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Background Over recent years, various advanced minimally invasive techniques have been developed for parathyroidectomy, and there was a universal acceptance of these less invasive procedures by surgeons. This study is designed to compare overall outcomes between endoscopic versus focused, single gland parathyroidectomy using intraoperative rapid parathyroid hormone (ioPTH) changes under general anesthesia in primary hyperparathyroidism (PHPT) patients. Method In this randomized clinical trial, 96 patients diagnosed with PHPT were randomly assigned into two groups endoscopic and focused parathyroidectomy. Baseline clinical and demographical data were collected along with perioperative features. The success rate was evaluated based on ioPTH changes. Results The ioPTH levels after five minutes in the endoscopic group were significantly lower than the focused group ( P  = 0.005). The success rate for endoscopic and the focused method was 95.3% and 77.1% during the first five minutes ( P  = 0.013) and 100% in both groups after ten minutes. A decrease in parathyroid hormone levels was significant in each group but not between each other. Postoperative calcium levels were significantly lower in the focused method ( P  = 0.042). The focused group also had a significantly shorter operation time than the endoscopic group ( P  < 0.001). Patient satisfaction with cosmetic outcome was significantly higher in the endoscopic group compared to the focused group. Conclusion The endoscopic technique was superior to the unilateral focused neck exploration parathyroidectomy in the management of single-gland PHPT. Influencing aspects included higher postoperative calcium levels, more rapid success achievement, and satisfactory cosmetic outcomes in the endoscopic group. However, patient selection and accurate adenoma localization are vital in this method.

BackgroundSecondary and tertiary renal hyperparathyroidism (RHPT) are common sequelae of chronic kidney disease and are associated with worse patient mortality and quality of life. Clinical guidelines remain lacking with regard to recommendations for using intraoperative parathyroid hormone (IOPTH) during surgery for RHPT. A prospective randomised study will help evaluate the role of IOPTH in guiding surgery for secondary and tertiary RHPT.Methods/designIntraoperative parathyroid hormone monitoring to guide surgery in renal hyperparathyroidism is a pragmatic, multicentre, five-arm, parallel-group, patient-blinded and outcome assessor-blinded prospective pilot trial used to evaluate the feasibility of performing a definitive trial. Eligible participants include adult patients diagnosed with secondary or tertiary hyperparathyroidism who are candidates for subtotal or total parathyroidectomy. Consenting patients will be randomly assigned, through central allocation, in a 1:1:1:1:1 fashion to undergo surgery with IOPTH monitoring (four experimental arms: postexcision IOPTH samples taken at 10, 15, 20 or 25 min) or to undergo surgery without IOPTH monitoring (control arm). The primary feasibility objective is to estimate the percentage of eligible patients that are randomised: ≥70% proceed; 50–69% modify protocol before proceeding; <50% fail to proceed. Secondary feasibility outcomes include the percentage of enrolled participants with complete data at 6 months trial follow-up (ie, ≥90% proceed; 80–89% modify protocol before proceeding; <80% fail to proceed) and the recruitment rate during the trial (ie, ≥5 patients per month to proceed; 2–4 patients per month to modify protocol before proceeding; <2 patients per month to fail to proceed). We estimate that 60 patients will be needed to achieve the primary feasibility outcome. Descriptive analysis will be conducted for feasibility outcomes. The results of our pilot study will inform the feasibility of a definitive trial, and if no major changes to our protocol are indicated, we will treat this study as a vanguard trial and enrol the 60 pilot patients into the definitive trial.Ethics and disseminationEthics approval was obtained from the Hamilton Integrated Research Ethics Board. Pilot trial results will be shared widely through local, national and international academic and clinical networks and will be disseminated through conference presentations and publication in peer-reviewed journals.Trial registration numberNCT06542315, registered on 6 August 2024.

