STUDY ON EXTRACTION OF THE PARATHYROID GLANDS IN THE TREATMENT OF SECONDARY HYPERPARATHYROIDISM

Total extraction of the parathyroid glands followed by autografting for patients of severe secondary hyperparathyroidism (SHPT) resistant to internal treatment not only improves the quality of life (QOL) of these patients undergoing maintenance dialysis, but also contributes to improvement of the vital prognosis. We performed surgical treatment for SHPT in 220 patients between April 2001 and November 2008; the surgery was conducted as the initial treatment in 205 patients, and as a relief surgery for recurrences after the initial operation in the remaining 16 patients. Fifteen of the 16 patients included patients who had undergone the initial operation in other hospitals. We assessed the results of the operation and the postoperative problems in these 220 patients. The male-to-female ratio of the 205 patients who underwent the surgery as the initial operation was 107: 98. The patients ranged in age from 18 to 82 years (mean, 56.2 years). The preoperative dialysis period ranged from 1 to 33 years (mean, 13.7 years). The preoperative intact-parathyroid hormone (i-PTH) level ranged from 233 to 2616 pg/ml (mean, 836 pg/ml), and the i-PTH level in the immediate postoperative period ranged from 2 to 622 pg/ml (mean, 36.1 pg/ml). Fifty-three of the 205 patients had a history of percutaneous ethanol injection therapy. The mean number of parathyroid glands extracted was 3.95. In the evaluation of the postoperative results in the 205 patients who underwent the surgery as the initial operation from the point of view of the i-PTH level, 177 of the 205 patients (86%) were classified into the total extraction group (serum i-PTH in the immediate postoperative period of 60 pg/ml or under), and 28 of the 205 patients (14%) were classified into the persistent SHPT group (serum i-PTH in the immediate postoperative period of 61 pg/ml or over). The 5-year survival rate after the initial operation was as favorable as 96.7%. On the other hand, the postoperative problems included postoperative persistent SHPT, recurrent glandular hypertrophy in the cervical mediastinum, and recurrent hypertrophy of the autografted gland in the forearm. Re-operation was undertaken in one of the 28 patients with persistent SHPT, while the remaining 27 continued to receive internal treatment. All 7 patients with recurrent glandular hypertrophy in the neck were treated by re-operation of the neck with a retractor, and successful control of the i-PTH level was achieved in all of the patients. Seven of 9 patients who subsequently underwent excision of the autograft because of recurrent hypertrophy of the autografted gland in the forearm maintained a high serum i-PTH level. Several sessions of the operation were needed in seven of 9 patients. Extraction of a residual gland in the neck or the mediastinum was required in 7 patients. These results indicate that definite total extraction of the parathyroid glands at the time of the initial operation and reconsideration of a method of transplantation of the gland are necessary.