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Background: Some, but not all, patients with primary hyperparathyroidism (PHPT) and kidney stone disease (KSD) are cured of their nephrolithiasis after parathyroidectomy. The goal of this study was to identify risk factors for recurrent KSD despite successful parathyroidectomy in known stone formers with PHPT., Study Design: We conducted a single-center retrospective review of patients presenting to urology clinic with KSD between January 2008 and July 2018, who were diagnosed with concurrent PHPT, and underwent definitive parathyroidectomy. Laboratory testing for serum calcium, PTH (parathyroid hormone), phosphorus and 25-OH-vitamin D, and 24-hour urine studies for volume, pH, calcium, citrate, oxalate, uric acid, sodium, and creatinine was performed pre- and post-parathyroidectomy. Stone recurrence was determined on routine diagnostic imaging or by symptomatic KSD., Results: Mean age at parathyroidectomy was 57 ± 14 years. Pre-parathyroidectomy, mean serum calcium, 24-hour urine calcium, and PTH were 10.6 ± 0.5 mg/dL, 378 ± 209 mg/day, and 114 ± 97 pg/mL, respectively. Twenty-six of 69 patients (38%) had multigland parathyroid disease. After parathyroidectomy, serum calcium and PTH levels normalized in 69 of 69 and 62 of 69 patients, respectively. However, 37 of 69 patients (54%) had persistent hypercalciuria postoperatively, and 16 of 69 (23%) had recurrent KSD, on average, 2.0 ± 1.6 years after parathyroidectomy. Patients with recurrent KSD post-parathyroidectomy were significantly younger compared with patients without recurrent KSD (51 ± 15 vs 60 ± 13 years, p = 0.02). In a logistic regression model, younger age remains a strong predictive factor for recurrent KSD., Conclusions: Nearly one-quarter of PHPT patients with KSD who undergo successful parathyroidectomy present with recurrent KSD despite normalization of serum calcium, and more than half exhibit persistent calciuria. These patients were younger and may require closer monitoring for stone recurrence after successful parathyroidectomy. Further studies are needed to better identify the etiology of KSD post-parathyroidectomy., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Surgical excision is the preferred treatment for multiple endocrine neoplasia type 1 (MEN1)-related primary hyperparathyroidism (PHPT), although controversy regarding the surgical strategy exists. We retrospectively investigated the short-term outcomes of PHPT by various surgical extents. Thirty-three patients who underwent parathyroidectomy due to MEN1-related PHPT at Yonsei Severance Hospital between 2005 and 2018 were included (age [mean ± SD], 43.4 ± 14.1 [range, 23-81] years). Total parathyroidectomy with auto-transplantation to the forearm (TPX) was the most common surgical method (17/33), followed by less-than-subtotal parathyroidectomy (LPX; 12/33) and subtotal parathyroidectomy (SPX; 4/33). There was no postoperative persistent hyperparathyroidism. Recurrence was high in the LPX group without significance (1 in TPX, 2 in SPX, and 3 in LPX, p = 0.076). Permanent and transient hypoparathyroidism were more common in TPX (n = 6/17, 35.3%, p = 0.031; n = 4/17, 23.5%, p = 0.154, respectively). Parathyroid venous sampling (PVS) was introduced in 2013 for preoperative localisation of hyperparathyroidism at our hospital; nine among 19 patients operated on after 2013 underwent pre-parathyroidectomy PVS, with various surgical extents, and no permanent hypoparathyroidism (p = 0.033) or post-LPX recurrence was observed. Although TPX with auto-transplantation is the standard surgery for MEN1-related PHPT, surgical extent individualisation is necessary, given the postoperative hypoparathyroidism rate of TPX and feasibility of PVS.

Objective: Measure attentional distraction of neck scars after open neck surgery compared to transoral endoscopic thyroidectomy via a vestibular approach (TOETVA) or transoral endoscopic parathyroidectomy via a vestibular approach (TOEPVA) using eye-tracking technology., Methods: Casual observers viewed facial images of patients who underwent open neck surgery, TOETVA/TOEPVA, or no surgery (controls). An eye-tracking monitor recorded eye fixations in real time. Multivariate Hotelling's analysis followed by post-hypothesis testing compared fixation durations for predefined regions of interest, including the eyes, nose, mouth, neck, and remaining face between open neck surgery patients, transoral neck surgery patients, and controls., Results: One hundred forty observers completed the experiment. The majority of their attention was directed towards the central triangle (eyes, nose, mouth). On multivariate analysis, distribution of attention was significantly different on the faces of those who underwent open neck surgery versus TOETVA/TOEPVA (T 2 = 43.66; F[32,131] = 14.5389, P < .0001). Observers attended significantly more to the neck (0.20 seconds, P < .0001; 95% CI, 0.13, 0.26 s) and less to the peripheral face (-0.24 seconds, P = .0031; 95% CI, -0.39, -0.08 s) of open neck surgery patients. In patients who followed up months after surgery, significant differences persisted (T 2 = 13.97; F[3451] = 4.6377, P = .0033). By contrast, fixation patterns for TOETVA/TOEPVA patients were not significantly different from controls (T 2 = 5.59, F[31,186] = 1.8602, P = .1345). Observer race and gender did not significantly affect attention to neck scars., Conclusion: Scars following open neck surgery draw attention in casual observers. This attentional distraction is prevented in TOETVA/TOEPVA patients due to the absence of a scar, even months after surgery. Moreover, visual processing of TOETVA/TOEPVA patients' faces is similar to that of controls. These data support the effectiveness of transoral neck surgery in giving patients a cosmetic result that does not distract the attention of observers., Level of Evidence: NA Laryngoscope, 130:1603-1608, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: We investigated outcomes in a cohort of patients with a biochemical diagnosis of primary hyperparathyroidism (pHPT) undergoing surgery for asymptomatic disease or target organ damage, where a focussed or four-gland operation was undertaken and the histopathology only reported a "large normal" parathyroid gland (LNP)., Methods and Materials: Patients subjected to a parathyroidectomy for pHPT between 2012 and 2018 with a pathology of LNP were included. Patients with fat depletion or additional histological features of adenoma or hyperplasia in any of the resected glands were excluded. A control group was formed from 50 consecutive patients with the histological finding of adenoma or hyperplasia during the same study period. The primary outcome was biochemical normalisation of pHPT at 1-2 weeks and after 6 months post-operatively., Results: Forty-eight LNP patients (2% of all parathyroidectomies) were included in the study group with 50 matched controls. LNP patients had a lower biochemical cure rate (81% vs. 98% P < 0.05) and a higher risk of recurrence (10% vs. 0%, P = 0.06). LNP patients had a milder form of pHPT (Ca 2+ 2.63 vs. 2.68 P < 0.05) with a smaller PTH and Ca 2+ drop post-operatively. For LNP patients with failure, a definite additional cause of pHPT was found in only two patients., Conclusion: This study highlights a controversial area in pHPT and reports LNP as a cause of pHPT. The biochemical analysis of this LNP group supports a benefit in resection in the setting of pHPT, although the risk of failure (persistence/recurrence) is higher than those with adenoma or hyperplasia. Stricter post-operative follow-up of LNP patients should be considered.

Parathyroid gland disorders are rare conditions with an incidence that displays great variability among populations. Its direct influence in calcium homeostasis originates variable symptoms that affect bone remodelling among other processes. This study aimed to provide data on the epidemiology and characteristics of patients admitted with these disorders in Spain between 2003 and 2017, and to analyse disease management and direct medical costs. Medical records in which a disorder of the parathyroid gland was registered as the admission motive were extracted from a nationwide hospital-discharge database via the Spanish Ministry of Health. Records from 12,903 patients were obtained, with predominance of female patients (74.70%) and of admissions due to hyperparathyroidism (90.23%). The number of patients admitted per year increased over the study period along the incidence of these disorders. The year 2017 incidence of hyperparathyroidism was 2.95 per 10,000, 4.03 per 10,000 in females and 1.37 in males; the same year, the incidence of hypoparathyroidism was 0.17 per 10,000. Length of hospital stay was significantly extended in patients with hypoparathyroidism (7.16 days), admitted mostly due to emergencies. Heart failure was diagnosed in more than 20% of admissions in patients with secondary and tertiary hyperparathyroidism and hypoparathyroidism, while this last group displayed the highest levels of mineral metabolism disruption. Parathyroidectomy was performed in 78.95% of all admissions for primary hyperparathyroidism. The total annual direct medical cost parathyroid gland disorders has increased over the study period, due to the increase of the costs associated to hyperparathyroidism, whereas the cost per patient remained relatively stable, with an average of €3,748, €3,430 and €3,737 for patients with hyperparathyroidism, hypoparathyroidism and other disorders of the parathyroid gland, respectively. This study provides novel data to extend the scarce available knowledge on parathyroid gland disorders' epidemiology and management in Spain., Competing Interests: The authors declare no competing interests. AM employment at BCN Health does not alter our adherence to PLOS ONE policies on sharing data and materials.

