Does preoperative localisation for total parthyroidectomy in patients with renal failure improve outcome?
Thomas Hanna, Jo Edwards, Helen Grimsmo & Jacob Akoh
Background: Secondary hyperparathyroidism is a common complication of established renal failure (ERF) and is associated with significant morbidity and mortality. The aims of this study were to determine patient and operative characteristics, which might predict persistent or recurrent hyperparathyroidism after surgery. To assess the influence of pre-operative imaging on the ability to locate and remove parathyroid glands during both the initial and repeat surgery and to assess the long-term effect of failed surgery.
Methods: A retrospective study of all chronic kidney disease patients who required a total parathyroidectomy because of failed medical management from 1st January 1999 to 31st December 2008. Patient characteristics, preoperative imaging, medical treatment, operative findings, histology and patient outcome were all studied. Differences between groups (dialysis dependent and non dialysis dependent) were tested by the ×2 statistic and a P value of <0.05 was regarded as significant.
Results: Seventy-five patients underwent total parathyroidectomy during this period and were followed up for an average of 44.5 months. Sixty-one (81%) had removal of all parathyroid glands with associated fall in parathyroid hormone level. Pre operative imaging was used in 15 patients (20%) and found to be unhelpful in directing surgery in 12 of 15 (80%) cases. Four patients underwent repeat parathyroid surgery for recurrent/persistent RHPT with pre operative imaging used in two cases.
Conclusion: A high success rate can be achieved without the use of pre-operative imaging and is therefore not indicated prior to the first parathyroidectomy operation. The long-term effects of pharmaceutical developments in this area are, at present unknown but are likely to change indications for initial surgery and reoperation. An agreed protocol is therefore essential for the management of CKD patients with secondary hyperparathyroidism.