Vitamin d status in patients operated for primary hyperparathyroidism: comparison of patients from southern and northern europe.

Aim. The interaction between vitamin D deficiency and primary hyperparathyroidism (PHPT) is not fully understood. The aim of this study was to investigate whether patients with PHPT from Spain and Sweden differed in vitamin D status and PHPT disease activity before and after surgery. Methods. We compared two cohorts of postmenopausal women from Spain (n = 126) and Sweden (n = 128) that had first-time surgery for sporadic, uniglandular PHPT. Biochemical variables reflecting bone metabolism and disease activity, including levels of 25-hydroxy vitamin D3 (25(OH)D) and bone mineral density, BMD, were measured pre- and one year postoperatively. Results. Median preoperative 25(OH)D levels were lower, and adenoma weight, PTH, and urinary calcium levels were higher in the Spanish cohort. The Spanish patients had higher preoperative levels of PTH (13.5 versus 11.0 pmol/L, P < 0.001), urinary calcium (7.3 versus 4.1 mmol/L, P < 0.001), and heavier adenomas (620 versus 500 g, P < 0.001). The mean increase in BMD was higher in patients from Spain and in patients with vitamin D deficiency one year after surgery. Conclusion. Postmenopasual women with PHPT from Spain had a more advanced disease and lower vitamin 25(OH)D levels. Improvement in bone density one year after surgery was higher in patients with preoperative vitamin D deficiency.

Weight difference between double parathyroid adenomas is the cause of false-positive IOPTH test after resection of the first lesion.

BACKGROUND: Some patients with double parathyroid adenoma show a greater than 50% decline in intraoperative parathyroid hormone (IOPTH) after resection of the first lesion. The present study was designed to test the hypothesis that significant adenoma weight differences may explain this inappropriate decline of IOPTH. METHODS: We reviewed prospective database records at two tertiary institutions. Patients with a histopathologic diagnosis of double adenoma and no familial history of hyperparathyroidism were included. Diagnosis of double adenoma was confirmed either preoperatively (double uptake), intraoperatively (bilateral exploration), or at reintervention. IOPTH was determined following the Miami protocol. The 10-min postexcision sample was considered as the 0-min sample for IOPTH determinations at the time of resection of the second lesion. RESULTS: Thirteen patients met the inclusion criteria. After resection of the first lesion, IOPTH failed to decline in four patients and a second adenoma was removed. They had similar weight (404 vs. 598 mg). In nine patients IOPTH showed a false greater than 50% decline. These patients had the largest adenoma removed first (846 +/- 226 mg), and only two had normal PTH serum concentrations 10 min after resection. The second adenoma was always smaller (284 +/- 177 mg; P = 0.02) and its resection either during the same operation (7 cases) or at reoperation (2 cases) led to normalization of IOPTH at 10 min in all cases. CONCLUSIONS: Two-thirds of patients with double parathyroid adenoma show a false-positive decline of IOPTH after resection of the first adenoma. This appears to be due to the initial removal of the larger lesion.

Surgery for sporadic primary hyperparathyroidism: controversies and evidence-based approach.

INTRODUCTION: Sporadic primary hyperparathyroidism is due to single adenoma in over 90-95% of instances. Careful medical history and precise preoperative identification of the enlarged gland by parathyroid Tc-mibi scintigraphy and neck ultrasound allow selecting patients for minimally invasive parathyroidectomy, a focused intervention with minimal skin opening and tissue dissection. Small (<300 mg) adenomas continue to challenge preoperative imaging, and most of them will still require a bilateral exploration. CONCLUSION: Surgery should never be indicated on the basis of positive or negative preoperative localization studies. Intraoperative quick parathyroid hormone measurements seem particularly helpful for cases with equivocal localization studies. The best minimal access approach is still a matter of debate, and options include small central incision, video-assisted parathyroidectomy, minimal lateral open approach, and purely endoscopic access via lateral approach. Radioguided surgery does not seem to have a role in routine cases but may be useful to find adenomas during reintervention on scarred difficult surgical fields.

Usefulness of preoperative Tc-mibi parathyroid scintigraphy in secondary hyperparathyroidism.

