Total Parathyroidectomy with Auto-transplantation and thymectomy

in ESRD patients

New Mansoura General Hospital (International) experience

Dr. Osama El-ShahatDr. Osama El-Shahat Consultant Nephrologist

Head of Nephrology Department New Mansoura General Hospital (international(

)Egypt(

IntroductionIntroduction::

Secondary hyperparathyroidism (2HPT) is a common complication in hemodialysis patients.

The majority of patients with 2HPT can be managed by medical treatment with vitamin D sterols and calcimimetics.

In severe cases of 2HPT, medical therapy alone may be ineffective.

Some patients require surgical treatment in the form of parathyroidectomy (PTX)

Coulston JE, e tal. Br J Surg. 2010 Nov;97(11):1674-9.

ProtocolProtocol of parathyroidectomy of parathyroidectomy

for patients with ESRD for patients with ESRD

PatientsPatients SelectionSelection : :

Patients with PTH more than 1500 pg .

Not responding to medical treatment.

Has no history of surgery in the neck

specially parathyroidectomy.

PrePreoperativeoperative : :

Labs. including CBC, LFT, KFT, INR, S. k, S.

Na & S. Po4 and S.Ca.

ENT & anesthesia consultation.

Heparin free HD session the day before the

surgery.

IntraIntraoperativeoperative::

Insertion of CVP .

2 amp. Of ca gluconate diluted in 50cc 0.9% Nacl over 1 hour during the surgery .

PostPostoperativeoperative::

- Check S.ca & phosphorus on return from theatre then every 6 h. till for 2 days then every 12 h. for 3 days then daily .

IV Ca infusion which , changing the dose according to S.Ca level .

Send the removed glands for histopathological examination.

Check PTH 1 week after the operation .

Follow Up Follow Up in Out patient clinicin Out patient clinic::

FrequencyFrequency: Weekly in the 1st month,

every 2 weeks in the 2nd & 3rd months& then monthly.

RequiredRequired lablab.: Monthly PTH in first 3 months then every 3 months Weekly S.Ca & S. phosphorus.

MedicationsMedications: Adjust to results .

ObjectivesObjectives

To present our experience in total parathyroidectomy with auto-transplantation of parathyroid gland and thymectomy.

PatientsPatients& & methodsmethods::Retrospective review of 28cases 28cases underwent total

parathyroidectomy, thymectomy and auto-transplantation performed over one year period. Patients were selected based on symptoms of CKD-MBD with intact PTHPTH level of 15001500 pg/mlpg/ml and above. No preoperative imaging was required due to lack of acceptable sensitivity in multi-gland disease. 4 4 glands excision was performedglands excision was performed. Tiny portions of a relatively healthy gland (equivalent to size of normal gland) were auto-transplantedauto-transplanted into sternomastoid muscle pouches.

Clinical dataClinical data

Age, years (range( 44.5 44.5 (30-60)

RRT at time of surgery HDHD

Duration of dialysis, years(range( 8.78.7 (3 – 19 )

S. PTHS. PTH

S. CaS. Ca

PostPost operativeoperative S. CaS. Ca

S. Po4S. Po4

ResultsResults

28 patients had curative surgery with the mean postoperative PTH 95.9 pg/ml. Two patients had persistent hyperparathyroidism where one or 2 glands were not found in the neck. One patient had recurrence , No surgical complications were reported.

ConclusionConclusion::

Our data demonstrates encouraging results in the treatment of this disabling disease.

Preoperative localization is not essential except in redo cases where the sensitivity of various imaging modalities is much better.

Multidisciplinary TeamMultidisciplinary Team