Hyperfunction of the remaining parathyroid glands was thought and total parathyroidectomy was suggested. However, an attempt to perform total parathyroidectomy failed and the patient’s hypercalcemia persisted.
C. Discuss the pros and cons of different surgical techniques used for parathyroidectomy.
D.Appraise the role of calcitonin and alendronate in this patient.
26 Comments
Amna Kununa
C. Discuss the pros and cons of different surgical techniques used for parathyroidectomy. *Standard bilateral neck exploration Indications:
Preoperative imaging studies fail to localise a single adenoma or detect bilateral foci.
Familial PHPT (predictably have involvement of multiple glands).
Pregnant and the available localization studies require radiation
Lithium-associated PHPT has a high chance of having multigland involvement
*Focused parathyroid exploration
clinically and by imaging to have a single parathyroid adenoma.
Not recommended for patients with known or suspected multigland disease
No suggestion of concomitant thyroid disease requiring surgical intervention
No family history of MEN syndromes.
Few randomised trials comparing focused parathyroidectomy with the traditional bilateral approach, cure rates appear to be similar, as well as the rate of recurrence, persistence and reoperation rates. But a shorter mean operative time and lower overall complication rates according to a 2017 systematic review and meta-analysis. A lower transient hypocalcemia rate primarily drove the lower complication rate.
Patients who underwent focused exploration had a lower incidence of symptomatic hypocalcemia but a higher incidence of vocal cord paresis.
D.Appraise the role of calcitonin and alendronate in this patient.
As per Fourth International Workshop on Asymptomatic Primary Hyperparathyroidism guidelines:
For patients whose primary indication for surgery is symptomatic and/or severe hypercalcemia, we typically use cinacalcetrather than bisphosphonates, particularly for those in whom bone density is not in the osteoporotic range.
For individuals who cannot have surgery and whose primary indication for surgery is osteoporosis and risk for fracture, we suggest bisphosphonates. Among the bisphosphonates, alendronate has been most extensively evaluated in patients with PHPT.
C. Discuss the pros and cons of different surgical techniques Was used for parathyroidectomy.I did not get the stem, was the surgery done or not?!
Types of surgery:
Total parathyroidectomy, decrease PTH level, reduce PTH effect on BMD, high risk of hungry bone syndrome, and risk of permanent hypocalcemia later on.
Subtotal parathyroidectomy, decrease Ca level temporary, relapse rate is high.
D.Appraise the role of calcitonin and alendronate in this patientBoth medications are not indicated since the patient has moderate, not severe, hypercalcemia. But let’s say the patient is having severe hypercalcemia, and I need to manage hypercalcemia.
Calcitonin is a good option for a short time to control hypercalcemia. It has a fast onset of action with a short half-life that is usually used during the first 48 hrs till bisphosphonate action starts to kick in.
Alendronate- could be used as an anti-hypercalcemic drug due to its antiresorptive effect. I would make sure that the patient does not have adynamic bone disorder before starting alendroate. If the patient has osteitis fibrosa, or osteomalasia type of CKD- MBD, I would use alendronate in half dose 35 mg weekly. The could help in improving BMD and decrease Ca level too.
C. Discuss the pros and cons of different surgical techniques used for parathyroidectomy. Total parathyroidectomy is removal of all 4 glands of the parathyroid the advantage is there will not be any recurrence but have disadvantages like hungry bone disease or bleeding.
SubTotal parathyroidectomy, implantation of part of gland in the forearm- advantages are less hypocalcemia and less bleeding, the disadvantage is recurrence rate is high.
D.Appraise the role of calcitonin and alendronate in this patient. Calcitonin reduces serum calcium levels by inhibiting osteoclast activity which resolves the bone there for it reduces the calcium in short term Aldoronate also reduces calcium by inhibiting the activity of osteoclast so it decreases bone resorption, it has a longer half life and is commonly used in osteoporosis not advised to use in our dialysis patients.
the pros and cons of different surgical techniques used for parathyroidectomy.total and subtotal parathyroidectomy the techniques are minimal invassive parathyroidectomy, video assisted , Appraise the role of calcitonin and alendronate in this patient.calcitonin inhibits resorption by inhibiting osteoclasts activity alendronate increase greater BMD than calcitonin
Subtotal parathyroidectomy: Minimally invasive parathyroidectomy has increased in popularity. This technique has limited dissection and has improved recovery time. Intraoperative monitoring of PTH level is done to ensure the removal of the abnormal gland. Fall of PTH level by 50% and into the normal range is expected within 10 to 15 min after removal of the abnormal gland.
Bisphosphonates( alendronate):inhibit osteoclast and decrease bone resorption so can decrease calcium level but low doses are recommended in dialysis patients.
Calcitonin appears to lower serum calcium by inhibiting osteoclastic activity. Calcitonin can lower serum calcium levels by 1 to 2 mg/dL within a few hours. Its usefulness in the treatment of cancer-associated hypercalcemia is limited by its short duration of action with the development of tachyphylaxis (often after about 48 hours) and by the lack of response in ≥ 40% of patients.
Localization and defining hypertrophic glands is usually used, but many surgeons do exploration of the glands. In our case, All glands may be hyper-functional. The failed attempt. Control of PTH intraoperatively is usually performed. A decrease %50 of PTH within 15 minutes can be seen. Radically removing all the glands is expected to cause the hungry bone syndrome.