BACKGROUND AND AIMS: The usefulness of Tc-mibi parathyroid scintigraphy (Tc-PS) in planning parathyroidectomy for secondary hyperparathyroidism is not well known. The aim of this study was to review our experience with Tc-PS concerning: (1) the identification of hyperplastic glands, (2) detection of major ectopias and (3) prevention of recurrences. PATIENTS AND METHODS: Thirty-three consecutive patients undergoing first-time subtotal parathyroidectomy for renal hyperparathyroidism had a dual-phase planar Tc-PS performed, and glands were classified as detected, weak, or not detected. The number and position of visualized glands were determined. Parathyroid weight, histology, and their relationship to Tc-PS were recorded after surgery. RESULTS: Of 132 potential glands, 48 (35%) were localized on the Tc-PS and 128 (96.9%) were identified intraoperatively. Tc-PS positive/weak glands were heavier than nonlocalized glands. Tc-PS contributed to successful surgery in four patients with a single difficult gland each (three retrieved from the neck and one--fifth gland--requiring mediastinotomy). There was one persistence (3%) because of a missed fourth undescended inferior parathyroid gland. Two recurrences 2 years after surgery were due to a fifth thoracic gland not shown in the preoperative Tc-PS. CONCLUSIONS: Preoperative Tc-PS helped in the intraoperative identification of moderate or major ectopias in 4/33 patients but was not useful to prevent recurrences from highly ectopic glands not visualized before first-time surgery.

Increased mortality and morbidity associated with thyroidectomy for intrathoracic goiters reaching the carina tracheae.

HYPOTHESIS: Complications associated with thyroidectomy for intrathoracic goiters have been underestimated because of the lack of a precise definition of high-risk patients. DESIGN: Retrospective multicenter multinational review of medical records and radiographic images of patients who underwent thyroidectomy for intrathoracic goiters reaching the carina tracheae. Demographic, clinical, operative, anatomical, and pathological data were recorded. RESULTS: There were 35 patients (mean +/- SE age, 63 +/- 11 years) included in the study. In 4 patients, the goiter was asymptomatic; 10 patients had dysphagia, 24 patients had dyspnea, and 3 patients had superior vena cava syndrome. A median sternotomy was required in 12 patients and a right-sided thoracotomy in 1 patient. The mean +/- SE operative time was 145 +/- 72 minutes (range, 50-360 minutes). Transient hypoparathyroidism developed in 13 patients. Four patients experienced transient hoarseness, and 1 patient had permanent vocal cord paralysis. There were no significant differences between the proportion of patients who underwent or did not undergo sternotomy or thoracotomy regarding vocal cord dysfunction (2 [15%] of 13 patients vs 3 [13%] of 22 patients) or hypoparathyroidism (5 [38%] of 13 vs 6 [28%] of 22 patients). The mean postoperative hospital stay was 10 days (range, 2-84 days). Four patients required reoperation. Two patients died. Nine of 14 patients with thyroid glands weighing at least 260 g required sternotomy vs 3 of 14 patients with thyroid glands weighing less than 260 g (P = .02). Overall, 18 [52%] of 35 patients were discharged without any complication. CONCLUSION: Intrathoracic goiters reaching the carina tracheae carry a high unreported risk of sternotomy, postoperative complications, reoperation, and death.

Nodal yield, morbidity, and recurrence after central neck dissection for papillary thyroid carcinoma.

