In managing secondary hyperparathyroidism (SHPT), subtotal parathyroidectomy (SPTx) and total parathyroidectomy with autotransplantation (TPTx + AT) appear similarly effective, a new study confirms. But TPTx + AT may provide better long-term control of parathyroid hormone levels (PTH).
Given the ongoing debate about which operation is superior, a team led by Polina V. Zmijewski, MD, MA, of Rhode Island Hospital in Providence, compared the outcomes of 23 dialysis patients who had SPTx and 23 who had TPTx +AT, all performed by the same surgeon.
By the first day after surgery, PTH had declined significantly more in the TPTx +AT group: 4.2 vs 32.6 pg/mL, according to results published in the Journal of the American College of Surgeons. By 6 months after surgery, significantly fewer TPTx patients had PTH increases exceeding 200 pg/mL: 6.7% vs 38.9%. Reoperation for recurrence or persistence was required in 6 SPTx and 2 TPTx + AT patients.
The groups had similar serum calcium levels the first day after surgery: 7.7 mg/dL for SPTx and 7.9 mg/dL for TPTx +AT. The time needed to achieve calcium homeostasis, indicated by hospital stay, did not differ significantly between groups: 3.7 days for SPTx vs 4.4 days for TPTx +AT. Neither did required doses of calcium and calcitriol at discharge.
More TPTx + AT patients, however, appeared at risk for long-term hypoparathyroidism: 26.7% vs 5.6% had PTH levels less than 15 pg/mL at 6 months. They were also significantly more likely to require calcium supplementation: 71.4% vs 36.8%. But severe hypocalcemia (less than 7 mg/dL) at more than 6 months was infrequent: 11.7% in the TPTx + AT group vs 9.5% in the SPTx group.
“There is clearly a trend toward increased rates of long-term hypoparathyroidism in the TPTX-AT group,” Dr Zmijewski and the team wrote. “However, despite poor or absent graft function, these patients are generally well managed with a regimen of calcium and calcitriol, as evidenced by similar rates of normocalcemia at more than 6 months postoperatively between the 2 groups (66.7% in SPTx patients and 70.5% in TPTx-AT patients).”
Overall, these study findings indicate that TPTx + AT keeps PTH levels from “trending upward” and provides “more durable” results in the long-term compared with SPTx, the team concluded.
The type of parathyroidectomy a patient received was determined by the surgeon at the time of operation and was based on the sizes of the parathyroid glands and technical feasibility. SPTx involved removal of all parathyroid tissue except a well-vascularized 30- to 50-mg remnant of the most normal parathyroid gland. In TPTx + AT, all parathyroid tissue was removed from the neck and 30 to 50 mg of minced parathyroid tissue from the most normal gland was implanted in 3 pockets on the upper chest. All patients received thymectomies to remove any supernumerary glands.
Zmijewski PV, Staloff JA, Wozniak MJ, Mazzaglia PJ. Subtotal parathyroidectomy vs total parathyroidectomy with autotransplantation for secondary hyperparathyroidism in dialysis patients: short- and long-term outcomes. J Am Coll Surg. (LINK)???