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1.
J Surg Res ; 257: 15-21, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32818780

RESUMO

BACKGROUND: The etiology of primary hyperparathyroidism (PHP) is single-gland adenoma in most patients. Imaging localization of single-gland disease allows for a focused operation. We sought to determine the accuracy of imaging for localizing a solitary parathyroid adenoma. METHODS: A single-institution retrospective review was performed of adult patients with PHP undergoing parathyroidectomy from January 2017 through December 2018. Surgeon-performed ultrasound (US), four-dimensional computed tomography (4DCT), and sestamibi were assessed for localization of a parathyroid adenoma yielding a single-gland parathyroidectomy. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for each imaging modality. RESULTS: One hundred fifty-four patients underwent parathyroidectomy for PHP during the study period, with 100 patients meeting inclusion criteria with a mean age of 61.1 (SD 10) y and 80% women. Mean calcium was 11.1 mg/dL (SD 0.7) and mean PTH was 116 pg/mL (SD 66). All 100 patients had surgeon-performed US with 17 localized, 51 patients had 4DCT with 41 (80%) localized, and 69 patients had sestamibi with 53 (77%) localized. Eighty-two patients underwent successful unilateral parathyroidectomy, 18 required bilateral neck exploration. US was the most specific imaging modality at 94%. Accuracy of imaging localization was 32% for US, 70% for sestamibi, and 86% for 4DCT. CONCLUSIONS: Surgeon-performed US is a highly specific imaging modality for preoperative localization of solitary parathyroid adenoma in patients with PHP. 4DCT is the most accurate imaging localization study and should be considered for patients with a nonlocalized US.


Assuntos
Tomografia Computadorizada Quadridimensional , Hiperparatireoidismo Primário/diagnóstico por imagem , Paratireoidectomia/métodos , Idoso , Cálcio/sangue , Feminino , Humanos , Hiperparatireoidismo Primário/cirurgia , Masculino , Pessoa de Meia-Idade , Hormônio Paratireóideo/sangue , Neoplasias das Paratireoides/diagnóstico por imagem , Neoplasias das Paratireoides/cirurgia , Estudos Retrospectivos , Sensibilidade e Especificidade , Ultrassonografia
2.
J Surg Res ; 257: 79-84, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32818787

RESUMO

BACKGROUND: The incidence of primary hyperparathyroidism (PHP) is likely underestimated. Nephrolithiasis may indicate PHP with indication for parathyroidectomy. We sought to determine the proportion of patients with an index diagnosis of nephrolithiasis that have serum calcium levels measured, parathyroid hormone (PTH) levels measured if hypercalcemic, and time to referral for definitive management if PHP is diagnosed. METHODS: A single-institution retrospective review was performed of adult patients presenting with nephrolithiasis between July 1, 2016 and December 31, 2018. Exclusion criteria included currently admitted patients, prior nephrolithiasis, congenital or acquired urinary tract anomalies, and patients on calciuretics. Records were assessed for serum calcium and PTH measurement, as well as referrals. Univariate statistical analysis was performed. RESULTS: Of 1782 patients with nephrolithiasis screened, 968 met inclusion criteria. Patients were 49.8% female, 88.9% white. Mean age was 53 y. Within this cohort, 620 (64.0%) patients had a calcium measured, with a mean elapsed time from presentation of 27 d (interquartile range [IQR] 0-8). Twelve patients (1.58%) with calcium measured were hypercalcemic and eight (66.7%) had PTH measured with a mean elapsed time from presentation of 183 d (IQR 72-310), all had elevated or non-suppressed PTH. Five (62.5%) were referred to surgeons with mean elapsed referral time of 270 d (IQR 95-492). CONCLUSIONS: Many with index nephrolithiasis are not assessed for hypercalcemia or hyperparathyroidism. Patients with serum calcium and PTH values indicating PHP diagnosis may have significant delay to parathyroidectomy. Targeted interventions with electronic health record alerts or automated reflex testing may improve care in this domain.


Assuntos
Hipercalcemia/sangue , Hiperparatireoidismo Primário/diagnóstico , Nefrolitíase/sangue , Hormônio Paratireóideo/sangue , Adulto , Idoso , Cálcio/sangue , Feminino , Humanos , Hipercalcemia/etiologia , Hiperparatireoidismo Primário/complicações , Hiperparatireoidismo Primário/cirurgia , Masculino , Pessoa de Meia-Idade , Nefrolitíase/etiologia , Paratireoidectomia
3.
Ter Arkh ; 92(10): 63-69, 2020 Nov 24.
Artigo em Russo | MEDLINE | ID: mdl-33346481