Introduction: Primary hyperparathyroidism (PHPT) is a relatively common condition in surgical practice. Availability of localisation studies has shifted the treatment from bilateral neck exploration to selective parathyroidectomy. Several imaging modalities, each with varying sensitivities, are available to detect abnormal parathyroid glands. Ultrasound is almost universally accepted as the first line radiological investigation however its sensitivity is particularly heterogeneous and operator-dependent., Material and Methods: We studied 250 consecutive patients with PHPT who underwent parathyroidectomy in our hospital over a period of 33 months. Pre-operative neck ultrasound, 99mTc-sestamibi and single-photon emission computed tomography (SPECT CT) were performed in 249, 237 and 198 patients respectively. Unilateral and bilateral neck exploration was performed in 190 and 60 patients, respectively. Sensitivity, positive predictive value (PPV) and accuracy were calculated comparing the results with surgical and pathology findings., Results: Mean pre and postoperative PTH and adjusted calcium were, 11 ± 10.6 pmol/L, 1.9 ± 3.6, 2.81 ± 0.2 and 2.45 ± 0.2 mmol/L. There were 71 (29.95%) discordant results between US, compared to sestamibi and SPECT CT. An average of 1.9 parathyroid glands were removed with a mean weight of 0.92 g. Overall success rate based on postoperative PTH levels was 94.8%. Overall sensitivity, PPV and accuracy for US were 80.80%, 92.35%, and 75.73% respectively; for sestamibi were 71.82%, 94.61%, 69.00% and for SPECT CT were; 70.21%, 97.78%, 69.11% respectively., Conclusion: Ultrasound performed by an experienced specialist sonographer is highly sensitive in localising abnormal parathyroid glands. It can be used as a main and sole investigation in the majority of patients. Sestamibi, SPECT CT and other investigations should be performed in a step-wise manner and reserved for patients with negative US, failed primary procedure and recurrences.

Background: Main surgical treatments for secondary hyperparathyroidism (SHPT) include subtotal parathyroidectomy (sPTX), total parathyroidectomy with autotransplantation (tPTX+AT), and total parathyroidectomy (tPTX); however, determining the best treatment is debatable. We conducted a network meta-analysis (NMA) comparing three treatments in terms of postoperative hypocalcemia (or hypoparathyroidism), postoperative recurrence, and reoperation., Methods: We searched PubMed, Medline, the Cochrane Library, and Embase for relevant research from inception to July 30, 2019. We performed our Bayesian NMA using R 3.51 software to assess odds ratios (OR) and 95% confidence intervals (CI). Network and forest plots displayed study outputs. Potential publication bias was assessed with funnel plots using software Stata/MP 13.0., Results: Twenty-six articles comprising 5063 patients were included in our NMA, which showed that postoperative hypocalcemia (or hypoparathyroidism) occurred more frequently in tPTX than in sPTX (OR = 3.50, 95% CI 1.10-11.0) or tPTX+AT patients (OR = 1.80, 95% CI 0.66-5.20). Regarding postoperative hypocalcemia (or hypoparathyroidism), there was no significant difference between sPTX and tPTX+AT (OR = 0.53, 95% CI 0.24-1.10). As for recurrence rates, statistically significant differences were observed between sPTX and tPTX (OR = 25.0, 95% CI 5.1-260), tPTX+AT and tPTX (OR = 20.0, 95% CI 4.2-200), and sPTX and tPTX+AT (OR = 1.30, 95% CI 0.65-2.50). Regarding reoperation rates, sPTX experienced higher incidence compared with tPTX+AT (OR = 1.20, 95% CI 0.53-2.70) or tPTX patients (OR = 2.70, 95% CI 1.20-14.00)., Conclusions: TPTX+AT is recommended as the most efficient and safe surgical SHPT treatment with minimal adverse effects. Large-scale randomized controlled trials are recommended to confirm the NMA results., Competing Interests: Declaration of competing interest All authors declare no conflict of interest., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: The three-port submental endoscopic approach and its variations were introduced in 2016 and have been used for thyroidectomy since. However, there has been no report of this approach being used for parathyroidectomy [1, 2]. The objective of this paper was thus to report our experience using a three-port submental approach for endoscopic parathyroidectomy in challenging cases such as tertiary parathyroidism., Methods: We compared the outcomes before and after endoscopic removal of the parathyroid glands using a three-port submental endoscopic approach., Results: Endoscopic subtotal parathyroidectomy was performed using submental approach in five patients with tertiary hyperparathyroidism from January 2018 to June 2019. The parathyroid hormone levels of the patients dropped significantly after undergoing subtotal parathyroidectomy (mean difference 2260 pg/ml; 95% CI 1883.74 to 2636.65), as did calcium levels (mean difference 2.84 mg/dl; 95% CI 1.90 to 3.78). No major adverse events occurred in this study., Conclusions: Submental approach parathyroidectomy allows for visualization of all parathyroid glands. Surgical scarring was minor and was hidden under the chin. The surgical outcomes were promising, and there were no major complications.

Aim: Hyperparathyroidism in chronic kidney disease-mineral and bone disorder is associated with significant morbidity and mortality. Parathyroidectomy is widely carried out as treatment despite complications such as hypocalcaemia post-surgery. Our centre has been using an ALP-based protocol to replace calcium postoperatively to prevent hypocalcaemia. We aim to describe and audit our calcium replacement protocol post-parathyroidectomy METHODS: We, retrospectively, analyse 167 end-stage kidney disease patients who had parathyroidectomy with auto-implantation in Singapore General Hospital between January 2008 and December 2013. Their calcium replacement postoperatively was initiated upon patient arrival back in ward on the same day of surgery based on their pre-op ALP prior to occurrence of hypocalcaemia. Patient demographics, surgical and laboratory parameters were reviewed from medical records. Changes in calcium postoperatively were reported to look for incidence of calcium derangement., Results: Mean calcium levels between pre-operation day and post-operation day 7 ranged from 2.31 to 2.70 mmol/L. Decline in serum calcium was common in all patients prior to starting calcium replacement. Eighteen patients (10.9%) experienced hypocalcaemia immediately post-operation prior to commencement of IV calcium replacement. Patients with immediate post-operation hypocalcaemia had lower pre-operation calcium but higher pre-operation alkaline phosphatase (ALP) and pre-operation intact parathyroid hormone. Hypercalcaemia is common likely from aggressive IV calcium replacement using the protocol. The average length of stay for patients prior to calcium stabilization and discharge was 9 days., Conclusion: Implementation of an ALP-based prophylactic calcium replacement protocol with daily serum calcium monitoring can ameliorate severe hypocalcaemia post-parathyroidectomy.

Intraoperative monitoring of parathyroid hormone can confirm the complete excision of hyperfunctional parathyroid tissue, as the plasma half-life of PTH is approximately 5 minutes. The purpose of this study was to analyse the values of parathormon (PTH) and the intraoperative impact in patients with secondary hyperparathyroidism of renal cause (sHPT). A series of 86 patients who were hospitalised in our clinic between February 2015 to December 2018, were included in the study rom. All patients underwent surgery with PTH monitoring. PTH was determined preoperatively, intraoperatively 15 minutes after parathyroidectomy and postoperatively. Out of a total of 86 patients, 6 patients had non-functional renal transplant. 81 patients were operated on per primam and 5 patients were operated for disease recurrence. There were 77 total parathyroidectomies and 4 subtotal parathyroidectomies. One patient had 5 parathyroid glands. There were 4 patients with recurrent hyper-plastic tissue excision. Blood samples were collected intraoperatively through the puncture of the jugular vein. The PTH value was determined by the Elecsys PTH STATÃÂî test. The mean value of preoperative PTH was 1658 pg / mL and decreased to 46.5 pg / mL at the end of the operation. Subsequently, the level of PTH harvested at 3-6 months increased slightly to 59.8 pg / mL. 80 (93%) of patients had elevated preoperative calcium values. Recurrent hyperparathyroidism was found in 1 of the 4 patients who underwent subtotal parathyroidectomy. IPTH value is influenced by the intraoperative manipulation of the parathyroid glands, the individual variability of PTH half-life and the physiological state of the patient. The decrease of PTH measured intraoperatively at 15 minutes after harvest with at least 90% of the preoperative value indicates the success of a total parathyroidectomy, with normalisation of calcium and PTH., (Celsius.)