Background Primary hyperparathyroidism (pHPT) is the third most common endocrine system disorder. Parathyroidectomy (PTx) is the gold standard of care in symptomatic patients. Patients who are not surgical candidates may benefit from percutaneous ethanol ablation, which is a minimally invasive procedure. This study aims to evaluate the effectiveness and safety of PTx vs. PEA. Method A single-centered randomized, not-blinded parallel clinical trial in consecutive patients with pHPT treated with percutaneous alcohol ablation (PEA) between January 2020 and November 2021. Patients with a confirmed solitary parathyroid adenoma and a biochemically verified pHPT were randomly enrolled in the PTx or PEA groups. Complications and lab data were evaluated 24 h, 2 weeks, 3 months, and 6 months following interventions. Effectiveness was defined as complete response (normal calcium and PTH), partial response (reduced but not normalized PTH with normal serum calcium), or disease persistence (elevated calcium and PTH). SPSS 22.0 was used for statistical analysis. Result The final sample comprised 68 patients in each group which 113 of whom were female (83.0%). Complete response was observed in 91.1% ( n  = 62) of the PEA group and 98.5% ( n  = 67) of the PTx group. According to repeated-measures analysis, Calcium, PTH, Phosphorus, and Alkaline phosphatase fell significantly and continuously in each intervention group, except for the persistent patients. According to ROC analysis, a cutoff of > 425.5 mm3 for the adenoma volume and > 13.5 mm for its largest diameter showed a sensitivity = 75% and specificity = 69% for partial response in the PEA group (AUC = 0.81 and 0.84, respectively). PTx group experienced statistically significant higher pain according to the Visual Analogue Scale (VAS score) ( p  < 0.001). Conclusion PTH, serum-adjusted Calcium, and adenoma size and volume were all significantly reduced by PTx and PEA, with no significant difference between them. PEA is an effective alternative to PTx, particularly in adenomas with a volume of less than 425.5 mm3 and a maximum diameter of 13.5 mm. Trial registration number IRCT20210204050241N1 (04/26/2021).

This study aimed to compare the postoperative effects of total parathyroidectomy plus forearm transplantation and radioguided parathyroidectomy on bone metabolism and bone mineral density (BMD). From June 2013 to October 2017, 67 patients with renal secondary hyperparathyroidism (SHPT) received surgical treatment. The control group included 30 cases of classical total parathyroidectomy plus forearm transplantation for SHPT. In the experimental group, 37 patients underwent 99mTc-MIBI-guided parathyroidectomy. Demographics, parathyroid hormone (PTH) level, blood calcium level, and pathological results were compared between the 2 groups. The curative effect of parathyroidectomy and its effect on BMD were also compared. The BMDs in the L1-L4 segments and femoral neck in both groups were significantly improved after operation (all P < .05). The T scores of the L1-L4 segments and femoral neck in both groups were significantly improved after operation (all P < .05). The improvement in the T score of the L4 in the experimental group was significantly higher than that in the control group (P < .05). No significant differences in the improvement in the L1-L3 segments and femoral neck were found between the 2 groups. Both traditional total parathyroidectomy plus forearm transplantation and 99mTc-MIBI-guided parathyroidectomy can improve PTH level, blood calcium level, phosphorus level, bone metabolism, and BMD to varying degrees in patients with SHPT. Compared with the traditional surgery, 99mTc-MIBI-guided parathyroidectomy can improve blood calcium and phosphorus metabolisms, reduce PTH level, and improve the T scores of L4 to a greater extent.