RESUMO

AIM: To study an activity of the Renin-Angiotensin-Aldosterone System (RAAS) components in patients with primary hyperparathyroidism (PHPT) before and after parathyroidectomy (PTE). MATERIALS AND METHODS: A comparative study of patients with PHPT and control group. The first stage of the study included 56 patients with PHPT (group 1) before and on the third day after PTE. The second stage was carried out in 27 patients with remission of PHPT (group 2). All patients and healthy volunteers were tested for the main parameters of phosphorus-calcium metabolism and the RAAS parameters (plasma renin activity PRA, serum aldosterone, angiotensin II AT II). RESULTS: Patients with active PHPT demonstrated changes in RAAS activity (lower PRA, higher AT II level) comparing to control group, that have statistical significance in group 1 (p0.001 for both parameters). There were no significant differences in aldosterone levels (p1=0.090;p2=0.140). On the third day after PTE (group 1), a decrease in aldosterone level (p=0.009) and a tendency to decrease in PRA (p=0.030) were detected. However, an increase in PRA (p=0.018), a decrease in AT II concentration (p=0.032) comparing to the initial values and their normalization were observed 12 months after surgery when permanent normal serum calcium and PTH levels had been achieved. There were controversial correlations between the parameters of phosphorus-calcium metabolism and RAAS. The influence of angiotensin-converting-enzyme inhibitors and AT II receptor blockers on phosphorus-calcium metabolism in patients with PHPT was not observed. CONCLUSION: In patients with PHPT, there were no сlear correlations of phosphorus-calcium metabolism parameters with RAAS, however an increase of AT II concentration was noted, that can take part in a development of hypertension for this endocrinopathy. PTE can have a positive effect on AT II level.


Assuntos
Hiperparatireoidismo Primário , Hipertensão , Aldosterona , Inibidores da Enzima Conversora de Angiotensina , Cálcio , Humanos , Hiperparatireoidismo Primário/cirurgia , Renina , Sistema Renina-Angiotensina
4.
Cochrane Database Syst Rev ; 10: CD010787, 2020 10 21.
Artigo em Inglês | MEDLINE | ID: mdl-33085088

RESUMO

BACKGROUND: Bilateral neck exploration (BNE) is the traditional approach to sporadic primary hyperparathyroidism. With the availability of the preoperative imaging techniques and intraoperative parathyroid hormone assays, minimally invasive parathyroidectomy (MIP) is fast becoming the favoured surgical approach. OBJECTIVES: To assess the effects of minimally invasive parathyroidectomy (MIP) guided by preoperative imaging and intraoperative parathyroid hormone monitoring versus bilateral neck exploration (BNE) for the surgical management of primary hyperparathyroidism. SEARCH METHODS: We searched CENTRAL, MEDLINE, WHO ICTRP and ClinicalTrials.gov. The date of the last search of all databases was 21 October 2019. There were no language restrictions applied. SELECTION CRITERIA: We included randomised controlled trials comparing MIP to BNE for the treatment of sporadic primary hyperparathyroidism in persons undergoing surgery for the first time. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts for relevance. Two review authors independently screened for inclusion, extracted data and carried out risk of bias assessment. The content expert senior author resolved conflicts. We assessed studies for overall certainty of the evidence using the GRADE instrument. We conducted meta-analyses using a random-effects model and performed statistical analyses according to the guidelines in the latest version of the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS: We identified five eligible studies, all conducted in European university hospitals. They included 266 adults, 136 participants were randomised to MIP and 130 participants to BNE. Data were available for all participants post-surgery up to one year, with the exception of missing data for two participants in the MIP group and for one participant in the BNE group at one year. Nine participants in the MIP group and 11 participants in the BNE group had missing data at five years. No study had a low risk of bias in all risk of bias domains. The risk ratio (RR) for success rate (eucalcaemia) at six months in the MIP group compared to the BNE group was 0.98 (95% confidence interval (CI) 0.94 to 1.03; P = 0.43; 5 studies, 266 participants; very low-certainty evidence). A total of 132/136 (97.1%) participants in the MIP group compared with 129/130 (99.2%) participants in the BNE group were judged as operative success. At five years, the RR was 0.94 (95% CI 0.83 to 1.08; P = 0.38; 1 study, 77 participants; very low-certainty evidence). A total of 34/38 (89.5%) participants in the MIP group compared with 37/39 (94.9%) participants in the BNE group were judged as operative success. The RR for the total incidence of perioperative adverse events was 0.50, in favour of MIP (95% CI 0.33 to 0.76; P = 0.001; 5 studies, 236 participants; low-certainty evidence). Perioperative adverse events occurred in 23/136 (16.9%) participants in the MIP group compared with 44/130 (33.9%) participants in the BNE group. The 95% prediction interval ranged between 0.25 and 0.99. These adverse events included symptomatic hypocalcaemia, vocal cord palsy, bleeding, fever and infection. Fifteen of 104 (14.4%) participants experienced symptomatic hypocalcaemia in the MIP group compared with 26/98 (26.5%) participants in the BNE group. The RR for this event comparing MIP with BNE at two days was 0.54 (95% CI 0.32 to 0.92; P = 0.02; 4 studies, 202 participants). Statistical significance was lost in sensitivity analyses, with a 95% prediction interval ranging between 0.17 and 1.74. Five out of 133 (3.8%) participants in the MIP group experienced vocal cord paralysis compared with 2/128 (1.6%) participants in the BNE group. The RR for this event was 1.87 (95% CI 0.47 to 7.51; P = 0.38; 5 studies, 261 participants). The 95% prediction interval ranged between 0.20 and 17.87. The effect on all-cause mortality was not explicitly reported and could not be adequately assessed (very low-certainty evidence). There was no clear difference for health-related quality of life between the treatment groups in two studies, but studies did not report numerical data (very low-certainty evidence). There was a possible treatment benefit for MIP compared to BNE in terms of cosmetic satisfaction (very low-certainty evidence). The mean difference (MD) for duration of surgery comparing BNE with MIP was in favour of the MIP group (-18 minutes, 95% CI -31 to -6; P = 0.004; 3 studies, 171 participants; very low-certainty evidence). The 95% prediction interval ranged between -162 minutes and 126 minutes. The studies did not report length of hospital stay. Four studies reported intraoperative conversion rate from MIP to open procedure information. Out of 115 included participants, there were 24 incidences of conversion, amounting to a conversion rate of 20.8%. AUTHORS' CONCLUSIONS: The success rates of MIP and BNE at six months were comparable. There were similar results at five years, but these were only based on one study. The incidence of perioperative symptomatic hypocalcaemia was lower in the MIP compared to the BNE group, whereas the incidence of vocal cord paralysis tended to be higher. Our systematic review did not provide clear evidence for the superiority of MIP over BNE. However, it was limited by low-certainty to very low-certainty evidence.