Background and Purpose: Our aim was to test the hypothesis that our recently introduced 4D-dynamic contrast-enhanced MR imaging with high spatial and temporal resolution has equivalent accuracy to 4D-CT for preoperative gland localization in primary hyperparathyroidism without requiring exposure to ionizing radiation., Materials and Methods: Inclusion criteria were the following: 1) confirmed biochemical diagnosis of primary hyperparathyroidism, 2) preoperative 4D-dynamic contrast-enhanced MR imaging, and 3) surgical cure with >50% decrease in serum parathyroid hormone intraoperatively. 4D-dynamic contrast-enhanced studies were reviewed independently by 2 neuroradiologists to identify the side, quadrant, and number of abnormal glands, and compared with surgical and pathologic results., Results: Fifty-four patients met the inclusion criteria: 37 had single-gland disease, and 17, multigland disease (9 with double-gland hyperplasia; 3 with 3-gland hyperplasia; and 5 with 4-gland hyperplasia). Interobserver agreement (κ) for the side (right versus left) was 0.92 for single-gland disease and 0.70 for multigland disease. Interobserver agreement for the quadrant (superior versus inferior) was 0.70 for single-gland disease and 0.69 for multigland disease. For single-gland disease, the gland was correctly located in 34/37 (92%) patients, with correct identification of the side in 37/37 (100%) and the quadrant in 34/37 (92%) patients. For multigland disease, the glands were correctly located in 35/47 (74%) patients, with correct identification of the side in 35/47 (74%) and the quadrant in 36/47 (77%)., Conclusions: The proposed high spatial and temporal resolution 4D-dynamic contrast-enhanced MR imaging provides excellent diagnostic performance for preoperative localization in primary hyperparathyroidism, with correct gland localization of 92% for single-gland disease and 74% in multigland disease, superior to 4D-CT studies., (© 2020 by American Journal of Neuroradiology.)

Background: Primary hyperparathyroidism (pHPT) is a common endocrine disorder, due to an excessive secretion of parathyroid hormone (PTH) from one or more parathyroid gland(s), where the only cure remains surgery. The surgical approach has become less invasive over the years, thanks to the advances in the preoperative localization of the enlarged parathyroid gland, as well as to the possibility to measure intra-operative parathyroid hormone (IOPTH). After the targeted removal of a parathyroid gland, IOPTH can confirm biochemically the cure of pHPT, such that it helps the surgeon to judge if the parathyroidectomy has been successful and there is no need of additional dissection. As with all laboratory tests, the quality of IOPTH total testing process is essential to the best utilization of patients' results. However, this can be affected by errors occurring in different phases. This review aims to describe the total testing process of IOPTH., Methods: We performed a search in Pubmed and a review of the literature on the current management of pHPT and the total testing process of IOPTH measurement., Results: Compared to previous studies focusing on single aspects of the IOPTH testing process, here we have analyzed all the steps crucial for the quality of IOPTH from the "pre-pre" to the "post-post" analytical phase., Conclusions: Clinicians and laboratory scientists should be aware of all the potential sources of errors in IOPTH measurement in order to improve their daily management of pHPT.

Background Primary hyperparathyroidism is the third most common endocrine disorder for which surgical procedure called parathyroidectomy is the most effective treatment. Since the early 20th century, parathyroid surgery has improved extensively. With the advances in preoperative imaging and with understanding the causes of disease, new and minimally invasive surgical approaches overrode the standard bilateral exploratory operations. Directed parathyroidectomy is currently the standard technique for treatment of primary hyperparathyroidism worldwide. Conclusions Surgery is the only definitive treatment of primary hyperparathyroidism. The most appropriate type of surgical procedure depends on the number and localization of the hyperactive parathyroid glands, availability of modern imaging techniques, limitation of each type of procedure and expertise.

Parathyroid surgery is frequently performed after at least two preoperative localisation studies, in addition to the use of intraoperative ioPTH. The key to performing a successful parathyroidectomy is reliant on the surgeon having an outstanding knowledge of parathyroid embryology and anatomy. With this, it is possible to undertake surgery with a simple neck ultrasound and without more expensive pre- and intraoperative localisation studies.

Background: Persistent/recurrent hyperparathyroidism occurs in 2%-5% of patients with sporadic primary hyperparathyroidism (PHPT). In this study, the incidence and time to recurrence in patients with single-gland disease (SGD), double adenomas (DAs), or four-gland hyperplasia (FGH) at initial parathyroidectomy were compared., Methods: This retrospective review included adult patients with sporadic PHPT who underwent initial parathyroidectomy with intraoperative parathyroid hormone monitoring (IOPTH) from 1/2000 to 12/2016 with ≥6 mo follow-up. An abnormal parathyroid was defined by a gland weight of ≥50 mg. A concurrent serum calcium >10.2 mg/dL and parathyroid hormone >40 pg/mL was defined as persistent PHPT if present <6 mo and recurrent PHPT if present ≥6 mo postoperatively after initial normocalcemia., Results: Of 1486 patients, 1203 (81%) had SGD, 159 (11%) DA, and 124 (8%) FGH. Among the 3 groups, there was no difference in the percent decrease from the baseline or time of excision to final postexcision IOPTH levels between groups (79% versus 80% versus 80%, respectively; P = 0.954) or in the proportion of patients with a final IOPTH ≥40 (22% versus 18% versus 14%; P = 0.059). Overall, 22 (1.5%) had persistent PHPT and 26 (1.7%) had recurrent PHPT. Persistent PHPT was more frequent with DAs (6; 3.8%) than other groups (SGD: 16, 1.3%; FGH: 0; P = 0.02). At median follow-up of 33 mo (IQR, 18-60), there was no difference in recurrence rate (1.6% versus 2.5% versus 2.4%; P = 0.57) or median time (mo) to recurrence (SGD: 59 [IQR, 21-86], DAs: 36 [IQR, 29-58], FGH: 23 [IQR, 17-40]; P = 0.46)., Conclusions: Recurrent PHPT occurred in 1.7% of patients who underwent curative initial parathyroidectomy, with no difference in incidence or time to recurrence between groups based on the number of glands removed. Patients with DA more commonly had persistent PHPT, raising the possibility of unrecognized FGH., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Ex vivo aspiration of parathyroid glands for the measurement of intraoperative parathyroid hormone (IOPTH) levels is a rapid point-of-care method to confirm parathyroid tissue during parathyroidectomy and an alternative to frozen section (FS). This study sought to determine the awareness and utilization of this technique among endocrine surgeons., Materials and Methods: A de-identified 12-question survey regarding techniques for intraoperative identification/confirmation of parathyroid tissue and the use of IOPTH monitoring was distributed to all 608 members of the American Association of Endocrine Surgeons., Results: Among the 182 (30%) respondents, FS was the most common primary technique utilized by 115 (63%) respondents to confirm parathyroid tissue; only 12 (7%) utilized ex vivo aspiration, although 78 (42%) were familiar with the technique. Availability and familiarity were the principal reasons for use of the primary technique; the most common barrier was time. Serum IOPTH monitoring was routinely used by 124 (74%). Of respondents who utilized FS, serum IOPTH monitoring was routinely used by 75% (86/115), including 71% (45/63) who reported time as a barrier to FS. Of these 45, only 15 (33%) were familiar with ex vivo parathyroid aspiration. Only 48% of surgeons knew how PTH samples were charged., Conclusions: FS was the most common method of identification/confirmation of parathyroid tissue. Although most respondents routinely performed IOPTH monitoring, relatively few utilized ex vivo aspiration as a technique for parathyroid identification and less than 50% were familiar with this technique. Broader dissemination about novel techniques such as ex vivo aspiration and cost awareness are recommended., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Identification of parathyroid tissue during surgery is necessary for its preservation in situ or for autotransplantation to avoid postoperative hypoparathyroidism. Frozen sections are the gold standard for distinguishing parathyroid tissue from other tissues during thyroidectomy. Although frozen sections are very accurate, they are costly and require pathologists and technical staff. Parathyroid tissue is rich in mitochondria, which harbor Krebs-cycle enzymes such as aspartate aminotransferase. In contrast, lactate dehydrogenase is expressed ubiquitously. These 2 enzymes are measured routinely as "leaked" enzymes. We hypothesized that the aspartate aminotransferase-to-lactate dehydrogenase ratio in suspended tissue could distinguish parathyroid tissue from other tissues., Methods: We analyzed 94 specimens (43 parathyroid, 19 thyroid cancers, 13 normal lymph nodes, 10 adipose, 6 thyroid, and 3 miscellaneous tissues) from 55 patients who underwent thyroid or parathyroid surgery between March 2018 and June 2019 in our institution. Trace amounts of remnant parathyroid tissue from autotransplantation specimens were suspended in 1 mL of normal saline and measured for aspartate aminotransferase and lactate dehydrogenase. Approximately 1 mm 3 of apparently distinct tissue minced by scissors (eg, thyroid gland, metastatic lymph node, etc) or washouts of needles used for preoperative aspiration biopsy were also measured for comparison., Results: The aspartate aminotransferase-to-lactate dehydrogenase ratios in suspended parathyroid tissue specimens were consistently greater than those of other tissues (P < .001, Mann-Whitney test); 0.27 was the optimal cutoff value with 100% sensitivity and specificity., Conclusion: This method distinguished parathyroid tissue quickly and conveniently from other tissues intraoperatively with minimum cost and without dedicated pathologic staff. This methodology may serve useful in decreasing the incidence of postoperative hypoparathyroidism, especially in settings with limited access to pathologists., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Importance: Guidelines advocate subtotal parathyroidectomy (SPTX) or total parathyroidectomy with autotransplantation (TPTX) with bilateral cervical thymectomy for primary hyperparathyroidism (pHPT) associated with multiple endocrine neoplasia type 1 (MEN1). However, both procedures are associated with a significant risk of permanent hypoparathyroidism., Objective: The aim of the current study was to compare long-term results of either single gland excision (SGE, 1-2 glands), SPTX and TPTX for the treatment of MEN1-associated pHPT., Design and Setting: Data of genetically confirmed MEN1 patients who underwent surgery for pHPT between 1987 and 2017 were retrieved from a prospective database and were retrospectively analysed., Results: Eighty-nine MEN1 patients underwent either TPTX (n = 38, 42.7%), SPTX (n = 23, 25.8%) or SGE (n = 28, 31.5%). The rate of disease persistence after initial surgery was 2.6%, 0% and 14.2% in the TPTX, SPTX and SGE groups, respectively. After median follow-up of 112 (range 7-411) months, the rate of recurrent pHPT was significantly higher in the SGE group (n = 19, 21.3%) compared with the TPTX (n = 4, 4.4%, P = .001) and the SPTX (n = 9, 10.1%, P = .03) groups. Analysis of the recurrence-free time among the surgical groups revealed a significant difference (P = .036). The median time to recurrence was significantly shorter after SGE (101, range 3-301 months) than after SPTX (139, range 28-278 months, P = .018) and TPTX (204, range 75-396 months, P = .049). Twelve (32%) patients who underwent TPTX developed permanent hypoparathyroidism compared with only 4 (17%, P = .06) in the SPTX and 0 in the SGE group (P = .001)., Conclusion: Given the high rate of postoperative permanent hypoparathyroidism after TPTX and SPTX, SGE is a valid option for the treatment of MEN1-associated pHPT., (© 2019 John Wiley & Sons Ltd.)

