After reviewing 20 years of data from their institution, Polish researchers confirm the safety and effectiveness of subtotal parathyroidectomy (PTx) for treating severe secondary hyperparathyroidism (SHPT) in dialysis patients.

Their research also confirmed the utility of intraoperative intact parathyroid hormone (iPTH) assay to gauge surgical success or signal the need for further surgical exploration for extra parathyroid glands. The criterion of effectiveness was a drop in iPTH concentration following parathyroid excision by 60% after 10 minutes and by at least 80% after 20 minutes compared with the preoperative value.

Using their institutional database, Aleksander Konturek, MD, of Jagiellonian University College of Medicine in Krakow, Poland, and colleagues identified 268 SHPT patients treated with an initial subtotal PTx and 29 with incomplete PTx between 1995 and 2014. Patients had parathyroid hormone (PTH) levels above 500 pg/mL and resistance to medical therapy. In addition, symptoms, such as ostalgia and arthralgia, pruritus, fractures, calcifications, and calciphylaxis, had intensified. Intraoperative iPTH assay was employed in 207 (69.7%) procedures.

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Subtotal PTx was largely successful over 2 years of follow-up, according to results published in Langenbeck’s Archives of Surgery. Persistent SHPT occurred in just 4.5% of subtotal PTx patients and 17.2% of those with incomplete PTx. Patients with intraoperative iPTH monitoring had a higher cure rate than non-monitored individuals (97.1% vs 87.8%, respectively). In-hospital mortality occurred in 1 patient.

In addition, hungry bone syndrome occurred in 31.3% of patients following subtotal PTx and 6.9% after incomplete PTx. Transient recurrent laryngeal nerve paresis occurred in 2.4% of 594 nerves at risk and permanent paresis in 0.8%.

Dr Konturek and colleagues concluded that “both subtotal PTX and TPTX+AT [total parathyroidectomy with autotransplant] and standard cervical thymectomy represent procedures that ensure a postoperative success with an acceptable and satisfactory percentage of permanent hypoparathyroidism.” Their findings generally agree with the literature, which thus far have not provided definitive criteria for selecting a particular method.

Reoperations were performed in 8 patients with significantly high PTH levels (mean 1296.6 pg/mL). Supernumerary or ectopic parathyroid glands were determined to be the source.

Subtotal PTx may be advantageous for patients awaiting kidney transplant as it overcomes parathyroid hormone autonomy, the researchers further noted.

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1. Konturek A, Barczyński M, Stopa M, and Nowak W. Subtotal parathyroidectomy for secondary renal hyperparathyroidism: a 20-year surgical outcome study. Langenbecks Arch Surg. doi:10.1007/s00423-016-1447-7.