Assuntos
Hiperparatireoidismo Primário/diagnóstico por imagem , Hiperparatireoidismo Primário/cirurgia , Monitorização Intraoperatória/métodos , Hormônio Paratireóideo/sangue , Paratireoidectomia/métodos , Adulto , Viés , Humanos , Hiperparatireoidismo Primário/sangue , Hipocalcemia/epidemiologia , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Pescoço/cirurgia , Esvaziamento Cervical/métodos , Duração da Cirurgia , Paratireoidectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Qualidade de Vida , Paralisia das Pregas Vocais/epidemiologia
6.
Ann Surg ; 272(5): 801-806, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32833757

RESUMO

BACKGROUND: Surgical removal of hyperfunctional parathyroid gland is the definitive treatment for primary hyperparathyroidism (pHPT). Postoperative follow-up shows variability in persistent/recurrent disease rate throughout different centers. OBJECTIVE: To evaluate the incidence of redo surgery after targeted parathyroidectomy for pHPT. METHODS: We performed a nationwide retrospective cohort study on the "Programme de Medicalisation des Systemes d'Information," the French administrative database that collects information on all healthcare facilities' discharges. We extracted data from 2009 to 2018 for all patients who underwent parathyroidectomy for pHPT between January 2011 to December 2016. The primary outcome was the reoperation rate within 2 years since first surgery. Patients who had a first attempt of surgery within the previous 24 months, familial hyperparathyroidism, multiglandular disease, and renal failure were excluded. Results were adjusted according to sex and the Elixhauser Comorbidity Index. Operative volume thresholds to define high-volume centers were achieved by the Chi-Squared Automatic Interaction Detector method. RESULTS: In the study period, 13,247 patients (median age 63, F/M=3.6) had a focused parathyroidectomy by open (88.7%) or endoscopic approach. Need of remedial surgery was 2.8% at 2 years. In multivariate analysis, factors predicting redo surgery were: cardiac history (P=0.008), obesity (P=0.048), endoscopic approach (P=0.005), and low-volume center (P<0.001). We evaluated that an annual caseload of 31 parathyroidectomies was the best threshold to discriminate high-volume centers and carries the lowest morbidity/failure rate. CONCLUSION: Although focused parathyroidectomy represents a standardized operation, cure rate is strongly associated with annual hospital caseload, type of procedure (endoscopic), and patients' features (obesity, cardiac history). Patients with risk factors for redo surgery should be considered for an open surgery in a high-volume center.


Assuntos
Hiperparatireoidismo Primário/cirurgia , Paratireoidectomia/métodos , Reoperação/estatística & dados numéricos , Idoso , Comorbidade , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
7.
Surgery ; 168(4): 594-600, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32811695