Renal hyperparathyroidism (rHPT) is a complex and challenging disorder. It develops early in the course of renal failure and is associated with increased risks of fractures, cardiovascular disease and death. It is treated medically, but when medical therapy cannot control the hyperparathyroidism, surgical parathyroidectomy is an option. In this review, we summarize the pathophysiology, diagnosis, and medical treatment; we describe the effects of renal transplantation; and discuss the indications and strategies in parathyroidectomy for rHPT. Renal hyperparathyroidism develops early in renal failure, mainly as a consequence of lower levels of vitamin D, hypocalcemia, diminished excretion of phosphate and inability to activate vitamin D. Treatment consists of supplying vitamin D and reducing phosphate intake. In later stages calcimimetics might be added. RHPT refractory to medical treatment can be managed surgically with parathyroidectomy. Risks of surgery are small but not negligible. Parathyroidectomy should likely not be too radical, especially if the patient is a candidate for future renal transplantation. Subtotal or total parathyroidectomy with autotransplantation are recognized surgical options. Renal transplantation improves rHPT but does not cure it.

Background: The aim of this study was to determine both the accuracy of near infrared fluorescence imaging to detect parathyroid glands and the potential indications of near infrared fluorescence imaging in thyroid and parathyroid surgery by correlating the autofluorescence signature with the pathologic specimen., Methods: This was an institutional review board-approved, prospective study of patients undergoing thyroidectomy and parathyroidectomy with near infrared fluorescence imaging. Each specimen sent to pathology was inspected with near infrared fluorescence imaging and predicted to be either parathyroid or non-parathyroid tissue by its autofluorescence signature and then correlated with the pathologic findings., Results: Autofluorescence was demonstrated to be present in 98% of the parathyroid glands, with 23% identified correctly with infrared based on the autofluorescence signature before visual identification by the surgeon. There were 550 specimens that were imaged with autofluorescence and then sent to pathology. For these samples, sensitivity, specificity, and positive and negative predictive values to predict parathyroid tissue were 98.5%, 97.2%, 95.1%, and 99.1%. In 5% of the total thyroidectomy specimens, incidentally resected parathyroid glands were identified with autofluorescence, leading to their subsequent reimplantation. In patients with parathyroid disease and negative preoperative localization, 21% of abnormal glands were recognized with autofluorescence before visual identification by the surgeon., Conclusion: Although the ability of infrared autofluorescence to confirm the presence of parathyroid tissue within surgical specimens was high, its power to find parathyroid glands in situ before visual recognition by surgeons was low. These advantages and limitations should be kept in mind when incorporating this technology into an endocrine surgical practice. Once a parathyroid seems to have been identified by the surgeon or tissue that looks like a parathyroid gland is identified, the autofluorescence signature is a very accurate assurance of parathyroid tissue., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background/aim: Recently, indocyanine green (ICG) fluorescence imaging has been used for the identification of the parathyroid glands (PG) during thyroid and parathyroid surgery. However, an overall consensus on the optimal technique, the dosage, the timing of the ICG administration and finally its interpretation and clinical usefulness is still lacking evidence. The aim of this review is to investigate the use of ICG angiography during thyroidectomy and/or parathyroidectomy for identification as well as for the perfusion integrity of the parathyroid glands., Materials and Methods: The PubMed database was systematically searched for publications regarding intraoperative ICG imaging in patients that undergo thyroidectomy or parathyroidectomy., Results: Eighteen publications reporting on 612 patients, namely 71 parathyroidectomy and 541 thyroidectomy patients met the inclusion criteria. Eleven publications reported the use of ICG angiography for the identification of the parathyroid glands during thyroidectomy and seven during parathyroidectomy for primary and secondary hyperparathyroidism., Conclusion: ICG fluorescence imaging is a simple, fast and reproducible method capable of intraoperatively visualizing and assessing the function of parathyroid glands, and can, therefore, assist surgeons in their decision-making. Despite all this, ICG fluorescence imaging technique for PG detection still lacks standardization and further studies are needed to establish its clinical utility., (Copyright© 2020, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Impairment of quality of life (QOL) is a key clinical characteristic of patients with end-stage renal disease (ESRD), and can be especially severe in the presence of secondary hyperparathyroidism (SHPT). Despite the proven success of parathyroidectomy (PTX) in controlling biochemical parameters in patients with severe SHPT, evidence is lacking regarding the effects of PTX on various clinical outcomes, including QOL., Methods: Twenty ESRD patients on maintenance hemodialysis with SHPT who underwent subtotal PTX were included in an observational longitudinal study. All studied patients underwent history-taking, clinical examinations, and laboratory investigations, including a complete blood count and measurements of serum calcium, phosphorus, magnesium, parathyroid hormone (PTH), and albumin levels preoperatively and at 3 months postoperatively. QOL was assessed before surgery and at 3 months after surgery using the Kidney Disease Quality of Life 36-Item Short-Form instrument., Results: After PTX, significant decreases in serum PTH and phosphorus levels were observed, as well as a significant increase in serum magnesium levels. Significant weight gain and improvements of QOL were also detected postoperatively., Conclusion: Subtotal PTX seems to be an efficient alternative to medical management in uncontrolled cases of SHPT, as it is capable of controlling the biochemical derangements that occur in hyperparathyroidism. Furthermore, PTX had a beneficial effect on clinical outcomes, as shown by weight gain and improvements in all QOL scales., Competing Interests: No potential conflict of interest relevant to this article was reported., (Copyright © 2019 Korean Endocrine Society.)

Background: Transoral endoscopic parathyroidectomy vestibular approach for secondary hyperparathyroidism (SHPT) is controversial with regard to the time consumed, safety, and feasibility. We present our initial experience with modified transoral endoscopic parathyroidectomy vestibular approach (m-TOEPVA) procedure for SHPT using total parathyroidectomy with autotransplantation., Materials and Methods: We retrospectively reviewed 10 patients with SHPT who underwent the m-TOEPVA procedure from December 2017 to April 2018 at our center., Results: There were a total of 6 male individuals and 4 female individuals with a median age of 58.5 years. Among whom, 5 were on hemodialysis and 5 on peritoneal dialysis. The median length of hospital stay and operative time was 5 (4, 5) days, and 321.5 (302.75, 362.25) minutes, respectively. Successful removal of 4 parathyroid glands was achieved in 8 of 10 patients (80%) and, in 8 patients (8/10, 80%), the intact parathyroid hormone successfully dropped to <300 pg/mL at 3 months postoperatively. Two patients with ectopic parathyroid gland in the superior mediastinum were noted preoperatively by MIBI scan and subsequently had successful removal. Except for 1 patient with prolonged hospital stay (11 d) due to hungry bone syndrome, there were no other major complications., Conclusion: m-TOEPVA by total parathyroidectomy with autotransplantation for SHPT is feasible, safe, and offers optimal cosmetic results. The most valuable part is that m-TOEPVA provides direct visualization and successful removal of the ectopic parathyroid glands in the superior mediastinum.