BACKGROUND: The role of central neck dissection (CND) in differentiated thyroid cancer remains controversial. This study aims at elucidating the potential benefits and drawbacks of CND associated to total thyroidectomy in papillary cancer. METHODS: Protocols of patients undergoing total thyroidectomy and CND for papillary cancer were reviewed. The following data were recorded: macroscopic appearance of central nodes; nodes obtained at operation; number of metastatic nodes and parathyroid glands incidentally resected; metastases, age, completeness, invasiveness, size score; postoperative s-Ca; complications; and recurrences. Differences between therapeutic (gross nodal involvement) and prophylactic (no apparent node involvement) CNDs were studied. RESULTS: Forty-three patients (mean age, 52 +/- 17 years) were studied. A mean of 8.4 +/- 6.6 nodes were resected per patient. A 60% prevalence (26/43) of presence of nodal involvement (N+) was found with no difference between low- and high-risk patients. Twenty-five (60%) patients developed transient hypocalcemia, which was associated with incidental parathyroidectomy, number of nodes resected, and thymectomy. Two patients (4.6%) developed permanent hypoparathyroidism and 3 (7%), transient vocal cord paralysis. Parathyroid glands were found in 19% of the specimens. At follow-up, there were no central neck recurrences, but 5 patients developed lateral recurrences despite treatment with I(131). All 5 patients had had therapeutic CND with 6 or more metastatic nodes obtained in the CND specimen. No lateral neck recurrences were observed after prophylactic CND or in patients with < 6 nodes involved. CONCLUSIONS: CND prevents central neck recurrences. Morbidity of bilateral CND is significant, and its systematic implementation in the absence on gross nodal involvement requires reassessment.

Bone mineral density in menopausal women with primary hyperparathyroidism before and after parathyroidectomy.

The relationship between osteoporosis and primary hyperparathyroidism (pHPT) has not been definitely established because both diseases occur predominantly in postmenopausal women, and because PTH has a paradoxical effect on bone. We have investigated the prevalence of reduced bone mineral density (BMD) in women with pHPT, its relationship with metabolic parameters, and its course after parathyroidectomy. A prospective observational study was carried out on perimenopausal and postmenopausal women consecutively diagnosed and operated on for pHPT. Demographic data were recorded, as well as, PTH, Ca, calciuria/24h, P, vitamin D, adenoma weight. The BMD was measured at three sites: femoral neck (FN), proximal femur (PF), and lumbar spine (LS). Fifty-two patients were included with a mean age of 61+/-12 years. The prevalence of reduced BMD (< or = 1SD, T-score) was 80%-100% depending on site. Parathyroid hormone was higher in patients with osteoporosis (319+/-181 pg/ml) than in those with osteopenia (230+/-83 pg/ml) or normal BMD (148+/-81 pg/ml;p < 0,04). Twenty-eight patients were investigated 1 year after parathyroidectomy. The BMD improved significantly at all sites, particularly in patients with osteoporosis. Age correlated inversely with BMD increases at the femoral sites (r= -0,47;p = 0,02) but not at the LS. 25-OHD3 plasma levels correlated inversely with BMD increases at PF (r= -0,76; p < 0,0001). In pHPT, there is a high prevalence of BMD abnormalities. No metabolic variables had a definite influence on BMD values but a tendency was observed for lower BMD in severe pHPT. One year after parathyroidectomy, there were significant BMD increases that were more marked at femoral sites, in younger patients, in patients with preoperative osteoporosis, and in those with lower plasma levels of 25-OHD3.

Prevalence of long-term upper aerodigestive symptoms after uncomplicated bilateral thyroidectomy.

BACKGROUND: Subjective nonspecific upper aerodigestive symptoms (UADS) are not uncommon after thyroidectomy. Their type, duration, and prevalence, however, have not been investigated in a controlled design. The objective of this study was to investigate the prevalence of UADS after thyroidectomy. METHODS: A consecutive cohort of 60 patients who had undergone uncomplicated total (n = 38) or near total (n = 22) thyroidectomy were investigated retrospectively at a mean of 4 years after surgery. An independent unblinded researcher interviewed each patient and asked for the presence or frequency of voice changes, cough, dysphagia, neck strangling, and annual incidence of common colds, before and after thyroidectomy. Sixty patients, matched for age, sex, and smoking habits, who had undergone laparoscopic cholecystectomy during the same years served as control subjects. RESULTS: The prevalence of UADS was similar before thyroidectomy (13%) and cholecystectomy (15%). After operation, UADS had a higher prevalence among thyroidectomized patients: nonspecific voice changes (28% vs 3%), neck strangling (22% vs 0%), and impaired swallowing (15% vs 3%) (P < or = .02 in each). Neck strangling was associated with voice changes and dysphagia (P < or = .03 each). CONCLUSIONS: Subjective UADS are common long after thyroidectomy. These symptoms may be related to injury to the extrinsic perithyroidal neural plexus innervating the pharyngeal and laryngeal structures.