RESUMO

BACKGROUND: Hypercalciuria is an important manifestation of primary hyperparathyroidism and may contribute to the risk of nephrolithiasis. This study examined the impact of parathyroidectomy on 24-hour urinary calcium (24-hour UCa) levels and rates of resolution of hypercalciuria after surgery. METHODS: A retrospective cohort study was performed of patients who underwent curative parathyroidectomy for primary hyperparathyroidism from 2007 to 2017. Baseline and postoperative urine and serum biochemistry levels were analyzed. The relationship between preoperative 24-hour UCa levels and the absolute decrease in postoperative UCa excretion was assessed using Spearman's rank correlation coefficient. RESULTS: Of 110 patients, 84 (76.4%) experienced a ≥20% decrease in 24-hour UCa level postoperatively. These patients had a higher baseline median 24-hour UCa level (293.5 vs 220.5 mg/24-hour; P = .001), higher baseline mean serum parathyroid hormone (106.5 vs 83; P = .05) and were more likely to have single gland disease (85.7% vs 65.4%, P = .04) compared with patients in whom 24-hour UCa excretion did not improve. Of the 28 patients (25%) who were hypercalciuric (24-hour UCa >400 mg/day) at baseline, 22 (79%) became normocalciuric postoperatively. A linear correlation was observed between preoperative 24-hour UCa levels and the decline in 24-hour UCa excretion after surgery (R2 = 0.59, P < .0001) such that the degree of improvement could be predicted using the following equation: absolute decrease in postoperative 24-hour UCa = 0.68 × preoperative 24-hour UCa-68. CONCLUSION: Parathyroidectomy reduces 24-hour UCa excretion in the majority of patients with PHPT and restores normocalciuria in 79% of patients with hypercalciuria at baseline.


Assuntos
Hipercalciúria/terapia , Hiperparatireoidismo Primário/cirurgia , Paratireoidectomia , Adulto , Idoso , Área Sob a Curva , Cálcio/urina , Feminino , Humanos , Hipercalciúria/etiologia , Hiperparatireoidismo Primário/sangue , Hiperparatireoidismo Primário/complicações , Hiperparatireoidismo Primário/urina , Masculino , Pessoa de Meia-Idade , Hormônio Paratireóideo/sangue , Estudos Retrospectivos
8.
J Robot Surg ; 14(6): 821-827, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32661866

RESUMO

Minimal invasive techniques in endocrine surgery were lately adopted by surgical teams due to significant complications related to inadequate operative space and high risk of injuring crucial surrounding structures, such as vessels and nerves. Over the last years, technological improvements introduced robotic systems and approaches in endocrine surgery. Several case reports and series have described the safety and efficacy of these procedures such as robotic thyroidectomy and robotic parathyroidectomy. In the current review, we included 15 studies which described robotic-assisted parathyroidectomy for cervical parathyroid adenoma, in patients diagnosed with primary hyperparathyroidism or secondary hyperparathyroidism. No significant negative short-term outcomes were observed, in terms of postoperative complications, such as temporary or permanent injury of RLN, postoperative hypoparathyroidism and blood loss. The cosmetic result was, definitely, superior in comparison to conventional open parathyroidectomy. Despite the fact that RAP is an effective and curative method for patients with PHPT or secondary hyperparathyroidism, there are no available randomized clinical trials to establish this modern procedure as a gold-standard treatment strategy for these patients.


Assuntos
Adenoma/cirurgia , Hiperparatireoidismo Primário/cirurgia , Hiperparatireoidismo Secundário/cirurgia , Neoplasias das Paratireoides/cirurgia , Paratireoidectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Feminino , Humanos , Masculino , Resultado do Tratamento
9.
Surgery ; 168(5): 838-844, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32665141

RESUMO

BACKGROUND: Primary hyperparathyroidism is underdiagnosed and undertreated nationally despite the benefits of parathyroidectomy. However, the degree of hospital-level variation in the management of primary hyperparathyroidism is unknown. METHODS: We performed a national, retrospective study of Veterans with primary hyperparathyroidism using the Veterans Affairs Corporate Data Warehouse from January 2000 to September 2015. The objective was to characterize the extent of hospital-level variation in the use of parathyroidectomy for the management of primary hyperparathyroidism within a national, integrated healthcare system. Rate of parathyroidectomy in patients with primary hyperparathyroidism was stratified by (1) geographic region, (2) facility complexity level, (3) volume of parathyroidectomies per facility, and (4) frequency of parathyroid hormone testing in hypercalcemic patients. RESULTS: Among 47,158 Veterans with primary hyperparathyroidism, 6,048 (12.8%) underwent parathyroidectomy. Rates of parathyroidectomy were significantly higher in the Continental (17.0%) and Pacific (16.0%) regions than in other areas (11.4%, P < .01). The highest complexity referral centers had the highest rate of parathyroidectomy (13.6%) compared with all other facilities (12.1%, P < .01). Centers that performed the highest volume of parathyroidectomies were more likely to offer surgery (13.3%) than low volume centers (8.9%, P < .01). Facilities with higher frequency of parathyroid hormone testing among hypercalcemic patients were more likely to offer parathyroidectomy (15.2%) than those with the lowest parathyroid hormone testing frequency (12.6%, P < .01). CONCLUSION: Although there is notable variation in parathyroidectomy use for definitive treatment of primary hyperparathyroidism between Veterans Affairs facilities, parathyroidectomy rates are low across the entire system. Further research is needed to understand additional local contextual and other patient and clinician-level factors for the undertreatment of primary hyperparathyroidism to subsequently guide corrective interventions.