Background: Near infrared autofluorescence (NIRAF) can guide intraoperative parathyroid gland (PG) identification. NIRAF detection devices typically rely on imaging and fiber probe-based approaches. Imaging modalities provide NIRAF pictures on adjacent display monitors, and fiber probe-based systems measure tissue NIRAF and provide real-time quantitative information to objectively aid PG identification. Both device types recently gained FDA approval for PG identification but have never been compared directly., Study Design: Patients undergoing thyroidectomy and/or parathyroidectomy were recruited prospectively. Target tissues were intraoperatively visualized with PDE-Neo II (imaging-based) and concurrently assessed with PTeye (fiber probe-based). For PDE-Neo II, NIRAF images were collected from in situ or excised tissues, alongside the surgeon's interpretation of visualized tissues, and retrospectively analyzed in a blinded fashion. The PTeye was concomitantly used to record NIRAF intensities and ratios from the same tissues in real time., Results: Twenty patients were enrolled for concurrent evaluation with both systems, which included 33 PGs and 19 nonparathyroid sites. NIRAF imaging demonstrated 90.9% sensitivity, 73.7% specificity, and 84.6% accuracy for PG identification when interpreted in real time by the surgeon compared with 81.8% sensitivity, 73.7% specificity, and 78.8% accuracy where images were quantitatively analyzed post hoc by an independent observer. In parallel, NIRAF detection with PTeye yielded 97.0% sensitivity, 84.2% specificity, and 92.3% accuracy in real time for the same specimens., Conclusions: Both NIRAF-based systems were beneficial for identifying PGs intraoperatively. Although NIRAF imaging provides valuable spatial information to localize PGs, NIRAF detection with fiber probe provides real-time quantitative information to identify PGs in presence of ambient room lights., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Brown tumours affecting the cervical spine are a rare but recognised complication of renal failure-related secondary hyperparathyroidism. We present a case of a 26 year-old female with radiculopathy who was managed successfully with 360° cervical spine fixation and parathyroidectomy.

Background: Primary hyperparathyroidism is often associated with non-disease-specific symptoms. The aim of this study was to evaluate whether normalization of hypercalcaemia with short-term medical treatment can be used to predict the effects of parathyroidectomy and guide in surgical decision-making., Methods: This observational study included patients who received calcimimetic treatment for 4 weeks before parathyroidectomy (30-60 mg daily). A panel of tests was used to assess various aspects of quality of life (European Organisation and Treatment of Cancer QLQ-C30 core questionnaire, Hospital Anxiety and Depression Scale and Positive State of Mind questionnaire), cognitive function (Montreal Cognitive Assessment) and muscle strength (timed-stands test). The tests were carried out at baseline, after 4 weeks of calcimimetic treatment, and at 6 weeks and 6 months after parathyroidectomy. The predictive values of changes during calcimimetic treatment were determined for each test., Results: The study included 110 patients of median age 62 years (91 women). Calcimimetic treatment resulted in normalization of calcium levels and improvements in quality-of-life parameters. The time spent on the timed-stands test was significantly shortened. Eleven of 38 participants with a baseline Montreal Cognitive Assessment score below 26, indicating mild cognitive impairment, reached scores of at least 26 during treatment with calcimimetic. Improvements during treatment with calcimimetic correlated well with postoperative outcomes (positive predictive values 74-96 per cent)., Conclusion: The method described in this study may be used to aid surgical decision-making for patients with primary hyperparathyroidism and non-disease-specific symptoms by predicting the effects of normalization of hypercalcaemia., (© 2019 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Background: Tertiary hyperparathyroidism (THPT) is characterized by hypercalcemia and hyperparathyroidism after renal allograft. Limited data exist regarding the use of intraoperative parathyroid hormone (IOPTH) for THPT. We examined our series of parathyroidectomies performed for THPT to determine clinical outcomes with respect to IOPTH., Materials and Methods: Patients who underwent parathyroidectomy for THPT (1999-2017) were identified for inclusion. Retrospective chart review was performed. Cure was defined as eucalcemia ≥6 mo after surgery. Statistical analysis was performed., Results: Of 41 patients included in the study, 41% (n = 17) were female. The median duration of dialysis before renal allograft was 34 mo (interquartile interval [IQI]:6-60). Preoperatively, the median calcium level was 10.4 mg/dL (IQI:10.0-11.2), median parathyroid hormone was 172 pg/mL (IQI:104-293), and renal function was minimally abnormal with median glomerular filtration rate 58 mL/min/1.73 m2 (IQI:49-71). At surgery, the median final IOPTH was 40 pg/mL (IQI:29-73), and median decrease in IOPTH was 78% (IQI:72-87), with 88% (n = 36) of patients demonstrating >50% decrease. Median calcium level ≥6 mo after surgery was 9.4 mg/dL (IQI:8.8-9.7), and only one patient had recurrent hypercalcemia. Failure to achieve >50% decrease in IOPTH was not significantly associated with recurrent hypercalcemia (P = 1.000). With a median follow-up time of 41 mo (IQI:25-70), only three patients had graft failure. The positive predictive value of IOPTH for cure was 89% (95% confidence interval: 0.752-0.971), with 0% negative predictive value and 87% accuracy (95% confidence interval: 0.726-0.957)., Conclusions: Subtotal parathyroidectomy is a successful operation with durable cure of THPT. IOPTH fails to predict long-term cure in THPT despite minimally abnormal renal function., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Minimally invasive (video-assisted thoracoscopic surgery) mediastinal parathyroidectomy has been described as a technique for surgical management of primary hyperparathyroidism due to ectopic parathyroid adenoma. Herein, we present the largest cohort of patients ( n  = 8) treated with robot-assisted mediastinal parathyroidectomy and describe our technique for this procedure, pre- and intraoperative variables, and postoperative outcomes. Materials and Methods: A single surgeon, single institution case series of eight consecutive robot-assisted mediastinal parathyroidectomies performed from April 2013 to March 2018. Preoperative workup, intraoperative variables, and postoperative outcomes were evaluated. Results: Of the eight patients, seven were women. Average age was 54 years (range: 28-69) and average body mass index 33.6 (range: 24.8-42.9). Seven patients had a preoperative diagnosis of primary hyperparathyroidism with preoperative parathyroid hormone (PTH) and calcium levels (PTH: 137 (70-192); Ca 2+ : 10.9 (10.2-12), and one patient had preoperative diagnosis of thymoma. Preoperative imaging studies included computed tomography (CT)-sestamibi ( n  = 3), CT neck ( n  = 4), CT chest ( n  = 6), and neck ultrasound ( n  = 6). Intraoperative PTH measurements found >50% reduction in all cases. Average length of surgery was 108.6 minutes (range: 76-186); average blood loss 26 cc. All specimens were parathyroid adenomas, with an average size of 16 mm (range: 7-35 mm). Seven of eight patients were discharged on postoperative day 1. No complications or recurrences occurred at a median follow-up of 18.5 days (range: 15-1,066 days). Conclusions: Robot-assisted thoracoscopic parathyroidectomy is a safe and effective technique, with immediate improvement in PTH levels. Thorough clinical, biochemical, and radiologic preoperative workup assists in operative planning and may improve diagnostic accuracy of anterior mediastinal masses.

Background: Optical coherence tomography (OCT) is a noninvasive imaging modality that may reproduce the microarchitecture of tissues in real-time. This study examines whether OCT can render distinct images of thyroid, parathyroid glands, adipose tissue, and lymph nodes in both healthy and pathological states., Methods: Twenty-seven patients undergoing thyroidectomy, parathyroidectomy, and/or neck dissection for thyroid cancer were recruited prospectively for imaging prior to histopathological analysis., Results: Based on 122 imaged specimens, qualitative OCT descriptions were derived for healthy thyroid, parathyroid gland, adipose tissue, and lymph node. The frequencies at which distinguishing features were present for each tissue type were 88%, 83%, 100%, and 82%. OCT appearance of pathological specimens were also described., Conclusions: Healthy neck tissues have distinct OCT appearances, which could facilitate parathyroid identification during thyroidectomies. However, images of parathyroid adenomas could be confused with those of lymph nodes, and benign and malignant thyroid nodules could not be differentiated., (© 2019 Wiley Periodicals, Inc.)