The antiresorptive effect of biphosphonates may decrease hypercalcemia and improve trabecular bones (vertebrae). The effect of alendronate is mediated through a decrease in bone turnover.The calcitonin effect is temporary and used for acute lowering not as maşntainance therapy
C. Discuss the pros and cons of different surgical techniques used for parathyroidectomy.The most important factors that increase the success rate of a parathyroidectomy are the establishment of the correct diagnosis and the surgeon’s good knowledge of anatomy A subtotal parathyroidectomy is a parathyroid surgery .Most people have four parathyroid glands, so in a standard subtotal parathyroidectomy three and a half glands are removed. The remaining portion of a parathyroid gland is called a remnant, and it remains on its original blood supply, in its original location. The goal of the surgery is to leave a remnant that is roughly the size of a normal parathyroid gland. The reason that surgeons in the past preferred a total parathyroidectomy to a subtotal parathyroidectomy is that they were afraid to do a re-operation in the neck. It is possible for parathyroid disease to re-occur after a successful surgery for hyperplasia. If there is a remnant in the neck, A total parathyroidectomy with autotransplantation has its own risks, that are different from a subtotal parathyroidectomy. After a total parathyroidectomy all patients will experience hypoparathyroidism, a condition where the PTH and Calcium levels are very low. D.Appraise the role of calcitonin and alendronate in this patient.The administration of calcitonin plus saline hydration should result in substantial reduction in serum calcium concentrations within 12 to 48 hours. The bisphosphonate will be effective by the second to fourth day and provide a more sustained effect, thereby maintaining control of the hypercalcemia. Calcitonin decreases serum calcium levels by inhibiting bone resorption and, to a lesser degree, by enhancing urinary calcium excretion. But may cause tachyphylaxis Alendronate controls osteoporosis by inhibit the activity osteoclast so decrease bone resorption. Not advised in dialysis patients
C. Discuss the pros and cons of different surgical techniques used for parathyroidectomy.1. Total 2. Subtotal or 3. Total with re-implantation of part of the gland into either the forearm or sternocleidomastoid muscle Hungry bone syndrome: Common post operative complication . D.Appraise the role of calcitonin and alendronate in this patient.calcitonin: Calcitonin prevents bone-breaking osteoclasts. Osteoclasts release bone calcium into your circulation. Calcitonin temporarily blocks osteoclasts, reducing blood calcium. Calcitonin decreases renal calcium reabsorption and release, lowering blood calcium levels. -short-acting with rebound hypercalcemia. alendronate: inhibits osteoclast-mediated bone resorption. With evidence of CKD-MBD—Antiresorptive osteoporosis medicines should not be given to individuals with eGFR between 15 and 30 mL/min/1.73 m2 (G4) or <15 (G5 or G5D). May need bone biopsy to confirm diagnosis before starting treatment .
C- total parathyroidectomy….avoid recurrence but may be complicated by hungry bone syndrome and vice versa in subtotal procedure
D- bisphosphonates became the first line ttt for hypercalcemia with good hydration instead of loop diuretics and calcitonin used in malignancy induced hypercalcemia mainly
c)-subtotal parathyroidectomy less rate of hypocalcemia but high rate of recurrence.
-total with implantation of part of gland in the forearm low rate of recurrence but high rate of hypocalcemia if the autograft did not work cones of the operation :recurrent laryngeal nerve injury, hungry bone disease
D)calcitonin: Inhibits osteoclastic bone resorption, decreases serum calcium, and increases renal excretion of phosphate, calcium, sodium magnesium and potassium by decreasing tubular reabsorption alendronate :Inhibits osteoclastic activity advised not to used in dialysis patient.
C. Pros : total or subtotal parathyroidectomy, implantation of part of gland in the forearm
Cons : recurrent laryngeal nerve injury
Bleeding, hungery bone disease
D. Calcitonin decrease Calcium level through inhibition of osteoclast activity in the bone so prevent resorption , inhibit reabsorption of calcium by the kidney
Alendronate :used in osteoporosis by inhibit the activity osteoclast so decrease bone resorption
C.Discuss the pros and cons of different surgical techniques used for parathyroidectomy. 1. Total 2. Subtotal or 3. Total with re-implantation of part of the gland into either the forearm or sternocleidomastoid muscle Hungry bone syndrome: Common post operative complication
Cacitoinin: Inhibit osteoclast bone resorption with hours, Modest effect, Tachyphylaxis Alendronate: Induced osteoclast apoptosis i.e kill the bone, Prolonged half-life, Useful in hypercalcemia of malignancy, Not advised in dialysis patients
C.Discuss the pros and cons of different surgical techniques used for parathyroidectomy
Total parathyroidectomy
Subtotal parathyroidectomy
Total with reimplantation of gland tissue in forearm or sternocleidomastoid muscle.
There is risk of bleeding, infection and sequele of hunger bone syndrome.
Appraise the role of calcitonin and alendronate in this patient. calcitonin:
Inhibit osteoclasts
Decrease renal calcium reabsorption.