Assuntos
Assistência à Saúde , Hiperparatireoidismo Primário/cirurgia , Paratireoidectomia/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Hiperparatireoidismo Primário/sangue , Masculino , Pessoa de Meia-Idade , Hormônio Paratireóideo/sangue , Estudos Retrospectivos , Estados Unidos , United States Department of Veterans Affairs
10.
Endocrinol. diabetes nutr. (Ed. impr.) ; 67(6): 357-363, jun.-jul. 2020. tab
Artigo em Espanhol | IBECS | ID: ibc-193360

RESUMO

INTRODUCCIÓN: El HPTP frecuentemente permanece sin diagnosticar en pacientes con hipercalcemia, lo que podría ocasionar un aumento de la morbilidad en estos sujetos. OBJETIVO: Identificar la presencia de hipercalcemia y de criterios de tratamiento quirúrgico (CTQ) no identificados desde al menos un año antes de su remisión a endocrinología en pacientes operados de HPTP. Valorar si este retraso terapéutico se asocia a mayor morbilidad. MÉTODOS: Estudio observacional en 116 pacientes consecutivos. Mediante la revisión de los registros anteriores a 12 meses previos a su derivación a endocrinología se dividieron en 4 grupos: hipercalcemia con CTQ (grupo 1, n = 43), hipercalcemia sin CTQ (grupo 2, n = 23), calcemias normales (grupo 3, n = 18) o ausencia de calcemias en dichos registros (grupo 4, n = 32). RESULTADOS: En 84 pacientes (72,4%) había calcemias previas, 66 (56,9%) con hipercalcemia, de ellos 43 (37%) con CTQ no valorados. La demora media hasta su remisión fue de 57 meses. Casi la mitad de las calcemias del grupo 1 procedían de urgencias. Respecto al grupo 4 los pacientes del grupo 1 tenían menor edad, mayor incidencia de nefrolitiasis e insuficiencia renal al remitírseles. Las calcemias en el momento de su derivación eran similares, superiores a las de los grupos 2 y 3. DISCUSIÓN: Los pacientes con HPTP y CTQ se remiten a endocrinología con un retraso medio de 5 años. La inadvertencia de la hipercalcemia y/o el desconocimiento de los CTQ retrasan esta derivación, determinada por hipercalcemias superiores, y se asocian a una afectación renal más severa. Son precisas medidas correctoras para evitar este retraso en el diagnóstico y curación del HPTP


INTRODUCTION: Primary hyperparathyroidism (PHPT) remains underdiagnosed among patients with hypercalcemia, potentially causing increased morbidity. OBJECTIVE: To identify in surgically operated patients the presence of overlooked hypercalcemia and patients with criteria for surgery (CFS) for PHPT at least one year prior to referral to Endocrinology, and to determine whether this diagnostic delay leads to increased morbidity. METHODS: An observational study was carried out in 116 consecutive patients. We evaluated electronic medical records registered at least 12 months prior to referral and divided them in four groups: hypercalcemia with CFS (group 1), hypercalcemia without CFS (group 2), normocalcemia (group 3), and cases without previous biochemical evaluation (group 4). RESULTS: A total of 84 patients (72.4%) had a previous measurement of serum calcium at a time interval of ≥ 12 months. Sixty-six (56.9%) had hypercalcemia and 43 of them (37%) had ≥ 1 CFS, with an average delay of 57 months in receiving proper evaluation. Almost half of the calcemia measurements in group 1 had been made in the emergency room. Patients from group 1 were younger, and had a greater frequency of nephrolithiasis and renal impairment than patients in group 4. The serum calcium values at referral were similar in both groups and higher than the values found in patients from the other two groups. DISCUSSION: In patients with PHPT and CFS, referral to an endocrinologist is made with an average delay of almost 5 years. The identified causes of this delay, which conditions more kidney disease, are unrecognized hypercalcemia and/or unawareness of the surgical criteria, while calcium elevations promote referral. Interventions are needed to avoid this delay in the diagnosis and resolution of PHPT


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Hiperparatireoidismo Primário/diagnóstico , Hiperparatireoidismo Primário/cirurgia , Tempo para o Tratamento , Diagnóstico Tardio , Indicadores de Morbimortalidade , Hipercalcemia/diagnóstico , Hipercalcemia/classificação , Estudos Retrospectivos , Fosfatase Alcalina/análise , Insuficiência Renal , Paratireoidectomia/normas , Encaminhamento e Consulta/normas
11.
J Surg Res ; 255: 130-134, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32543378