Background: The interest in correlation between hospital and surgeon practice volume and postoperative outcomes has grown considerably over the last decades; it has been suggested that surgery is likely to be associated with higher cure rates, lower morbidity and more favourable results in cost-effectiveness when performed in a high-volume setting. The aim of this paper is to undertake an evidence-based literature review of the relationship between surgical volume and clinical outcomes in parathyroidectomy for primary hyperparathyroidism. We used accepted quality markers to identify the relationship between volume and outcome with a view to defining a reproducible minimal surgical volume-related standard of care in parathyroid surgery., Methods: A peer review literature analysis of volume and outcomes in parathyroid surgery was carried out and assessed from an evidence-based perspective. Results were discussed at the 2019 Conference of the European Society of Endocrine Surgeons devoted to "Volumes, Outcomes and Quality Standards in Endocrine Surgery"., Results: Literature reports no prospective randomised studies; thus, a low level of evidence may be achieved., Conclusions: Parathyroid surgery is at increased risk of failures, morbidity and need for reoperations and cost when performed in low-volume settings; thus, it should be concentrated in dedicated settings, with adequate annual volume and expertise. Acceptable results may be achieved moving parathyroid surgery cases away from low-volume settings (< 15 parathyroidectomies/year). Challenging procedures (primary hyperparathyroidism without unequivocal preoperative localization, hereditary variants, paediatric patients, reoperations) should be confined to high-volume settings (> 40 parathyroidectomies/year).

Intraoperative parathyroid hormone monitoring (IPM) has been shown to be a useful adjunct during parathyroidectomy to ensure operative success at many specialized medical centers worldwide. Using the Miami or ">50% intraoperative PTH drop" criterion, IPM confirms the complete excision of all hyperfunctioning parathyroid tissue before the operation is finished, and helps guide the surgeon to identify additional hyperfunctioning parathyroid glands that may necessitate further extensive neck exploration when intraoperative parathyroid hormone (PTH) levels do not drop sufficiently. The intraoperative PTH assay is also used to differentiate parathyroid from non-parathyroid tissues during operations using fine needle aspiration samples and to lateralize the side of the neck harboring the hypersecreting parathyroid through differential jugular venous sampling when preoperative localization studies are negative or equivocal. The use of IPM underscores the recognition and understanding of sporadic primary hyperparathyroidism (SPHPT) as a disease of function rather than form, where the surgeon is better equipped to treat such patients with quantitative instead of qualitative information for durable long-term operative success. There has been a significant paradigm shift over the last 2 decades from conventional to focused parathyroidectomy guided by IPM. This approach has proven to be a safe and rapid operation requiring minimal dissection performed in an ambulatory setting for the treatment of SPHPT., Competing Interests: No potential conflict of interest relevant to this article was reported., (Copyright © 2019 Korean Endocrine Society.)

Background: Secondary hyperparathyroidism is a common complication in patients with chronic kidney disease that requires vigilant treatment due to its high mortality rate. Pharmacologic therapy is recommended as an initial treatment; if there is no response, a total parathyroidectomy is performed. In some cases, surgery is accompanied by auto-transplantation of parathyroid tissue., Case Presentation: The patient was diagnosed with chronic kidney disease and received a kidney transplant. However, due to rejection of the transplanted kidney, medical nephrectomy was carried out and routine hemodialysis was initiated and observed. At this time, secondary hyperparathyroidism with elevated parathyroid hormone and hyperphosphatemia developed and pharmacologic treatment was applied. However, there was no response to pharmacologic treatment; therefore, total parathyroidectomy with auto-transplantation was performed. Eight years after surgery, a growing mass was observed in the transplantation site, accompanied by an elevation of parathyroid hormone. A complete resection of the mass was performed, and the patient was diagnosed with parathyroid carcinoma. Additional adjuvant radiation therapy was ordered, and the patient is being monitored., Conclusions: This is a rare but remarkable case of parathyroid carcinoma arising from auto-transplanted parathyroid tissue after total parathyroidectomy in a patient with secondary hyperparathyroidism. We suggest caution should be taken when choosing to auto- transplant parathyroid tissue and that careful postoperative observation should be performed.

Background: Ectopic mediastinal parathyroid tumor (EMPT) is a rare cause of primary hyperparathyroidism (PHPT); it is difficult to resect using the cervical approach. We describe a case of using video-assisted thoracic surgery (VATS) for EMPT resection., Case Presentation: A 67-year-old woman with a history of postoperative thyroid cancer had no symptoms. She was diagnosed with PHPT and underwent thyroid cancer surgery. She had serum calcium and intact parathyroid hormone (PTH) levels of 11.1 mg/dL and 206 pg/mL, respectively. Chest computed tomography showed a 10-mm nodule in the anterior mediastinum. Technetium-99 m methoxyisobutyl isonitrile scintigraphy showed an abnormal uptake lesion in the anterior mediastinum. She was diagnosed with PHPT caused by EMPT and underwent VATS. The pathological examination confirmed parathyroid adenoma. Her serum calcium and intact PTH levels were normal from 15 min after tumor resection. She has had no recurrence of EMPT., Conclusions: The VATS approach was effective for the resection of EMPT.

Introduction: The transcervical approach has been the primary route of access for thyroid and parathyroid glands since its description by Kocher 140 years ago. Several approaches have been suggested for minimizing the surgical scar but none of them have become common practice. Thus, a role for a new novel technique still exists for improving surgical esthetic outcome. Trans-oral endoscopic trans-vestibular approach (TOETVA) has recently been reported as a novel approach for the extraction of thyroid or parathyroid tumors., Aims: To show the safety and feasibility of TOETVA for thyroid and parathyroid surgery in Israel., Methods: Case series of patients who underwent TOETVA at our institution. The study was approved by our Institutional Board IRB retrospectively., Results: Ten patients (5 thyroidectomies and 5 parathyroidectomies) underwent TOETVA and were included in the study. The average time of surgery was 3.3 hours. One patient had transient vocal cord paralysis, a second patient had altered sensation of chin and a third patient had seroma that was resolved by aspiration. Surgery was successful in all patients and complete resection of the thyroid lobe as well as the parathyroid adenomas was achieved. No permanent complications were encountered., Conclusions: In this study TOETVA was found to be feasible and safe for the resection of selected thyroid and parathyroid tumors., Discussion: We report the first series of patients in Israel undergoing TOETVA for thyroid and parathyroid tumors. The learning curve is steep and improving. Surgery was uneventful and safe. The results are comparable to other reports from various centers which adopted this novel technique.

Rationale: We studied the feasibility of total arathyroidectomy(tPTX)+multi-point transplantation in the forearm for treatment of secondary hyperparathyroidism. Considering the controversial nature of the appropriate timing for and location of this type of surgery, relevant research is relatively rare. Our experience may be a relatively successful one., Patient Concerns: Our patient was a 28-year-old woman with end-stage renal disease (ESRD), who was on dialysis for 7 years, and a 2-year history of progressively aggravated bone pain. She also had hypercalcemia and hyperphosphatemia., Diagnoses: Given the patient's history of long-term dialysis, bone pain, high levels of intact parathyroid hormone(i-PTH) and hypercalcemia, we performed ultrasonography which showed solid nodules in the bilateral parathyroid glands. She was accordingly diagnosed with SHPT., Interventions: The patient underwent tPTX+multi-point subcutaneous transplantation in the forearm., Outcomes: Her i-PTH level dropped to < 300 pg/mL, and the symptoms of bone pain markedly reduced after surgery., Lessons: Total parathyroidectomy+multi-point subcutaneous transplantation in the forearm may be a reliable surgical approach for patients with ESRD.

Objectives: The aim of the study was to evaluate the laboratory parameters and symptoms after parathyroidectomy (PTX) in dialysis patients with secondary hyperparathyroidism (SHPT), and to briefly analyze the different therapeutic effects of the three surgical methods. Methods: A total of 182 dialysis patients who underwent PTX between February 2012 and January 2018 at the Second Affiliated Hospital of Soochow University were included in this study and followed for 12 months. Laboratory parameters such as calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), and intact parathyroid hormone (iPTH) were measured before and after operation. According to the follow-up time and type of operation, we calculated the percentage of laboratory indicators reaching the recommended range of the KDIGO guidelines after surgery. We also analyzed the improvement of bone pain and pruritus, as well as surgical complications. Results: After the operation, the levels of iPTH, Ca, and P decreased significantly at each time point. ALP increased at the first postoperative week and gradually decreased to normal range after 3 months. Symptoms, such as bone pain and pruritus, were significantly relieved. According to the follow-up time and three surgical methods (subtotal parathyroidectomy, total parathyroidectomy, total parathyroidectomy plus autologous transplantation), we found that the ratio of each laboratory parameter reaching the recommended range of KDIGO guidelines was significantly different. Conclusion: PTX is a safe and effective therapy for treating SHPT that is refractory to medical therapies and accompanied by related signs and symptoms in dialysis patients. All three operative techniques were effective in controlling SHPT.