Used to decrease serum calcium but temporary action.
alendronate:
inhibits osteoclast-mediated bone resorption.
should not used in dialysis patients
Need bone biopsy before giving
PATIENT NEEDS FOR SUBTOTAL PARATHYROIEDECTOMY IF THEY WILL GO FOR TOTAL PARATHYROIEDECTOMY NEED TO IMBLANT NORMAL PARATHYROIEDGLAND TO FOREARM , ALENDRONATE CAN NOT BE USED FOR THOSE TYPE OF PATIENT , CALCITONIN CAN BE OF HELP
C- surgical technique for parathyroidectomy
Total , subtotal parathyroidectomy or total parathyroidectomy with reimplantation in normal gland in sternocleidomastoid or forarm.
D- the role of calcitonin can be used in these case dueto considerd emergency state as lower serum calcium by inhibiting osteoclastic activity. A dosage of 4 to 8 IU/kg subcutaneously every 12 hours .
Alendronate: is one of bisphoshonate can
inhibit osteoclastic bone resorption and are effective in the treatment of hypercalcemia but cannot used in these case dueto pt on hemodialysis
techniques of parathyroid surgery include:
1-Targeted parathyroidectomy: best option for post kidney transplantation hyperparathyroidism, assosciated with high rate of recurrence
2-Sub- or near-total parathyroidectomy: is associated with a low rate of postoperative permanent hypocalcemia but a risk of potentially having to reoperate in the neck when recurrent HPT develops
3-Total parathyroidectomy with autotransplantation: assosciated with a lower rate of recurrence of hyperparathyroidism,The disadvantage of a total parathyroidectomy with autotransplantation is the potential for profound hypoparathyroidism and hypocalcemia if the autograft fails.
4-Total parathyroidectomy without autotransplantation: assoscited with risk of hypoparathyroidism
calcitonin: 32 AA peptide, bind to osteoclast and inhibit bone reorption. it can be used for short duration, long term use is assosciated with cancer risk
aledronate is oral bisphosphonate that can improve bone density and decrease fracture risk. but its use should be avoided in patients with eGFR below 30
C. Minimal invasive vs Open parathyreoidectomy
Risk of incomplete removal in minimal invasive especially with large glands.
in Open parathyreoidectomy there is more risk of infection, bleeding.
Complication are : Hungry bone syndrom with rapid uptake of calcium and phosphat by bones what cause a severe hypocalcemia. This can last for weeks as bones re mineralise and should be treated with high dose active vitamin D and calcium.
If the patient underwent forarm autotransplantation we can expect recurrence of the secondary hyperparathyreoidismus or in failure because of fibrotic transformaiton of tissures.
D. Calcitonin can cause rapid lowering of calcium level. it is produced by thyroid cells (C Type). Calcitonin act on osteoclasts and inhibit it what cause decreased quantity of realsed calcium from bone to blood . it also promote uptake of calcium from blood to bone . So Calcitonin will cause lowering of calcium level.
Alendronate: inhibt also osteoclast . it belongs to biphosphanate group, it increase bone density and decrease fracture. it is used mostly to treat osteoporosis. Risk of lower jaw necrosis in Dialysis patient is high and not adviced to used in advanced renal insufficieny.
Parathyroidectomy one of options for treatment 2nry and tertiary hyperparathyroidism 1. Total 2. Subtotal or 3. Total with re-implantation of part of the gland into either the forearm or sternocleidomastoid muscle Hungry bone syndrome: ## Common post operative complication ## rapidly uptake of ca and phosphate for mineralization And subsequently by hypocalcemia and hypophosphatemia #High doses of calcium and calcitriol are required
Calcitonine inhibits the activity of osteoclast antagonises the effect of parathyroid hormone calcitonin decreases renal calcium reabsorption and release, lowering blood calcium levels increase renal excretion of calcium, phosphate, sodium, magnesium, and potassium
Alendronate *Used in hypercalcemia stat – SHPTH *Inhibite osteoclastic activity prlonged halfe life *Not advised in dialysis pt.
c- The 2 primary surgical options for the treatment of HPT are 1- bilateral neck exploration (BNE) 2-minimally invasive parathyroidectomy (MIP)
.D.Appraise the role of calcitonin and alendronate in this patient.Calcitonin (thyrocalcitonin) is a rapidly acting peptide hormone normally secreted in response to hypercalcemia by the C cells of the thyroid. Calcitonin appears to lower serum calcium by inhibiting osteoclastic activity. A dosage of 4 to 8 IU/kg subcutaneously every 12 hours of salmon calcitonin is safe. Calcitonin can lower serum calcium levels by 1 to 2 mg/dL within a few hours. limited by its short duration of action with the development of tachyphylaxis (often after about 48 hours)
alendronate: inhibit osteoclastic bone resorption and are effective in the treatment of hypercalcemia due to conditions causing increased bone resorption
C.Discuss the pros and cons of different surgical techniques used for parathyroidectomy
parathyrodiectomy may be either:
Subtotal or total with re-implantation of part of the gland into either the forearm
subtotal may be associated with recurrence of secondary hyperparathyroidism and the problem with re-implantation is that, frequently the re-implanted tissue becomes fibrotic or doesn’t function or rarely develop parathroidomatosis
-Hungry bone syndrome:
Relatively common complication of parathyrodectomy
Occur in patient with long standing,severe hyperparathyroidism
After drop in PTH, the bone rapidly take up Ca & PO4 as they re-mineralize resulting in hypocalcemia and hypophosphatemia
May last for weeks or more
High doses of calcium and calcitriol are required to prevent symptomatic hypocalcemia
D. Appraise the role of calcitonin and alendronate in this patient.
Cacitoinin
Inhibit osteoclast bone resorption within hours but may cause tachyphylaxis Alendronate
Induced osteoclast apoptosis i.e kill the bone
Prolonged half-life
Useful in hypercalcemia of malignancy
Not advised in dialysis patients
Discuss the pros and cons of different surgical techniques used for parathyroidectomy.