RESUMO

BACKGROUND: Surgery is the definitive management of primary hyperparathyroidism and the only curative therapy. However, many surgeons are hesitant to operate on individuals with mild primary hyperparathyroidism, with an even greater reluctance to operate on those who underwent a previous parathyroidectomy. We hypothesize that patients with mild primary hyperparathyroidism who undergo a re-operation have equivalent outcomes compared with those who undergo a first-time (FT) operation. METHODS: We reviewed a prospective database of 459 patients with mild primary hyperparathyroidism who underwent surgery by one endocrine surgeon. Of these patients, 59 had a re-operative (RE-OP) parathyroid surgery. We compared these patients to those with mild primary hyperparathyroidism who had FT surgery (n = 400) using either the Pearson chi-square, Fisher's exact test, or Student's t-test where appropriate. RESULTS: The mean age of our cohort was 60 ± 14 y, with 86% females. Patients in the RE-OP group had similar preoperative calcium and parathyroid hormone levels compared with those in the FT group. Most patients who underwent a RE-OP surgery had four gland hyperplasia on pathology (49.2%). Patients in the RE-OP and FT groups both had high and similar cure rates (100% versus 99.8%, P = 0.70). RE-OP patients had a higher rate of recurrent hyperparathyroidism (10.3% versus 3.3%, P = 0.025). CONCLUSIONS: In patients with mild primary hyperparathyroidism, those who undergo RE-OP parathyroidectomy have a high cure rate that is similar to FT surgery. Therefore, we recommend that these patients with recurrence of mild hyperparathyroid disease be considered for parathyroidectomy.


Assuntos
Hiperparatireoidismo Primário/cirurgia , Paratireoidectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Reoperação/efeitos adversos , Adulto , Idoso , Cálcio/sangue , Feminino , Seguimentos , Humanos , Hiperparatireoidismo Primário/sangue , Hiperparatireoidismo Primário/diagnóstico , Hiperplasia/diagnóstico , Hiperplasia/cirurgia , Masculino , Pessoa de Meia-Idade , Glândulas Paratireoides/patologia , Glândulas Paratireoides/cirurgia , Hormônio Paratireóideo/sangue , Complicações Pós-Operatórias/etiologia , Recidiva , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento
12.
Am J Surg ; 220(3): 533-535, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32362380

RESUMO

BACKGROUND: Most patients with primary hyperparathyroidism undergo localization prior to operation with variable success. Therefore, in this study we investigated the safety of parathyroidectomy without imaging. METHODS: A prospective database of 2057 surgical patients with primary hyperparathyroidism from 2001 to 2019 was reviewed. Patients were categorized by use of preoperative imaging (ultrasound, sestamibi, CT scan), pathology, and cure. RESULTS: 1879 (91%) patients underwent preoperative imaging. CT scan was the most sensitive study (92%), though specificity was only 64%. Patients with imaging were older, had higher pre- and postoperative calcium, more likely to undergo unilateral exploration and have an adenoma (p < 0.001-0.038). No differences were seen in nerve injury (<1%), postoperative hypocalcemia (<1%), or cure rate. CONCLUSIONS: While localization may lead to minimally-invasive operations, we observed no differences in postoperative complications or cure rates in the hands of an experienced surgeon. Therefore, preoperative parathyroid localization does not improve outcomes for hyperparathyroidism and can be ordered sparingly.


Assuntos
Hiperparatireoidismo Primário/cirurgia , Glândulas Paratireoides/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Paratireoidectomia , Cuidados Pré-Operatórios , Estudos Prospectivos , Sensibilidade e Especificidade
13.
Clin Nucl Med ; 45(8): 636-637, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32453078

RESUMO

We present the first intraoperative detection of a hyperplastic parathyroid gland with a positron emitter F-fluorocholine and handheld probe, with the estimation of the absorbed dose to the surgeon and surgical staff. Intraoperative positron emitter detection enabled the resection of a small parathyroid gland, resulting in normal postoperative values of PTH and serum calcium in a 69-year-old woman. Calculated whole-body dose to the surgical staff and surgeons' fingers is well below the annual limits for exposed workers and the general public. Intraoperative F-FCH detection with handheld probe is a safe and feasible method for localizing small parathyroid glands.


Assuntos
Hiperparatireoidismo Primário/diagnóstico por imagem , Monitorização Intraoperatória/métodos , Glândulas Paratireoides/diagnóstico por imagem , Tomografia por Emissão de Pósitrons/métodos , Idoso , Colina/análogos & derivados , Feminino , Humanos , Hiperparatireoidismo Primário/patologia , Hiperparatireoidismo Primário/cirurgia , Monitorização Intraoperatória/instrumentação , Glândulas Paratireoides/patologia , Glândulas Paratireoides/cirurgia , Tomografia por Emissão de Pósitrons/instrumentação , Compostos Radiofarmacêuticos
14.
J Steroid Biochem Mol Biol ; 201: 105695, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32407867

