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Parathyroidectomy in Chronic Kidney Disease; a “Hand on”

Workshop

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Course Faculty

1. Ahmed Halawa MD FRCS

Consultant Transplant Surgeon, Sheffield Teaching Hospital, UK.

2. Osama El Shahat MD

Consultant Nephrologist, Head of Nephrology dept. Mansoura International Hospital,

Mansoura, Egypt

3. Gamal Metwally MD

Consultant General Surgeon, Head of Surgery dept. Mansoura International Hospital,

Mansoura, Egypt.

4. Ashraf Hamed MD

Consultant Surgeon, Mansoura International Hospital, Mansoura, Egypt.

5. Ibrahim Shalaby MD

Consultant Surgeon. Mansoura International Hospital, Mansoura, Egypt.

6. Ahmed Lotfy MD

Lecturer of Endocrine Surgery, University of Mansoura, Mansoura, Egypt.

7. Hussein Sheashaa MD

Professor of Nephrology and Transplantation, Nephrology and Urology Centre,

University of Mansoura, Mansoura, Egypt.

8. Zaghloul Goada MD

Consultant Nephrologist, Damanhour Medical National Institute, General

Organization of Teaching Hospitals and Institutes, Ministry of Health, Egypt.

9. Osama El Belky MD

Consultant Surgeon, Damanhour Medical National Institute, General Organization of

Teaching Hospitals and Institutes, Ministry of Health, Egypt.

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Background

Renal hyperparathyroidism is quite a common disease affecting the vast majority of chronic

kidney disease (CKD) patients. With effective medical treatment, only 5-10% of CKD

patients require surgical treatment. The medical treatment includes a wide variety of

medications to replace the inactive vitamin D, suppress the hyperactive parathyroid glands

and also to counteract the hyperphosphatemia. Based on my previous visits to Egypt and also

supported by publications from this country, the financial difficulties the CKD patients are

suffering from does not allow the delivery of a successful medical treatment mainly due to

the inability to use an effective and more expensive phosphate binder and active vitamin D.

This has led to an increased prevalence of the florid disease compared to developed countries.

The situation was made worse by lack of understanding of the principles of diagnosis and

surgical treatment of renal hyperparathyroidism among many clinicians. Surgeons rely

mainly on imaging in localization of the hyperplastic glands which is well known to be not

sensitive enough in this multigland disease. This often has led to inadequate management of

this disease. Also the multicentric nature of this condition (multigland, rather than a single

gland disease) is often undermined. The published reports from Egypt demonstrated only few

centres dealing with this disease; however the number of patients reported is quite small with

variable outcomes. The final outcome demonstrates more patients require surgery for the

poorly controlled hyperparathyroidism that unmasks the lack of appropriate surgical

experience in many district areas of Egypt.

Aims and objectives of the course

This module has been specifically developed for surgeons in districts areas of Egypt to

increase the awareness of this disabling disease and also to popularize the standard surgical

management of renal hyperparathyroidism. The choice is between total parathyroidectomy

with auto-transplantation of 50 mg of relatively normal parathyroid tissues into sternomastoid

pockets and subtotal parathyroidectomy (removing 3½ glands), both combined with

thymectomy. The choice between these two approaches depends primarily on the availability

of histopathologist trained in frozen section of the parathyroid glands.

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The course also emphasises the value and the implementation of evidenced-based peri-

operative management of this disease including the indication of imaging and the selection of

the imaging modality when indicated.

“Training the trainers” is another objective of the course, where already trained surgeons are

trained to pass the skills, information, attitudes and values to other colleagues.This strategy

creates an educational culture that allows autonomy and continuity of the training process.

Teaching strategy

This course will be taught using an interactive style utilising key examples of where theory

links to practice. The overall teaching strategy will be a blended approach (theoretical and

practical) with a major focus on problem solving, reflective practice and critical thinking

supported by tutorials on key concepts and self-study appropriate for postgraduate students.

The course encourages the trainers to analyse the current practice against the best available

evidence with strong emphasis on professionalism, ethics and clinical governance.

The course will be delivered over 6 days (one full study day and 5 full days surgical training).

The delegates (maximum 5) will be taught the theoretical background of renal

hyperparathyroidism and CKD - mineral bone disease with emphasis on the pre and post-

operative management. Audit presentations and also case scenarios are discussed during this

study day. The lectures will be given by experienced surgeons and nephrologists covering

both the surgical and medical aspects. The delegates are required to attend the whole 6 days

(100% attendance is essential) to achieve the learning objectives.