Techniques of parathyroid surgery includes:
Targeted parathyroidectomy
Sub-or near-total parathyroidectomy
Total parathyroidectomy with autotransplantation
Total parathyroidectomy without autotransplantation
The choice is dependent upon on whether it is primary surgery or re-operative, whether the the patient has an existing or planned renal transplant and whether the patient has a compelling reason to avoid reoperative neck surgery
The initial parathyroid surgery, in most end-stage kidney disease patients has multi-gland hyperplasia, for which a subtotal, near-total or total parathyroidectomy typically performed at the initial surgery
Patients with existing or planned renal transplant, it is suggested to perform either a sub- or near total parathyroidectomy, or a total parathyroidectomy with autotransplantation, rather than a total parathyroidectomy without autotransplantation (associated with hypercalcaemia)
Patients without contra-indications to reoperative neck surgery, a sub-or near-total parathyroidectomy rather than a total parathyroidectomy with autotransplantation is suggested. He suggested techniques had a lower risk of post-operative permanent hypercalcaemia because the claimant is attached to his original blood supply. Capt of next recurrence potentially greater in patients undergoing these procedures rather than total parathyroidectomy
Patients with compelling reason to avoid reoperative neck surgery, total parathyroidectomy with autotransplantation, rather than sub-or near-total parathyroidectomy is advised (more associated with hypercalcaemia)
Patients excluded from renal transplant, it is suggested that a total parathyroidectomy without autotransplantation should be done. Patients were excluded from renal transplantation requires continue dialysis, which exposed them to a high risk of developing recurrent hyperparathyroidism
Appraise the role of calcitonin and alendronate in this patient.Calcitonin:
This drug antagonises the effect of parathyroid hormone
it directly inhibits osteoclastic bone resorption
It promotes the renal excretion of calcium, phosphate, sodium, magnesium, and potassium
It is indicated for the use of severe hypercalcaemia, and should be used in combination with other therapies that also addresses the hypercalcaemia
This drug is known to predispose or cause osteosarcomatous especially in patients with severe hyperparathyroidism, and is currently not available in South Africa
Alendronate:
This drug can be used for the treatment of hypercalcaemia, but are contraindicated in patients with glomerular filtration rate of less than 35 millitres per minute
Inhibits bone resorption via actions on osteoclasts or on osteoclast precursors; decreases the rate of bone resorption, leading to an indirect increase in bone mineral density
Discuss the pros and cons of different surgical techniques used for parathyroidectomy.
Techniques of parathyroid surgery include:
Targeted parathyroidectomy
Sub- or near-total parathyroidectomy
Total parathyroidectomy with autotransplantation
Total parathyroidectomy without autotransplantation
Since the residual is linked to its blood supply, sub- or near-total parathyroidectomy reduces the likelihood of persistent hypocalcemia. Anatomic parathyroid remnants are more resistant to ischemia and failure than neovascularized autografts.
the risk of neck recurrence is potentially greater in patients undergoing sub- or near-total rather than total parathyroidectomy (with autotransplantation), which may necessitate reoperations in the cervical area
Most end-stage kidney disease (ESKD) patients have multi-gland hyperplasia, for which a subtotal, near-total, or total parathyroidectomy is typically performed as the initial surgery.
For patients with an existing or planned renal transplant, we suggest performing either a sub- or near-total parathyroidectomy, or a total parathyroidectomy with autotransplantation, rather than a total parathyroidectomy without autotransplantation.
For most patients who have no contraindications to re-operative neck surgery, we typically perform a sub- or near-total parathyroidectomy rather than a total parathyroidectomy with autotransplantation.
.Appraise the role of calcitonin and alendronate in this patient.
calcitonin:
Calcitonin prevents bone-breaking osteoclasts. Osteoclasts release bone calcium into your circulation.
Calcitonin temporarily blocks osteoclasts, reducing blood calcium.
Calcitonin decreases renal calcium reabsorption and release, lowering blood calcium levels.
-short-acting with rebound hypercalcemia. alendronate: inhibits osteoclast-mediated bone resorption.
With evidence of CKD-MBD—Antiresorptive osteoporosis medicines should not be given to individuals with eGFR between 15 and 30 mL/min/1.73 m2 (G4) or <15 (G5 or G5D).
May need bone biopsy to confirm diagnosis before starting treatment
C.Discuss the pros and cons of different surgical techniques used for parathyroidectomy.-Approach to parathyrodiectomy may be either:
Subtotal or
Total with re-implantation of part of the gland into either the forearm or sternocleidomastoid muscle
Which one is better is controversial !
However, subtotal may be associated with recurrence of secondary hyperparathyroidism and the problem with re-implantation is that, frequently the re-implanted tissue becomes fibrotic or doesn’t function or rarely develop parathroidomatosis i.e. the microscopic cells produce high levels of PTH.