RESUMO

In patients with primary hyperparathyroidism, the size of the adenoma is a major determinant of biochemical indices, disease severity, and manner of presentation. However, the large variation in adenoma weight, both within and between populations and a steady decline in parathyroid adenoma weights over time remain largely unexplained. Based on the results in a small number of patients almost two decades ago we proposed that vitamin D nutritional status of the patient explains both the disease manifestations and much of the variation in adenoma size. Accordingly, we examined the relationship between vitamin D nutrition, as assessed by serum levels of 25-hydroxyvitamin D, and parathyroid gland weight, the best available index of disease severity, in a large number of patients (n = 440) with primary hyperparathyroidism. A significant inverse relationship was found between serum 25-hydroxyvitamin D level and log adenoma weight (r = -0.361; p < 0.001). Also, the adenoma weight was significantly related directly to serum PTH, calcium, and alkaline phosphatase as dependent variables. In patients with vitamin D deficiency (defined as serum 25-hydroxyvitamin D levels 15 ng/mL or lower), gland weight, PTH, AP, and adjusted calcium were each significantly higher than in patients with 25-hydroxyvitamin D levels of 16 ng/mL or higher, but serum 1,25-dihydroxyvitamin D levels were similar in both groups. We interpret this to mean that suboptimal vitamin D nutrition stimulates parathyroid adenoma growth by a mechanism unrelated to 1,25-dihydroxyvitamin D deficiency. We conclude that variable vitamin D nutritional status in the population may partly explain the differences in disease presentation.


Assuntos
Hiperparatireoidismo Primário , Neoplasias das Paratireoides , Deficiência de Vitamina D , Vitamina D/análogos & derivados , Adulto , Idoso , Feminino , Humanos , Hiperparatireoidismo Primário/sangue , Hiperparatireoidismo Primário/patologia , Hiperparatireoidismo Primário/cirurgia , Masculino , Pessoa de Meia-Idade , Estado Nutricional , Neoplasias das Paratireoides/sangue , Neoplasias das Paratireoides/patologia , Neoplasias das Paratireoides/cirurgia , Carga Tumoral , Vitamina D/sangue , Deficiência de Vitamina D/sangue , Deficiência de Vitamina D/patologia , Deficiência de Vitamina D/cirurgia
15.
Surgery ; 168(2): 328-334, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32376047

RESUMO

Recent innovations in molecular and genetic diagnostic techniques have led to rapid advances in genomic medicine and their application to the clinic. The identification and classification of various genetic associations, syndromes, and susceptibility genes in endocrine surgical disorders are increasingly relevant to patient care. Hereditary endocrine disorders represent a significant proportion of disease encountered by endocrine surgeons. Hence, genetic testing has emerged as an important adjunct for the diagnosis and management of patients with endocrine surgical disorders. This article summarizes commonly encountered inherited endocrine disorders and their tumor susceptibility genes, with a focus on the clinical utility of genetic testing and its impact on the surgical management of endocrine disorders.


Assuntos
Neoplasias das Glândulas Suprarrenais/genética , Procedimentos Cirúrgicos Endócrinos , Predisposição Genética para Doença , Testes Genéticos , Hiperparatireoidismo Primário/genética , Neoplasias da Glândula Tireoide/genética , Neoplasias das Glândulas Suprarrenais/cirurgia , Humanos , Hiperparatireoidismo Primário/cirurgia , Neoplasias da Glândula Tireoide/cirurgia
16.
Ann R Coll Surg Engl ; 102(5): 363-368, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32233846

RESUMO

INTRODUCTION: Hypercalcaemic crisis is a rare manifestation of hyperparathyroidism and occurs in 1.6-6% of patients with primary hyperparathyroidism (pHPT). Although such high serum calcium levels (>14mg/dl) are attributed to malignancy, it is also associated with benign disease of the parathyroid glands. The aim of this study was to evaluate the clinical features and treatment modalities of patients with severe hypercalcaemia who underwent surgery for pHPT. METHODS: The medical records of 537 patients who underwent parathyroidectomy in our department for pHPT between 2005 and 2019 were reviewed retrospectively. Twenty-four (4.4%) of the patients were described as having severe hypercalcaemia. RESULTS: Among 24 patients, 71% were female and the mean age was 55.7 years (range: 40-71 years). The mean serum calcium level at time of diagnosis was 15.9mg/dl (range: 14-22.7mg/dl). According to postoperative pathology reports, solitary adenoma, parathyroid cancer and parathyromatosis were diagnosed with the rates of 87.5%, 8.3% and 4.1% respectively. The mean weight of the solitary parathyroid lesions was 14.9g (standard deviation: 8.9g, range: 4-38g). The mean longest diameter was 2.87cm (standard deviation: 1.4cm, range: 1-5.5cm). Serum calcium levels were within the normal range on the first postoperative day in 75% of the cases. CONCLUSIONS: Severe hypercalcaemia is a rare but urgent condition of pHPT and requires prompt management. Accelerated surgery after adequate medical treatment should be performed. It is important to emphasise that giant adenoma, which is a benign disease, may be a more common cause of severe hypercalcaemia than carcinoma, unlike previously thought.


