Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa

Ahmed HalawaMSc PGCE FRCS MD FRCS(Gen)

Consultant SurgeonSheffield Teaching Hospitals

Senior LecturerUniversity of SheffieldUniversity of Liverpool

Failed medical treatment to control the hyperparathyroidism in a well dialysed patient indicated by: High PTH High Ca with normal PTH.Hyperphosphataemia. Vit D level 25(OH)D is >50 nmol/l (20 ng/ml).

3 glands 3% 4 glands 84% 5 or more 13%

Superior glands are posterior to the nerve (more consistent)

Inferior glands are anterior to the nerve (less consistent)

PTH Due to bone resistance, level above 3-5 times

the absolute value is considered abnormal

Ca (Normal or high)

Hyperphosphataemia

Vit D level

No radiological investigations are required

High-resolution ultrasoundSensitivity 65-85%65-85% for adenoma; 30-90%30-90% for enlarged glandResults suboptimal in pts with multinodular thyroid disease, pts with short thick neck, ectopic glands (15-20%)(15-20%)May be useful in detecting Sestamibi scan negative adenomas

CT with contrast/thin section

Sensitivity of 46-87%46-87%Good for ectopic glands in the chest

MRI

Sensitivity of 65-80%65-80%Good for ectopic glands

Sestamibi

85-95%85-95% accurate in localizing adenoma in primary HPT Sestamibi-SPECT

Sensitivity 60%60% for enlarged gland and 98%98% for solitary adenomas

Only Required for Redo Parathyroidectomy

Sensitivity (%)Sensitivity (%) 95% CI95% CI

Solitary Solitary adenomaadenoma

88.488.4 87 - 8987 - 89

HyperplasiaHyperplasia 44.444.4 41 - 4841 - 48

Double Double adenomaadenoma

3030 -2 - 62-2 - 62

CarcinomaCarcinoma 3333 3333Johnson N, AJR Am J Roentgenol. 2007 Jun;188(6):1706-15.

Tc-SestamibiTc-SestamibiSensit ivity Meta-analysisSensit ivity Meta-analysis

67-year-old woman with hyperparathyroidism and left tracheoesophageal groove adenoma that could easily be

mistaken for posterior thyroid nodule.

LEFT- 99mTc-sestamibi SPECT image shows physiologic uptake in salivary glands and thyroid gland, with focus of more intense uptake overlying superior pole of right thyroid lobe ( arrow). RIGHT-52-year-old woman with hyperparathyroidism and right superior parathyroid adenoma. Two-hour delayed SPECT image shows radiotracer retention in adenoma ( arrow) but clearing of tracer from overlying thyroid.

Tc-SestamibiTc-SestamibiSensit ivity Meta-analysisSensit ivity Meta-analysis

40-year-old woman who presented with recurrent hypercalcaemia and hyperparathyroidism after

resection of both left-sided glands.

39-year-old woman with left superior adenoma showing typical MRI signal characteristics .

No place for a “Cowboy Surgeon”

Previous dialysis line generates fibrosis (damage) Vascular calcification (bleeding) Engorged neck veins (bleeding) Anticoagulation on dialysis (bleeding) Anaemia and platelet abnormality (bleeding) The glands are closely related to RLN (damage) Inconstancy of the inferior glands (recurrence) Supernumerary gland(s) (recurrence) Thymectomy (bleeding into the chest)

Only 5-10% will come to surgery

Bilateral Neck Exploration If 4 glands found, minimum 3 ½ glands

removed and thymectomy

Total parathyroidectomy

Thymectomy

No auto-transplantation

Total parathyroidectomy

Thymectomy

No auto-transplantation?

Undescended thymus is associated with undescended inferior para thyroid gland

The inferior parathyroid glands may be higher that the superior glands, but stays anterior to the RLN

Fat

PTH should be >100 pm/ml to prevent the disease, but no guarantee

Reduced osteoblasts and osteoclasts, no accumulation of osteoid and markedly low bone turnover

 Induced by overtreatment of secondary hyperparathyroidism and not a disease

Fractures

No adequately powered RCT

Recurrence

Adynamic bone disease (ABD)

Develops from third pharyngeal pouch like the inferior parathyroid

Has some parathyroid rests that become active by persistent stimulation (CKD), they may develop into a full gland.