Background Parathyroidectomy has been proposed as a method for reducing parathyroid hormone levels. We evaluated the effects of ultrasound-guided bilateral superficial cervical plexus block (BSCPB) on the quality of recovery of uremia patients with secondary hyperparathyroidism (SHPT) following parathyroidectomy. Methods Eighty-two uremia patients who underwent parathyroidectomy and exhibited SHPT were randomly allocated to the BSCPB group or the control group (CON group). The patients received ultrasound-guided BSCPB with 7.5 ml of ropivacaine 0.5% on each side (BSCPB group) or equal amount of 0.9% normal saline (CON group). The primary outcome of the Quality of Recovery-40(QoR-40) score was recorded on the day before surgery and postoperative day 1(POD1). Secondary outcomes including total consumption of remifentanil, time to first required rescue analgesia, number of patients requiring rescue analgesia, and total consumption of tramadol during the first 24 h after surgery were recorded. The occurrence of postoperative nausea or vomiting (PONV) and the visual analogue scale (VAS) scores were assessed and recorded. Results The scores on the pain and emotional state dimensions of the QoR-40 and the total QoR-40 score were higher in the BSCPB group than in the CON group on POD1 ( P  = 0.000). Compared with the CON group, the total consumption of remifentanil was significantly decreased in the BSCPB group ( P  = 0.000). The BSCPB group exhibited longer time to first required rescue analgesia ( P  = 0.018), fewer patients requiring rescue analgesia ( P  = 0.000), and lower postoperative total consumption of tramadol during the first 24 h after surgery (P = 0.000) than the CON group. The incidence of PONV was significantly lower in the BSCPB group than in the CON group ( P  = 0.013). The VAS scores in the BSCPB group were lower than those in the CON group at all time-points after surgery ( P  = 0.000). Conclusion Ultrasound-guided BSCPB with ropivacaine 0.5% can enhance the quality of recovery, postoperative analgesia, and reduce the incidence of PONV in uremia patients with SHPT following parathyroidectomy. Trial registration ChiCTR1900027185 . (Prospective registered). Initial registration date was 04/11/2019.

Background Open cervical parathyroidectomy is the standard of care for the treatment of primary hyperparathyroidism (PHP). However, in patients with a history of keloid or hypertrophic scar formation, the cosmetic result may sometimes be unsatisfactory. Furthermore, in the presence of mediastinal glands, a more morbid approach is sometimes necessary, involving a sternal split or thoracotomy. Robotic parathyroidectomy, either transaxillary or transthoracic, could be an alternative in both settings. Methods Between 2008 and 2013, 14 patients with PHP and a well-localized single adenoma underwent robotic transaxillary cervical (TAC) ( n  = 8) or transthoracic mediastinal (TTM) ( n  = 6) parathyroidectomy at an academic tertiary medical center and their outcomes were analyzed. Results All 14 operations were completed successfully as planned. For TAC and TTM parathyroidectomies, mean operative time was 184 and 168 min, respectively. With the exception of one TTM patient, intraoperative PTH determination indicated a >50 % drop in all patients 10 min after excision and no patients presented with recurrent disease on follow-up. Average length of hospital stay was 1 day after TAC parathyroidectomy and 2.2 days after TTM. On a visual analog pain scale (0–10), average pain scores after TAC were 6/10 on postoperative day 1 and 1/10 on day 14, compared to 7.7/10 and 1.5/10, respectively, after TTM. Complications included development of seroma in 1 patient in the TAC group and pericardial and pleural effusion in 1 patient in the TTM cohort. Conclusions This initial study shows that robotic TAC and TTM parathyroidectomy are feasible in selected PHP patients with preoperatively well-localized disease. Although the TAC approach offers a potential cosmetic benefit in patients with a history of keloid or hypertrophic scar formation, a more generalized use cannot be recommended based on current evidence. The robotic TTM approach presents a minimally invasive alternative to resections previously performed through thoracotomy and sternotomy.

Secondary hyperparathyroidism (SHPT) is common among patients with end-stage renal disease (ESRD). SHPT is associated with high-turnover bone disease, interstitial and vascular calcifications, cardiovascular morbidity and mortality. The pharmacological management of SHPT has progressed in recent years. The introduction of targeted therapies, such as selective vitamin D receptors activators and calcium-sensing receptor modulators, offers an increased opportunity to adequately control elevated parathyroid hormone (PTH), especially in patients with chronic kidney disease under dialysis treatment. Calcimimetic medications such as cinacalcet negatively feedback on the parathyroid glands and do not have the consequences of calcium augmentation. However, there are no randomised, prospective data that demonstrate improved quality of life, improvement in anemia, reduction in phosphate binders, reduction in use of vitamin D analogs, or reduction in mortality. Literature supports cinacalcet therapy to improve patient outcomes, especially with regard to vascular calcifications and presumably the very lethal condition of calciphylaxis. However, cinacalcet is administered orally and has been associated with gastrointestinal intolerance along with hypocalcemia. In addition, poor adherence has been observed among dialysis patients self-administering oral cinacalcet. On the other hand, successful surgical parathyroidectomy (sPTX) can yield a dramatic reduction in PTH level and clinical symptoms. The advanced pharmacological treatments of SHPT often obviate parathyroidectomy; however, some researchers have reported that sPTX may be more cost-effective than cinacalcet in some patients with ESRD and suffering uncontrolled SHPT.