In general parathroidectomy when indicated in a right time may be associated with improved survival in dialysis patients
-Hungry bone syndrome:
Relatively common complication of parathyrodectomy
Occur in patient with long standing,severe hyperparathyroidism
After drop in PTH, the bone rapidly take up Ca & PO4 as they re-mineralize resulting in hypocalcemia and hypophosphatemia
May last for weeks or months
High doses of calcium and calcitriol are required to prevent symptomatic hypocalcemia
-Despite survival advantage ,parathyroidectomy may be associated with increased morbidity.
D.Appraise the role of calcitonin and alendronate in this patient.1.Cacitoinin
Discuss the pros and cons of different surgical techniques used for parathyroidectomy.? unilateral parathyroidectomy
smaller incision .
regional anesthesia.
less hypocalcemia .
consider as day surgery operation .
risk of laryngeal nerve injury is low.
total parathyroidectomy. cons
recurrent and superior laryngeal nerve injury .
hypocalcemia post operation .
keloid formation .
hematoma.
recurrent hypercalcemia.
Appraise the role of calcitonin and alendronate in this patient.?
calcitonine has a rapid Ca lowering efffect within 2-3 hours,initial management in hypercalcemia.act on osteoclast and inhibit renal reabsoption .
alendronate has potent effect on osteoclast as inhibit the bone resorption .
if patient complain from vomiting ,nausea can give it IV.
C. Discuss the pros and cons of different surgical techniques used for parathyroidectomy.
*Standard bilateral neck exploration
Indications:
*Focused parathyroid exploration
Few randomised trials comparing focused parathyroidectomy with the traditional bilateral approach, cure rates appear to be similar, as well as the rate of recurrence, persistence and reoperation rates. But a shorter mean operative time and lower overall complication rates according to a 2017 systematic review and meta-analysis. A lower transient hypocalcemia rate primarily drove the lower complication rate.
Patients who underwent focused exploration had a lower incidence of symptomatic hypocalcemia but a higher incidence of vocal cord paresis.
D. Appraise the role of calcitonin and alendronate in this patient.
As per Fourth International Workshop on Asymptomatic Primary Hyperparathyroidism guidelines:
C. Discuss the pros and cons of different surgical techniques Was used for parathyroidectomy.I did not get the stem, was the surgery done or not?!
Types of surgery:
Total parathyroidectomy, decrease PTH level, reduce PTH effect on BMD, high risk of hungry bone syndrome, and risk of permanent hypocalcemia later on.
Subtotal parathyroidectomy, decrease Ca level temporary, relapse rate is high.
D. Appraise the role of calcitonin and alendronate in this patientBoth medications are not indicated since the patient has moderate, not severe, hypercalcemia. But let’s say the patient is having severe hypercalcemia, and I need to manage hypercalcemia.
Calcitonin is a good option for a short time to control hypercalcemia. It has a fast onset of action with a short half-life that is usually used during the first 48 hrs till bisphosphonate action starts to kick in.
Alendronate- could be used as an anti-hypercalcemic drug due to its antiresorptive effect. I would make sure that the patient does not have adynamic bone disorder before starting alendroate. If the patient has osteitis fibrosa, or osteomalasia type of CKD- MBD, I would use alendronate in half dose 35 mg weekly. The could help in improving BMD and decrease Ca level too.
-total parathyroidctomy. Open surgery
subtotal minimal invasive surgery
C. Discuss the pros and cons of different surgical techniques used for parathyroidectomy.
Total parathyroidectomy is removal of all 4 glands of the parathyroid the advantage is there will not be any recurrence but have disadvantages like hungry bone disease or bleeding.
SubTotal parathyroidectomy, implantation of part of gland in the forearm- advantages are less hypocalcemia and less bleeding, the disadvantage is recurrence rate is high.
D. Appraise the role of calcitonin and alendronate in this patient.
Calcitonin reduces serum calcium levels by inhibiting osteoclast activity which resolves the bone there for it reduces the calcium in short term
Aldoronate also reduces calcium by inhibiting the activity of osteoclast so it decreases bone resorption, it has a longer half life and is commonly used in osteoporosis not advised to use in our dialysis patients.
the pros and cons of different surgical techniques used for parathyroidectomy.total and subtotal parathyroidectomy the techniques are minimal invassive parathyroidectomy, video assisted ,
Appraise the role of calcitonin and alendronate in this patient.calcitonin inhibits resorption by inhibiting osteoclasts activity
alendronate increase greater BMD than calcitonin
Subtotal parathyroidectomy: Minimally invasive parathyroidectomy has increased in popularity. This technique has limited dissection and has improved recovery time. Intraoperative monitoring of PTH level is done to ensure the removal of the abnormal gland. Fall of PTH level by 50% and into the normal range is expected within 10 to 15 min after removal of the abnormal gland.
Total parathyroidectomy: All parathyroid glands are identified and compared. Potential complications include transient and permanent hypocalcemia secondary to hypoparathyroidism and recurrent laryngeal nerve injury.
Bisphosphonates( alendronate):inhibit osteoclast and decrease bone resorption so can decrease calcium level but low doses are recommended in dialysis patients.