Each surgeon will have the opportunity to assess in many parathyroidectomy operations and

operate under the supervision “hands on” of experienced consultant surgeons from 3 leading

centres from Sheffield (UK), Mansoura (Egypt) and Damanhour (Egypt). Trainees will be

involved in post-operative care of these patients during the course.

Venue and Date

Mansoura International Hospital (Mansoura, Egypt) is hosting the course with provision of

the necessary facilities for the training staff and the delegates. The course will delivered in

October and April each year; however the exact date will be confirmed well in advance.

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Organizing Bodies

The Egyptian Medical Syndicate (Eldakahleyia branch) in association with Sheffield

Teaching Hospitals, UK.

Sponsoring Bodies and Course Fees

The course is designed to be a non-profit making training event sponsored by the “Egyptian

Medical Syndicate”. 300 US dollars (or equivalent in local currency) to be paid to the

Egyptian Medical Syndicate (Eldekahlyia branch) to cover administration and other

additional expenses. Sheffield Teaching Hospital, UK is supporting the course by providing

the necessary expertise.

Pre-requisite experience before taking this course:

The delegate should provide evidence of satisfactory experience in neck surgery particularly

thyroidectomy evidenced by reference letter from the head of the surgical department. Also a

supporting letter from the head of the nephrology department is required to demonstrate the

need to provide the parathyroidectomy service locally.

Assessment

The delegates will be assessed for their abilities to manage renal hyperparathyroidectomy

both medically and surgically (work-based assessment) by experienced faculty members.

Certificate of satisfactory performance will be awarded by the “Egyptian Medical Syndicate”

to successful candidates.

Mentoring

After successful completion of the core training, the course faculty will provide mentoring

facilities (free of charge) for the delegates in their work place on request. This mentoring

option allows continuing high standard of care and also helps to spread the learning

objectives of the course to many counties of Egypt.

Audit

The candidates are advised to audit their activities annually and present their results in

national nephrology meetings. Centres are invited to present their audits and discuss difficult

cases in the introductory days of the future courses.

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Future Development

The study (introductory) day will be developed to “CKD - Mineral Bone Disease Day” inviting

both parathyroid surgeons and nephrologists expert in the field to present their experience in

medical and surgical management of this disabling disease.

This training event can be held in other centres in Egypt and also in other emerging countries

(after mutual agreement with the ISN) in line with the ISN principles and procedures

including the declaration of Istanbul.

Course Enquiries

Tel:

Dr Osama El Shahat +201021031918, +201115633877

Dr Gamal Metwally +201223447285, +201028842232

Dr Ahmed Halawa +447787542128

Fax: +20502215760

E-mail address for enquiries and booking: parathyroidectomy.course@yahoo.com

Corresponding address:

Parathyroidectomy Course

Attention to: Dr Osama El Shahat

Nephrology Department - Mansoura International Hospital

Madinat El Salam - Mansoura - Egypt

Suggested Readings

1. Companion to Specialist Surgical Practice: Endocrine Surgery. 5th Edition. Edited by

Tom W J Lennard. Elsevier Saunders.

2. British Society of Endocrine and Thyroid Surgeons (BSETS).

http://www.baets.org.uk/

3. British Renal Society (BRS).

http://www.britishrenal.org/

4. The American Association of Endocrine Surgeons.

https://www.endocrinesurgery.org/

5. Endocrine Surgery, an Issue of Surgical Clinics, 1e (The Clinics: Surgery) by Peter J.

Mazzaglia MD FACS (9 Aug 2014).

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References

1. Afifi A. Renal Osteodystrophy in Developing Countries. Artificial Organs. 2002:

26: 767–769. doi: 10.1046/j.1525-1594.2002.07068.x

2. Barsoum RS. Burden of chronic kidney disease: North Africa. Kidney International

Supplements. 2013: 3, 164–166.

3. Goodman WG. The consequences of uncontrolled secondary hyperparathyroidism

and its treatment in chronic kidney disease. Seminars in Dialysis. 2004;17:209-216.

4. Saafan HA, Salam MA, Elshafey IA, Kader AH, Hamza AH. Tertiary

Hyperparathyroidism in Children on Chronic Dialysis: Role of Surgery. Annals of

Pediatric Surgery. 2007; 3 (2) :69-74

5. Sturgeon CM, Sprague SM, Metcalfe W. Variation in parathyroid hormone

immunoassay Results - a critical governance issue in the management of chronic

kidney disease. Nephrol Dial Transplant. 2011;26:3440-3445.