Parathyroidectomy (PTX) remains an important intervention for dialysis patients with poorly controlled secondary hyperparathyroidism (SHPT), though there are only retrospective and observational data that show a mortality benefit to this procedure. Potential consequences that we seek to avoid after PTX include persistent or recurrent hyperparathyroidism, and parathyroid insufficiency. There is considerable subjectivity in defining and diagnosing these conditions, given that we poorly understand the optimal PTH targets (particularly post PTX) needed to maintain bone and vascular health. While lowering PTH after PTX decreases bone turnover, long-term changes in bone activity have been poorly explored. High turnover bone disease, usually present at the time a PTX is considered, often swings to a state of low turnover in the setting of sufficiently low PTH levels. It remains unclear if all low bone turnover equate with disease. However, such changes in bone turnover appear to predispose to vascular calcification, with positive calcium balance after PTX being a potential contributor. We know little of how the post-PTX state resets calcium balance, how calcium and VDRA requirements change or what kind of adjustments are needed to avoid calcium loading. The current consensus cautions against excessive reduction of PTH although there is insufficient evidence-based guidance regarding the management of chronic kidney disease - mineral bone disease (CKD-MBD) parameters in the post-PTX state. This article aims to compile existing research, provide an overview of current practice with regard to PTX and post-PTX chronic management. It highlights gaps and controversies and aims to re-orient the focus to clinically relevant contemporary priorities in CKD-MBD management after PTX., (© 2019 Wiley Periodicals, Inc.)

Objective: To assess the capacity of different techniques to reduce non-operative times during parathyroid surgery. The impact of monitored anesthesia care (MAC) instead of general anesthesia, and the pre-operative placement of a second peripheral intravenous catheter (PIV) were analyzed., Methods: A retrospective case series at an academic medical center was performed to study patients undergoing parathyroidectomy by a single surgeon between November 2013 and October 2016. Three operating room (OR) time measurements were compared: pre-incision time, post-closure time, and total OR time., Results: Surgeries performed under MAC (n = 21) had statistically shorter pre-incision (33.2 min vs. 39.7 min, p < .001), post-closure (10.1 min vs. 16.2 min, p = .002), and total operative times (113.0 min vs. 151.5 min, p < .001) compared to those in which general anesthesia (n = 169) was used. Of the 169 patients who underwent general anesthesia, 25 had a second PIV placed preoperatively and 144 had only a single PIV. All 3 time periods were statistically shorter in patients who had a second PIV versus those who had only a single PIV (pre-incision 32.2 min vs. 41.0 min, p < .001; post-closure 12.2 min vs. 16.9 min, p < .001; total 117.9 min vs. 157.4 min, p < .001)., Conclusions: In patients undergoing parathyroid surgery in which ioPTH levels will be used, the placement of a second PIV in the pre-operative holding area and performance of surgery under MAC can significantly shorten non-operative and total OR time., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Preoperative localization of abnormal parathyroid glands in primary hyperparathyroidism is often obtained by sestamibi, and ultrasonography. We aimed to identify which modality is most accurate when laterality of abnormal glands on preoperative imaging is discordant., Methods: A single institution retrospective review identified 112 consecutive patients with primary hyperparathyroidism who underwent successful parathyroidectomy and sestamibi with pertechnetate., Results: Sestamibi with pertechnetate had a sensitivity of 72% and positive predictive value of 90%; ultrasonography had sensitivity of 50% and positive predictive value 80%. Patients with thyroiditis had lesser sensitivity and positive predictive value on sestamibi with pertechnetate (53% and 77%, respectively), in contrast to ultrasonography (54%, 88%, respectively). The sensitivity and positive predictive value of sestamibi with pertechnetate and ultrasonography did not differ in patients with thyroid nodules. Seventeen patients (15%) had discordant laterality on preoperative imaging. In discordant cases, sestamibi with pertechnetate was correct in 53% overall but in only 17% of those with thyroiditis (P = .01), whereas ultrasonography was correct in 26% overall but in 50% of those with thyroiditis (P = .01)., Conclusion: Thyroiditis decreased the sensitivity and positive predictive value of sestamibi with pertechnetate in primary hyperparathyroidism. In patients with discordant laterality on preoperative imaging, sestamibi with pertechnetate is the more accurate choice to guide operative planning, although ultrasonography may be a better guide in those with thyroiditis., (Copyright © 2019. Published by Elsevier Inc.)

The present study investigates the incidence of perioperative hyperkalemia and the influence factors of serum potassium levels during and after parathyroidectomy (PTX) in hemodialysis patients with renal hyperparathyroidism (rHPT). A total of 204 hemodialysis patients with refractory rHPT undergoing successful total parathyroidectomy with autotransplantation (tPTX + AT) were analyzed retrospectively. Hyperkalemia was defined as serum potassium levels ≥ 5.5 mmol/L. The preoperative baseline level of serum potassium (K base + ) was defined as a mean of the three preoperative prehemodialysis serum potassium levels. The higher levels of serum potassium during and immediately after surgery were recorded as K d0 + and the peak prehemodialysis serum potassium levels 3 days after surgery as K d3 + . 136/204 (66.7%) patients suffered from hyperkalemia during or immediately after surgery and 65/204 (31.9%) patients were affected with prehemodialysis hyperkalemia 3 days after surgery. K base + was the only influencing factor for K d0 + . Serum K base + , preoperative serum alkaline phosphatase, and total calcium supplement dosage during intravenous calcium supplement were the influencing factors for K d3 + . In the case of PTX, the serum potassium levels of patients with higher serum K base + and severe postoperative hypocalcemia need to be monitored with extended attention perioperatively.

Intraoperative PTH monitoring (IOPTH) made minimally invasive parathyroidectomy in patients with primary HPT possible. However, with the increasing accuracy of preoperative localization studies there is a growing discussion if IOPTH is necessary in patients with localized single gland disease (concordant preoperative localization studies). Different interpretation criteria have been developed - each with their particular advantages and disadvantages, but the "perfect" criterion is still missing. Despite several pitfalls, which can be recognized intraoperatively and do not necessarily lead to a more extensive surgery, IOPTH seems to be a useful adjunct in surgery for PHPT. However, according to current guidelines, selected patients may be operated without IOPTH but need to be informed about the possibly increased risk of recurrent disease., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: Thermal ablation and parathyroidectomy (PTX) have been recommended for patients with secondary hyperparathyroidism (SHPT). However, it is uncertain which is the better method. The aim of the present meta-analysis was to evaluate the efficacy and surgical complications of the two treatment methods., Methods: The following databases were searched from inception to December 31, 2018: PubMed, EMBASE, the Cochrane Library, CNKI, and Wanfang. Eligible studies comparing thermal ablation and PTX for SHPT were included. Data were analysed using Review Manager Version 5.3., Results: Six studies were included in the meta-analysis. Four cohort studies and two randomized controlled trials involving 326 patients with SHPT were identified. There was no difference concerning parathyroid hormone (PTH) levels (MD 58.04, 95% CI -17.60-133.68, P = 0.13), calcium levels (MD -0.07, 95% CI -0.17-0.04, P = 0.21), phosphorus levels (MD 0.21, 95% CI -0.18-0.61, P = 0.29), or hoarseness (OR 0.53, 95% CI 0.24-1.16, P = 0.11) between the two surgical methods. Compared with PTX, thermal ablation reduced the risk of hypocalcaemia (OR 0.23, 95% CI 0.11-0.47, P < 0.01). However, thermal ablation increased the risk of SHPT persistence and/or recurrence compared with PTX (OR 4.24, 95% CI 1.44-15.76, P = 0.03)., Conclusion: Thermal ablation and PTX were effective surgical approaches for SHTP. Thermal ablation reduced the risk of hypocalcaemia and increased the risk of SHPT persistence and recurrence. More large multicentre randomized controlled trials are necessary to confirm the conclusions., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Tumoral calcinosis (TC) is a rare disease derived from uremic secondary hyperparathyroidism (SHPT). However, parathyroidectomy (PTX) seems to be ineffective at relieving TC in some patients. In this study, we investigated the relationship between PTX and TC shrinkage., Methods: We retrospectively followed up nine TC patients who underwent PTX, dividing them into two groups: those with TC size reduced by > 80% were in the "effective group" (group A), and the rest in the "ineffective group" (group B)., Results: We enrolled nine patients (7 men; mean age 38.6 ± 10.9 years) with SHPT-related TC. One patient with calciphylaxis was excluded due to sudden death. The efficiency of PTX in causing TC regression was 62.5% (5 patients in group A). Group A had a shorter overall duration of TC (6 [5.5, 6.0] vs. 9 [8.0, 10.0] months; P = 0.02) and higher serum levels of alkaline phosphatase (ALP; 408.0 [217.9, 1101.7] vs. 90.8 [71.0, 102.1] pg/ml; P = 0.03) and high-sensitivity C-reactive protein (hs-CRP; 82.7 [55.0, 112.4] vs. 3.1 [3.1, 4.5] mg/l; P = 0.02). Average calcium supplementation within 1 week of surgery was significantly greater in group A than in group B (96.8 [64.1, 105.3] vs. 20.1 [13.1, 32.7] g; P = 0.04). Patients in both the groups demonstrated similar serum phosphate levels before PTX, but these levels were higher in group B than in group A at follow-up times (3 months, P = 0.03; 6 months, P = 0.03)., Conclusions: The shorter duration of pre-existing TC and higher ALP levels before PTX, as well as lower serum phosphate levels after PTX, were correlated with effective SHPT-TC shrinkage.

