parathyroidectomies performed in patients with chronic kidney disease, 17.2%  had at least one unplanned readmission rate within the first 30-days, and 2.4% had more than one readmission. Overall, readmission rates for chronic kidney disease patients are nearly 5-times that of the general population (Ferrandino et al, 2017).

Hypocalcemia/hungry bone syndrome accounted for 40% of readmissions. While readmissions occurred uniformly throughout the 30 days after discharge, those for hypocalcemia/hungry bone syndrome peaked in the first 10 days and decreased over time.

Weight loss/malnutrition at time of parathyroidectomy and length of stay of 5-6 days conferred increased risk of readmission with adjusted odds ratios of 3.31 and 1.87, respectively. Relative to primary hyperparathyroidism, parathyroidectomies performed for secondary hyperparathyroidism were associated with higher risk of readmission.

The authors conclude: “While there are few patient-specific predictors of readmission, we note that the bulk of these readmissions can be attributed to hypocalcemia. To improve readmission rates after parathyroidectomy in CKD patients, we propose focusing on accurate, appropriate medication reconciliation, and optimizing communication and transitions of care to outside facilities (skilled nursing, dialysis, etc.) to facilitate the comprehensive care of this high-risk patient population” (Ferrandino et al, p.964).

Additional Reading: Sharma J, et al. Improved long-term survival of dialysis patients after near-total parathyroidectomy. Journal of the American College of Surgeons. 2012 Apr;214(4):400-407. doi:10.1016/j.jamcollsurg.2011.12.046.

Westerdahl J, et al. Risk factors for postoperative hypocalcemia after surgery for primary hyperparathyroidism. Archives of Surgery. 2000 Feb;135(2):142-147.

Symptomatic hyperthyroidism following parathyroidectomy

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A discussion in January included postoperative hyperthyroidism following parathyroidectomy.

Reference: Patel SG, et al. Hyperthyroidism after parathyroid surgery: A prospective analysis of potential contributing factors. (unpublished)

Summary:

In a prospective study of 101 patients between 2014 and 2015, Patel et al examined surgical extent, anatomic findings, thyroid manipulation, anesthetic medication, and outcomes in order to identify potential intraoperative contributing factors for hyperthyroidism after parathyroidectomy.

Unilateral exploration was found to be significantly less often associated with postoperative hyperthyroidism than bilateral exploration. Additionally, incidence was lower with intraoperative ephedrine and four-fold higher with bilateral exploration. The authors recommend that “postoperative TSH screening for those who require bilateral exploration and/or symptoms of hyperthyroidism should be strongly considered.”

It is stated that this prospective study is the first “to evaluate the type and extent of thyroid manipulation during parathyroid exploration as a cause of hyperthyroidism.”

Due to the fact that the data/manuscript is currently unpublished, minimal information is shared here. We will post a notification when it is published. Our deepest thanks to Dr. Patel for his generosity in sharing this information.

Additional reading: Madill EM, Cooray SD, Bach LA. Palpation thyroiditis following subtotal parathyroidectomy for hyperparathyroidism. Endocrinology, Diabetes & Metabolism Case Reports. 2016 July; pii: 16-0049. doi: 10.1530/EDM-16-0049

Mai VQ et al. Palpation thyroiditis causing new-onset atrial fibrillation. Thyroid. 2008;18(5):571-573. doi:10.1089/thy.2007.0246

Stang MT, et al. Hyperthyroidism after parathyroid exploration. Surgery. 2005 Dec;138(6):1058-1064.

 

Mortality risk reduction associated with PTH reduction for Secondary Hyperparathyroidism

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One discussion this week included parathyroid hormone (PTH) levels.

Reference: Komaba H, et al. Parathyroidectomy and survival among Japanese hemodialysis patients with secondary hyperparathyroidism. Kidney International. 2015 Aug;88(2):350-359. doi: 10.1038/ki.2015.72

Summary: In a nationwide study of 114,064 hemodialysis patients, Komaba et al asked if PTx for severe SHPT improves survival of dialysis patients.  They compared patient outcomes by PTH levels, and by those with a history of parathyroidectomy (PTx) (6,6280) and those without PTx (107,436).

fig2

(p.353)

Excess PTH is shown to increase cardiac fibrosis; elevations in serum calcium, phophorus, and PTH levels are associated with death and cardiovascular events primarily due to vascular calcification (p.350).

fig4

(p.355)

For cardiovascular death, there was a significant increase in the multivariate-adjusted HR for patients with intact PTH levels < 60 pg/ml (HR, 1.11; 95% CI, 1.02–1.20) and those with intact PTH levels >500 pg/ml (HR, 1.41; 95% CI, 1.20–1.64). In contrast, such an increased risk of mortality was not observed in patients with a history of PTx, despite the fact that these patients had severe SHPT preoperatively.