BackgroundFor many years bilateral neck exploration (BNE) was the gold standard operation for primary hyperparathyroidism (pPHP). With advances in preoperative pathological gland localization and intraoperative parathyroid hormone (IPTH) monitoring, minimally invasive approaches have evolved. This study is aimed to compare BNE and focused parathyroidectomy (FP) in a prospective, randomized, blind trial.Patients and methodsBetween 2005 and 2007, 48 patients with pPHP were enrolled in our study. Twenty three patients were randomized to the BNE group and 24 to the FP group. Patients in the FP group underwent preoperative localization studies. All parathyroidectomies were guided by intraoperative intact parathyroid hormone (IIPTH) monitoring. In the BNE group, neither IIPTH nor preoperative localization studies were performed.ResultsAll patients were cured by the primary operation. Overall, the operative time was similar in both groups. In the focused exploration (FE) group, compared to the BNE group, there was lower pain intensity at 4, 8, 16, 24, 36 and 48 h after surgery (p < 0.001), lower consumption of analgesics (p < 0.001), lower analgesia request rate (p < 0.001), shorter scar length (p < 0.001), higher cosmetic satisfaction rate 2 days, 1 month (p < 0.001) and 6 months after surgery (p < 0.05), but after 1 year cosmetic satisfaction rate became not significant (p = 0.38). Focused exploration (FE) was more expensive (p < 0.05). We did not find any difference in quality of life after 1 month and 6 months after surgery in both groups.ConclusionBoth methods of parathyroidectomy for PHP are safe and effective. Focused exploration (FE) has several advantages: lower postoperative pain, lower analgesic request rate, lower analgesic consumption, shorter scar length, better cosmetic satisfaction rate in a short time period.

Background Quick intraoperative parathormone assay (qPTHa) during paratyroidectomy has become a standard procedure for patients with primary hyperparathyroidism (PHPT). This paper aims to compare endoscopic bilateral neck exploration (BE) versus focused parathyroidectomy plus qPTHa during minimally invasive video-assisted parathyroidectomy (QM). The endpoints of the study are the mean operative time and outcome of the surgical procedure (PTH and calcemia normalization at one and six months postoperatively). Methods Forty patients with PHPT, positive to preoperative localization studies (ultrasonography evaluation and 99 Tc-MIBI scan) for a single parathyroid adenoma, were randomly allotted into two groups. In the first group (QM), 20 patients (17 women, three men, mean age 57.6 years) underwent focused endoscopic parathyroidectomy (MIVAP tecnicque) plus qPTHa . In the second group (BE) 20 patients (17 women, three men, mean age 59.6 years) underwent endoscopic parathyroidectomy plus bilateral exploration in order to check the integrity of the remaining glands. Results There were no significant differences between groups at baseline. No conversion to cervicotomy was required. No postoperative complications were reported. The mean operative time was 32.0 vs 33.1 min [BE and QM group respectively, p = not significant ( ns )]. A second macroscopically enlarged gland was removed in four patients in the BE group. Only one out of four glands was reported to be hyperplastic in the final histology. All patients were discharged on the first postoperative day. Calcemia levels were normalized in all patient of both groups, despite persistently high level of serum PTH in one patient in the QM group. Conclusions BE can be performed endoscopically, avoiding both the time necessary for qPTHa and its cost, with the same effectiveness, but might in few cases lead to the unjustified removal of parathyroid glands slightly enlarged but not necessarily pathologic.