Calcitonin appears to lower serum calcium by inhibiting osteoclastic activity. Calcitonin can lower serum calcium levels by 1 to 2 mg/dL within a few hours. Its usefulness in the treatment of cancer-associated hypercalcemia is limited by its short duration of action with the development of tachyphylaxis (often after about 48 hours) and by the lack of response in ≥ 40% of patients.
Surgical technique
a) Request general anesthesia
b) Can remove all 4 glands.
a) less tax on the patient.
b) reduce recovery time.
c) less surgical complication.
d) not available in all clinics
a) Minimum invasion.
b) fewer surgical wounds.
a) Less invasive.
b) Minmum visible scaring.
c) Less recovery time.
d) Less pain
Calcitonin
Alendronate
Localization and defining hypertrophic glands is usually used, but many surgeons do exploration of the glands. In our case, All glands may be hyper-functional. The failed attempt. Control of PTH intraoperatively is usually performed. A decrease %50 of PTH within 15 minutes can be seen. Radically removing all the glands is expected to cause the hungry bone syndrome.
The antiresorptive effect of biphosphonates may decrease hypercalcemia and improve trabecular bones (vertebrae). The effect of alendronate is mediated through a decrease in bone turnover.The calcitonin effect is temporary and used for acute lowering not as maşntainance therapy
C. Discuss the pros and cons of different surgical techniques used for parathyroidectomy.The most important factors that increase the success rate of a parathyroidectomy are the establishment of the correct diagnosis and the surgeon’s good knowledge of anatomy
A subtotal parathyroidectomy is a parathyroid surgery .Most people have four parathyroid glands, so in a standard subtotal parathyroidectomy three and a half glands are removed. The remaining portion of a parathyroid gland is called a remnant, and it remains on its original blood supply, in its original location. The goal of the surgery is to leave a remnant that is roughly the size of a normal parathyroid gland.
The reason that surgeons in the past preferred a total parathyroidectomy to a subtotal parathyroidectomy is that they were afraid to do a re-operation in the neck. It is possible for parathyroid disease to re-occur after a successful surgery for hyperplasia. If there is a remnant in the neck,
A total parathyroidectomy with autotransplantation has its own risks, that are different from a subtotal parathyroidectomy. After a total parathyroidectomy all patients will experience hypoparathyroidism, a condition where the PTH and Calcium levels are very low.
D. Appraise the role of calcitonin and alendronate in this patient.The administration of calcitonin plus saline hydration should result in substantial reduction in serum calcium concentrations within 12 to 48 hours. The bisphosphonate will be effective by the second to fourth day and provide a more sustained effect, thereby maintaining control of the hypercalcemia.
Calcitonin decreases serum calcium levels by inhibiting bone resorption and, to a lesser degree, by enhancing urinary calcium excretion. But may cause tachyphylaxis
Alendronate controls osteoporosis by inhibit the activity osteoclast so decrease bone resorption. Not advised in dialysis patients
C. Discuss the pros and cons of different surgical techniques used for parathyroidectomy. 1. Total
2. Subtotal or
3. Total with re-implantation of part of the gland into either the forearm or sternocleidomastoid muscle
Hungry bone syndrome:
Common post operative complication .
D. Appraise the role of calcitonin and alendronate in this patient. calcitonin:
Calcitonin prevents bone-breaking osteoclasts. Osteoclasts release bone calcium into your circulation.
Calcitonin temporarily blocks osteoclasts, reducing blood calcium.
Calcitonin decreases renal calcium reabsorption and release, lowering blood calcium levels.
-short-acting with rebound hypercalcemia.
alendronate:
inhibits osteoclast-mediated bone resorption.
With evidence of CKD-MBD—Antiresorptive osteoporosis medicines should not be given to individuals with eGFR between 15 and 30 mL/min/1.73 m2 (G4) or <15 (G5 or G5D).
May need bone biopsy to confirm diagnosis before starting treatment .
C- total parathyroidectomy….avoid recurrence but may be complicated by hungry bone syndrome and vice versa in subtotal procedure
D- bisphosphonates became the first line ttt for hypercalcemia with good hydration instead of loop diuretics and calcitonin used in malignancy induced hypercalcemia mainly
c)-subtotal parathyroidectomy less rate of hypocalcemia but high rate of recurrence.
-total with implantation of part of gland in the forearm low rate of recurrence but high rate of hypocalcemia if the autograft did not work
cones of the operation :recurrent laryngeal nerve injury, hungry bone disease
D)calcitonin: Inhibits osteoclastic bone resorption, decreases serum calcium, and increases renal excretion of phosphate, calcium, sodium magnesium and potassium by decreasing tubular reabsorption
alendronate :Inhibits osteoclastic activity advised not to used in dialysis patient.
C. Pros : total or subtotal parathyroidectomy, implantation of part of gland in the forearm
Cons : recurrent laryngeal nerve injury
Bleeding, hungery bone disease
D. Calcitonin decrease Calcium level through inhibition of osteoclast activity in the bone so prevent resorption , inhibit reabsorption of calcium by the kidney
Alendronate :used in osteoporosis by inhibit the activity osteoclast so decrease bone resorption
C.Discuss the pros and cons of different surgical techniques used for parathyroidectomy.