Assuntos
Adenoma/complicações , Carcinoma/complicações , Hipercalcemia/etiologia , Hiperparatireoidismo Primário/etiologia , Neoplasias das Paratireoides/complicações , Adenoma/sangue , Adenoma/cirurgia , Adulto , Idoso , Cálcio/sangue , Carcinoma/sangue , Carcinoma/cirurgia , Difosfonatos/administração & dosagem , Feminino , Furosemida/administração & dosagem , Humanos , Hipercalcemia/sangue , Hipercalcemia/diagnóstico , Hipercalcemia/terapia , Hiperparatireoidismo Primário/sangue , Hiperparatireoidismo Primário/cirurgia , Masculino , Pessoa de Meia-Idade , Glândulas Paratireoides/patologia , Glândulas Paratireoides/cirurgia , Neoplasias das Paratireoides/sangue , Paratireoidectomia , Período Pós-Operatório , Diálise Renal , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento
17.
Ann R Coll Surg Engl ; 102(6): e111-e114, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32233855

RESUMO

INTRODUCTION: Bilateral giant parathyroid adenoma in the absence of multiple endocrine neoplasia (MEN) type 1 is extremely rare and literature on this subject is limited. CASE HISTORY: A 79-year-old man presented with acute kidney injury secondary to hypercalcaemia. Blood test results indicated primary hyperparathyroidism. Ultrasonography revealed bilateral parathyroid adenomas measuring 19.4mm x 19.5mm x 18.8mm (left) and 15.2mm x 18.3mm x 19.6mm (left) whereas on computed tomography, the measurements were 31mm x 20mm (left) and 30mm x 14mm (right). Intraoperatively, giant adenomas measuring 50mm x 25mm x 12mm (left, weighing 8.101g) and 48mm x 22mm x 10mm (right, weighing 7.339g) were identified and excised. Parathyroid hormone level dropped from 44.6pmol/l preoperatively to 8.9pmol/l postoperatively (normal range 1.3-7.6pmol/l). The patient was discharged with no complications. CONCLUSIONS: We report a rare phenomenon where bilateral giant parathyroid adenoma occurred in the absence of MEN type 1. It highlights the importance of cross-sectional imaging in delineating the anatomy of adenomas as their size can be grossly underestimated by ultrasonography alone.


Assuntos
Adenoma/diagnóstico , Hiperparatireoidismo Primário/diagnóstico , Glândulas Paratireoides/patologia , Neoplasias das Paratireoides/diagnóstico , Paratireoidectomia , Lesão Renal Aguda/sangue , Lesão Renal Aguda/etiologia , Adenoma/complicações , Adenoma/patologia , Adenoma/cirurgia , Idoso , Cálcio/sangue , Diagnóstico Diferencial , Humanos , Hipercalcemia/sangue , Hipercalcemia/etiologia , Hiperparatireoidismo Primário/sangue , Hiperparatireoidismo Primário/etiologia , Hiperparatireoidismo Primário/cirurgia , Masculino , Neoplasia Endócrina Múltipla Tipo 1/diagnóstico , Glândulas Paratireoides/diagnóstico por imagem , Glândulas Paratireoides/cirurgia , Hormônio Paratireóideo/sangue , Neoplasias das Paratireoides/complicações , Neoplasias das Paratireoides/patologia , Neoplasias das Paratireoides/cirurgia , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Carga Tumoral , Ultrassonografia
19.
Eur J Endocrinol ; 183(1): 21-30, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32348956

RESUMO

Objective: The neurophysiological mechanisms underlying cognitive dysfunction in primary hyperparathyroidism (PHPT) and the brain regions affected are not clear. We assessed neural activation during cognitive testing (matrix reasoning, paired associates, and logical memory) using functional MRI (fMRI) in 23 patients with PHPT and 23 healthy controls. A subset with PHPT was re-assessed 6 months post-parathyroidectomy (PTX). Design: This is an observational study comparing neural activation by fMRI in patients with PHPT to normative controls. Postmenopausal women were studied at a tertiary referral center. Results: There were no between-group differences in cognitive task performance. Patients with PHPT had lower neural activation vs controls (max Z = 4.02, all P < 0.01) during matrix reasoning in brain regions involved in executive function (left frontal lobe (k = 57) and right medial frontal gyrus (k = 72)) and motor function (right precentral gyrus (k = 51)). During paired associates (verbal memory), those with PHPT had greater activation in the right inferior parietal lobule (language/mathematical operations; k = 65, P < 0.01). Greater activation in this region bilaterally correlated with higher PTH (k = 96, P < 0.01). Post-PTX, activation decreased during matrix reasoning, but in different regions than those affected pre-PTX. Conclusions: PHPT is associated with differences in task-related neural activation patterns, but no difference in cognitive performance. While this may indicate compensation to maintain the same cognitive function, there was no clear improvement in neural activation after PTX. Larger, longitudinal studies that include PHPT patients followed without surgery are needed to determine if PTX could prevent worsening of altered neural activation patterns in PHPT.


Assuntos
Encéfalo/fisiopatologia , Disfunção Cognitiva/fisiopatologia , Hiperparatireoidismo Primário/fisiopatologia , Idoso , Mapeamento Encefálico , Disfunção Cognitiva/complicações , Feminino , Humanos , Hiperparatireoidismo Primário/complicações , Hiperparatireoidismo Primário/cirurgia , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Testes Neuropsicológicos , Paratireoidectomia
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