Purpose: The optimal surgical approach of parathyroidectomy for patients with secondary hyperparathyroidism (SHPT) has been controversial. The updated meta-analysis aimed to compare the effectiveness of subtotal parathyroidectomy (SPTX) versus total parathyroidectomy with autotransplantation (TPTX + AT)., Methods: A thorough systematic search was performed on the databases of PubMed, EMBASE, and Cochrane library to identify eligible studies. Data were extracted and pooled into a meta-analysis. The primary outcomes were the symptomatic improvement, radiological changes, hypocalcemia rate, the requirement for vitamin D analogues, time to recurrence, recurrence, persistence, and reoperation rates of SPTX versus TPTX + AT., Results: A total of 18 studies with 3656 patients (1864 patients in SPTX and 1792 patients in TPTX + AT group) were included, and 15 studies were included in quantitative synthesis. No significant difference was observed in symptomatic improvement (93.3%, 89.0%; P = 0.99), radiological changes (85.4%, 85.3%; P = 0.91), hypocalcemia rate (16.6%, 18.1%; P = 0.29), persistence rate (6.1%, 2.0%; P = 0.16), time to recurrence (mean difference 1.46; P = 0.87), recurrence rate (9.2%, 7.1%; P = 0.76), and reoperation rate (5.3%, 5.8%; P = 0.66) between SPTX and TPTX + AT groups. Longer operative time (150 vs. 120 min), prolonged in-hospital stay (5.0 vs. 4.1 days), lower 1-month serum calcium level, and higher requirement for vitamin D analogues at 12 months were significantly observed in patients who underwent TPTX + AT compared to SPTX., Conclusions: The two surgical approaches were both effective at controlling SHPT in clinical and laboratory terms. However, most of the data shown were not statistically significant. It was acceptable that surgeons chose either SPTX or TPTX + AT for SHPT.

We report the presentation, management and outcomes of patients operated for hyperparathyroidism at our hospital. Patient sunder going surgery for hyper parathyroidism from 20 05 to 2 015 were retrospectively reviewed. Preoperative biochemistry, diagnostic scans and surgical procedures were studied. Follow up for cure rates, complications and histology were recorded. Out of 72 patients reviewed 54 (75%) were females and the rest males. The mean age was 48.04±15.5 years. Musculoskeletal complains were the most common (76.4%) among the cases reviewed. Asymptomatic hypercalcemia was seen in 13 (18.1%). The mean preoperative PTH level was 658.95 pg/ml and the mean preoperative calcium was 11.9 mg/dl. Bilateral neck exploration was done in 42 (58.3%) while focused unilateral approach was done in 27 (37.5%) cases. Solitary adenoma was the most frequent pathology in 58 (80.5%) patients. Asymptomatic hyperparathyroidism was less frequently detected in our population owing to lack of screening programme. Our patients are younger with a greater severity of the disease both symptomatically and biochemically compared to the West. In almost two decades, preoperative symptoms, calcium and PTH levels have changed marginally. Bilateral explorations are now giving way to focused less invasive procedures.

Purpose: To evaluate a single-center extensive experience and effectiveness in surgical treatment of primary hyperparathyroidism (pHPT) with the use of rapid intraoperative parathyroid hormone (ioPTH) monitoring in patients with single gland (SGpH) or multiple gland (MGpH) disease., Methods: This retrospective, single-center cohort study included 214 patients with pHPT treated from January 2010 to June 2017. In total, 172 patients fulfilled the inclusion criteria having at least one preoperative localization image study and measurement of ioPTH. Statistical analysis was made by the chi-square test and Student's t tests., Results: Of the 172 patients, 146 were women (85%) and 26 men (15%), with a mean age of 56.9 years; 153 (89%) had SGpH and 19 (11%) MGpH. The mean follow-up was 41.8 months. A total of 153 surgical procedures were performed as minimal invasive parathyroidectomy (MIP) based on a SGpH diagnosis; operative success was achieved in 150 cases (98%), according to ioPTH concentrations. The remainder (19 procedures) were performed as bilateral neck exploration (BNE) based on a MGpH diagnosis; operative success was achieved in 16 cases (84%). ioPTH correctly modified the initially planned operation in 26.3% of patients with MGpH., Conclusions: ioPTH enables the surgical treatment of patients with pHPT with focused approaches and excellent results, as it helps the surgeon to identify cases of MGpH. ioPTH adds value to cases where preoperative imaging failed to detect the affected gland or the results are inconclusive. According to the literature, its application seems to be of marginal benefit in cases in which there are two concordant preoperative imaging studies.

Reoperative parathyroid surgery (REOPS) is often associated with lower cure rates and greater risk of nerve injury and hypoparathyroidism. The aim of this study was to evaluate cure rates, pathology, complications, and the efficacy of preoperative localization in patients requiring REOPS. Between 1992 and 2017, 2491 consecutive patients underwent parathyroidectomy for primary hyperparathyroidism. With Institutional Review Board approval, our prospectively collected parathyroidectomy outcomes database was queried for operative findings, outcomes, pathology, and localization methodology. Three hundred forty-six patients had REOPS (111 men/32% and 235 women/68%), with an overall cure rate of 91 per cent and a mean follow-up of 1.9 ± 0.7 years. The average preoperative serum calcium and parathyroid hormone were 11 ± 1 mg/dL and 373 ± 796 pg/mL, respectively. Normalization of intraoperative parathyroid hormone occurred in 248 patients and it was predictive of cure in 98.8 per cent of patients. A single adenoma was resected in 253 patients (75%), and the superior gland location was most common at 57 per cent. Ectopic glands were identified in only 33 patients. When preoperative imaging localized a lesion, a tumor was identified in that location in 75.4 per cent of sestamibi or SPECT/CT scans, 57.8 per cent of CT, 61.2 per cent of MRI, and 46.2 per cent of US. When at least two imaging modalities were concordant, sensitivity improved to 91.6 per cent ( P < 0.001). Complication rates of permanent hypoparathyroidism and recurrent nerve palsy occurred in 0.03 per cent of patients. REOP for recurrent or persistent primary hyperparathyroidism has a cure rate of 91 per cent. Most missed parathyroid tumors are in the neck, and multimodal imaging improves preoperative localization and success.

Objective: Despite the improvements in ultrasound (US) and scintigraphy, 10-20% of patients with primary hyperparathyroidism (PHPT) still have discordant findings. We performed a systematic review and meta-analysis to assess the safety and the diagnostic performance of US-guided PTH washout (FNA-PTH) in patients with PHPT, a suspected parathyroid lesion on US but negative or equivocal scintigraphy., Methods: The review was registered on PROSPERO (CRD42019124249). PubMed, Scopus, CENTRAL and Web of Science were searched until February 2019. Original articles reporting complications and diagnostic performance of FNA-PTH in biochemically and histopathologically diagnosed PHPT were selected. The risk of bias of included studies was assessed through QUADAS-2. Summary operating points were estimated using a random-effects model., Results: Out of 2573 retrieved papers, nine cohort studies were included in the review. No major procedure-related complications were found. Pooled sensitivity was 95% (95% CI: 91-98; I 2: = 14%) and positive predictive value was 97% (95% CI: 93-100; I 2: = 39%). There were not enough data for specificity and negative predictive value to perform a meta-analysis. However, pooling results of all lesions, they were estimated to be 83 and 73%, respectively., Conclusions: In patients with biochemically proven PHPT and discordant imaging, FNA-PTH was a safe and accurate procedure. In this specific setting of patients, FNA-PTH could be used as a rule-in test for minimally invasive parathyroidectomy.