1. Total
2. Subtotal or
3. Total with re-implantation of part of the gland into either the forearm or sternocleidomastoid muscle
Hungry bone syndrome:
Common post operative complication
Cacitoinin: Inhibit osteoclast bone resorption with hours, Modest effect, Tachyphylaxis
Alendronate: Induced osteoclast apoptosis i.e kill the bone, Prolonged half-life, Useful in hypercalcemia of malignancy, Not advised in dialysis patients
C.Discuss the pros and cons of different surgical techniques used for parathyroidectomy
Total parathyroidectomy
Subtotal parathyroidectomy
Total with reimplantation of gland tissue in forearm or sternocleidomastoid muscle.
There is risk of bleeding, infection and sequele of hunger bone syndrome.
Appraise the role of calcitonin and alendronate in this patient.
calcitonin:
Inhibit osteoclasts
Decrease renal calcium reabsorption.
Used to decrease serum calcium but temporary action.
alendronate:
inhibits osteoclast-mediated bone resorption.
should not used in dialysis patients
Need bone biopsy before giving
PATIENT NEEDS FOR SUBTOTAL PARATHYROIEDECTOMY IF THEY WILL GO FOR TOTAL PARATHYROIEDECTOMY NEED TO IMBLANT NORMAL PARATHYROIEDGLAND TO FOREARM , ALENDRONATE CAN NOT BE USED FOR THOSE TYPE OF PATIENT , CALCITONIN CAN BE OF HELP
C- surgical technique for parathyroidectomy
Total , subtotal parathyroidectomy or total parathyroidectomy with reimplantation in normal gland in sternocleidomastoid or forarm.
D- the role of calcitonin can be used in these case dueto considerd emergency state as lower serum calcium by inhibiting osteoclastic activity. A dosage of 4 to 8 IU/kg subcutaneously every 12 hours .
Alendronate: is one of bisphoshonate can
inhibit osteoclastic bone resorption and are effective in the treatment of hypercalcemia but cannot used in these case dueto pt on hemodialysis
techniques of parathyroid surgery include:
1-Targeted parathyroidectomy: best option for post kidney transplantation hyperparathyroidism, assosciated with high rate of recurrence
2-Sub- or near-total parathyroidectomy: is associated with a low rate of postoperative permanent hypocalcemia but a risk of potentially having to reoperate in the neck when recurrent HPT develops
3-Total parathyroidectomy with autotransplantation: assosciated with a lower rate of recurrence of hyperparathyroidism,The disadvantage of a total parathyroidectomy with autotransplantation is the potential for profound hypoparathyroidism and hypocalcemia if the autograft fails.
4-Total parathyroidectomy without autotransplantation: assoscited with risk of hypoparathyroidism
calcitonin: 32 AA peptide, bind to osteoclast and inhibit bone reorption. it can be used for short duration, long term use is assosciated with cancer risk
aledronate is oral bisphosphonate that can improve bone density and decrease fracture risk. but its use should be avoided in patients with eGFR below 30
C. Minimal invasive vs Open parathyreoidectomy
Risk of incomplete removal in minimal invasive especially with large glands.
in Open parathyreoidectomy there is more risk of infection, bleeding.
Complication are : Hungry bone syndrom with rapid uptake of calcium and phosphat by bones what cause a severe hypocalcemia. This can last for weeks as bones re mineralise and should be treated with high dose active vitamin D and calcium.
If the patient underwent forarm autotransplantation we can expect recurrence of the secondary hyperparathyreoidismus or in failure because of fibrotic transformaiton of tissures.
D. Calcitonin can cause rapid lowering of calcium level. it is produced by thyroid cells (C Type). Calcitonin act on osteoclasts and inhibit it what cause decreased quantity of realsed calcium from bone to blood . it also promote uptake of calcium from blood to bone . So Calcitonin will cause lowering of calcium level.
Alendronate: inhibt also osteoclast . it belongs to biphosphanate group, it increase bone density and decrease fracture. it is used mostly to treat osteoporosis. Risk of lower jaw necrosis in Dialysis patient is high and not adviced to used in advanced renal insufficieny.
Parathyroidectomy one of options for treatment 2nry and tertiary
hyperparathyroidism
1. Total
2. Subtotal or
3. Total with re-implantation of part of the gland into either the forearm or sternocleidomastoid muscle
Hungry bone syndrome:
## Common post operative complication
## rapidly uptake of ca and phosphate for mineralization
And subsequently by hypocalcemia and hypophosphatemia
#High doses of calcium and calcitriol are required
Calcitonine
inhibits the activity of osteoclast antagonises the effect of parathyroid hormone
calcitonin decreases renal calcium reabsorption and release, lowering blood calcium levels
increase renal excretion of calcium, phosphate, sodium, magnesium, and potassium
Alendronate
*Used in hypercalcemia stat – SHPTH
*Inhibite osteoclastic activity prlonged halfe life
*Not advised in dialysis pt.
c-
The 2 primary surgical options for the treatment of HPT are
1- bilateral neck exploration (BNE)
2-minimally invasive parathyroidectomy (MIP)
.D. Appraise the role of calcitonin and alendronate in this patient.Calcitonin
(thyrocalcitonin) is a rapidly acting peptide hormone normally secreted in response to hypercalcemia by the C cells of the thyroid. Calcitonin appears to lower serum calcium by inhibiting osteoclastic activity. A dosage of 4 to 8 IU/kg subcutaneously every 12 hours of salmon calcitonin is safe. Calcitonin can lower serum calcium levels by 1 to 2 mg/dL within a few hours. limited by its short duration of action with the development of tachyphylaxis (often after about 48 hours)
alendronate:
inhibit osteoclastic bone resorption and are effective in the treatment of hypercalcemia due to conditions causing increased bone resorption
C.Discuss the pros and cons of different surgical techniques used for parathyroidectomy
parathyrodiectomy may be either:
Subtotal or total with re-implantation of part of the gland into either the forearm
subtotal may be associated with recurrence of secondary hyperparathyroidism and the problem with re-implantation is that, frequently the re-implanted tissue becomes fibrotic or doesn’t function or rarely develop parathroidomatosis
-Hungry bone syndrome:
Relatively common complication of parathyrodectomy
Occur in patient with long standing,severe hyperparathyroidism
After drop in PTH, the bone rapidly take up Ca & PO4 as they re-mineralize resulting in hypocalcemia and hypophosphatemia
May last for weeks or more
High doses of calcium and calcitriol are required to prevent symptomatic hypocalcemia
D. Appraise the role of calcitonin and alendronate in this patient.
Cacitoinin
Inhibit osteoclast bone resorption within hours but may cause tachyphylaxis
Alendronate
Induced osteoclast apoptosis i.e kill the bone
Prolonged half-life
Useful in hypercalcemia of malignancy
Not advised in dialysis patients
Discuss the pros and cons of different surgical techniques used for parathyroidectomy.
Techniques of parathyroid surgery includes:
The choice is dependent upon on whether it is primary surgery or re-operative, whether the the patient has an existing or planned renal transplant and whether the patient has a compelling reason to avoid reoperative neck surgery
The initial parathyroid surgery, in most end-stage kidney disease patients has multi-gland hyperplasia, for which a subtotal, near-total or total parathyroidectomy typically performed at the initial surgery
Patients with existing or planned renal transplant, it is suggested to perform either a sub- or near total parathyroidectomy, or a total parathyroidectomy with autotransplantation, rather than a total parathyroidectomy without autotransplantation (associated with hypercalcaemia)
Patients without contra-indications to reoperative neck surgery, a sub-or near-total parathyroidectomy rather than a total parathyroidectomy with autotransplantation is suggested. He suggested techniques had a lower risk of post-operative permanent hypercalcaemia because the claimant is attached to his original blood supply. Capt of next recurrence potentially greater in patients undergoing these procedures rather than total parathyroidectomy
Patients with compelling reason to avoid reoperative neck surgery, total parathyroidectomy with autotransplantation, rather than sub-or near-total parathyroidectomy is advised (more associated with hypercalcaemia)
Patients excluded from renal transplant, it is suggested that a total parathyroidectomy without autotransplantation should be done. Patients were excluded from renal transplantation requires continue dialysis, which exposed them to a high risk of developing recurrent hyperparathyroidism
Appraise the role of calcitonin and alendronate in this patient.Calcitonin:
Alendronate:
Discuss the pros and cons of different surgical techniques used for parathyroidectomy.
Techniques of parathyroid surgery include:
Targeted parathyroidectomy
Sub- or near-total parathyroidectomy
Total parathyroidectomy with autotransplantation
Total parathyroidectomy without autotransplantation
Since the residual is linked to its blood supply, sub- or near-total parathyroidectomy reduces the likelihood of persistent hypocalcemia. Anatomic parathyroid remnants are more resistant to ischemia and failure than neovascularized autografts.
. Appraise the role of calcitonin and alendronate in this patient.
calcitonin:
Calcitonin prevents bone-breaking osteoclasts. Osteoclasts release bone calcium into your circulation.
Calcitonin temporarily blocks osteoclasts, reducing blood calcium.
Calcitonin decreases renal calcium reabsorption and release, lowering blood calcium levels.
-short-acting with rebound hypercalcemia.
alendronate:
inhibits osteoclast-mediated bone resorption.
With evidence of CKD-MBD—Antiresorptive osteoporosis medicines should not be given to individuals with eGFR between 15 and 30 mL/min/1.73 m2 (G4) or <15 (G5 or G5D).
May need bone biopsy to confirm diagnosis before starting treatment
C.Discuss the pros and cons of different surgical techniques used for parathyroidectomy.-Approach to parathyrodiectomy may be either:
-Hungry bone syndrome:
-Despite survival advantage ,parathyroidectomy may be associated with increased morbidity.
D. Appraise the role of calcitonin and alendronate in this patient.1.Cacitoinin
2.Alendronate
Discuss the pros and cons of different surgical techniques used for parathyroidectomy.?
unilateral parathyroidectomy
smaller incision .
regional anesthesia.
less hypocalcemia .
consider as day surgery operation .
risk of laryngeal nerve injury is low.
total parathyroidectomy.
cons
recurrent and superior laryngeal nerve injury .
hypocalcemia post operation .
keloid formation .
hematoma.
recurrent hypercalcemia.
Appraise the role of calcitonin and alendronate in this patient.?
calcitonine has a rapid Ca lowering efffect within 2-3 hours,initial management in hypercalcemia.act on osteoclast and inhibit renal reabsoption .
alendronate has potent effect on osteoclast as inhibit the bone resorption .
if patient complain from vomiting ,nausea can give it IV.