Evaluation and Management of Primary Hyperparathyroidism: Summary Statement and Guidelines from the Fifth International Workshop.

The last international guidelines on the evaluation and management of primary hyperparathyroidism (PHPT) were published in 2014. Research since that time has led to new insights into epidemiology, pathophysiology, diagnosis, measurements, genetics, outcomes, presentations, new imaging modalities, target and other organ systems, pregnancy, evaluation, and management. Advances in all these areas are demonstrated by the reference list in which the majority of listings were published after the last set of guidelines.

Etiology and Pathophysiology of Hypoparathyroidism: A Narrative Review.

The approach utilized a systematic review of the medical literature executed with specifically designed criteria that focused on the etiologies and pathogenesis of hypoparathyroidism. Enhanced attention by endocrine surgeons to new knowledge about parathyroid gland viability are reviewed along with the role of intraoperative parathyroid hormone (ioPTH) monitoring during and after neck surgery. Nonsurgical etiologies account for a significant proportion of cases of hypoparathyroidism (~25%), and among them, genetic etiologies are key.

Surgical Aspects of Primary Hyperparathyroidism.

Parathyroidectomy (PTX) is the treatment of choice for symptomatic primary hyperparathyroidism (PHPT). It is also the treatment of choice in asymptomatic PHPT with evidence for target organ involvement. This review updates surgical aspects of PHPT and proposes the following definitions based on international expert consensus: selective PTX (and reasons for conversion to an extended procedure), bilateral neck exploration for non-localized or multigland disease, subtotal PTX, total PTX with immediate or delayed autotransplantation, and transcervical thymectomy and extended en bloc PTX for parathyroid carcinoma.

Late Recovery of Parathyroid Function after Total Thyroidectomy in Children and Adults: Is There a Difference?

Background: Parathyroid failure after total thyroidectomy is the commonest adverse event amongst both children and adults. The phenomenon of late recovery of parathyroid function, especially in young patients with persistent hypoparathyroidism, is not well understood. This study investigated differences in rates of parathyroid recovery in children and adults and factors influencing this.

Etiology and Diagnosis of Permanent Hypoparathyroidism after Total Thyroidectomy.

Postoperative parathyroid failure is the commonest adverse effect of total thyroidectomy, which is a widely used surgical procedure to treat both benign and malignant thyroid disorders. The present review focuses on the scientific gap and lack of data regarding the time period elapsed between the immediate postoperative period, when hypocalcemia is usually detected by the surgeon, and permanent hypoparathyroidism often seen by an endocrinologist months or years later. Parathyroid failure after thyroidectomy results from a combination of trauma, devascularization, inadvertent resection, and/or autotransplantation, all resulting in an early drop of iPTH (intact parathyroid hormone) requiring replacement therapy with calcium and calcitriol.

Muscle strength, physical performance, and metabolic changes after subtotal parathyroidectomy for secondary hyperparathyroidism.

Background: Hyperparathyroidism in patients on chronic hemodialysis presents with bone pain, pruritus, and extra-skeletal calcifications. Little attention has been paid to low plasma protein concentrations and muscle weakness in these patients. The present study was undertaken to characterize the impact of subtotal parathyroidectomy for chronic hemodialysis on body composition, muscle strength, plasma proteins, quality of life, and long-term clinical course.

Prevalence of basal ganglia and carotid artery calcifications in patients with permanent hypoparathyroidism after total thyroidectomy.

Objective: Permanent hypoparathyroidism is an uncommon disease resulting most frequently from neck surgery. It has been associated with visceral calcifications but few studies have specifically this in patients with post-surgical hypoparathyroidism. The aim of the present study was to assess the prevalence of basal ganglia and carotid artery calcifications in patients with long-term post-thyroidectomy hypoparathyroidism compared with a control population.

Influence of gender and women's age on the prevalence of parathyroid failure after total thyroidectomy for multinodular goiter.

Background: Female gender, particularly of a young age, has been reported as a risk factor for hypocalcemia after total thyroidectomy. There are no studies, however, addressing specifically the influence of women's age and menstrual status on postoperative parathyroid function.

Methods: Cohort study of consecutive patients undergoing total thyroidectomy for benign goiter between 2000-2017, excluding those with associated hyperparathyroidism, reoperation or conservative procedures.

MANAGEMENT OF ENDOCRINE DISEASE: Unmet therapeutic, educational and scientific needs in parathyroid disorders.

PARAT, a new European Society of Endocrinology program, aims to identify unmet scientific and educational needs of parathyroid disorders, such as primary hyperparathyroidism (PHPT), including parathyroid cancer (PC), and hypoparathyroidism (HypoPT). The discussions and consensus statements from the first PARAT workshop (September 2018) are reviewed. PHPT has a high prevalence in Western communities, PHPT has a high prevalence in Western communities, yet evidence is sparse concerning the natural history and whether morbidity and long-term outcomes are related to hypercalcemia or plasma PTH concentrations, or both.

Parathyroid autotransplantation in thyroid surgery.

Background: Careful parathyroid gland dissection and in situ preservation was the time-honored approach to prevent parathyroid failure after total thyroidectomy. The relative success of parathyroid autotransplantation of hyperplastic parathyroid tissue in patients with renal or hereditary hyperparathyroidism did popularize the use of normal parathyroid tissue autografts during thyroidectomy to prevent permanent hypoparathyroidism. Proof of autograft function in this setting, however, is controversial.

The PGRIS and parathyroid splinting concepts for the analysis and prognosis of protracted hypoparathyroidism.

Most patients with hypocalcemia after total thyroidectomy will recover the parathyroid function in a few weeks, but some 20-30% of them will still be in the need for replacement therapy one month after surgery and about 5-10% of those will develop permanent hypoparathyroidism. Although postoperative hypocalcemia has been related to several demographic and metabolic causes, parathyroid hormone (PTH) decline, resulting from autotransplantation, inadvertent excision or devascularization of the parathyroid glands, is the common final pathway. The number of parathyroid glands remaining in situ (PGRIS) is a key variable to understand the pathogenesis of protracted hypoparathyroidism and the chances for restoration of the parathyroid function.

A nomogram to predict the likelihood of permanent hypoparathyroidism after total thyroidectomy based on delayed serum calcium and iPTH measurements.

Background: Retrospective studies have shown that delayed high-normal serum calcium and detectable iPTH are independent variables positively influencing outcome of prolonged parathyroid failure after total thyroidectomy (TT). The aim of the present study was to examine prospectively the ability of these two variables to predict permanent hypoparathyroidism in patients under replacement therapy for postoperative hypocalcemia.

Methods: Prospective observational multicenter study of patients undergoing TT followed by postoperative parathyroid failure (serum calcium <8 mg/dL within 24 h and PTH <15 pg/mL 4 h after surgery).

Clinical profile and long-term follow-up of 32 patients with postoperative permanent hypoparathyroidism.

Background: Parathyroid failure is the most common complication after total thyroidectomy but permanent impairment of the parathyroid function is unusual. Limited data is available assessing long-term follow-up, quality of life and complications occurring in patients with permanent hypoparathyroidism (PH). We aimed to assess the incidence of complications derived from PH status, their influence on the quality of life perceived by PH patients and its relation to standard medical treatment with calcium salts and active vitamin D analogues.

Time to parathyroid function recovery in patients with protracted hypoparathyroidism after total thyroidectomy.

Objective: Hypocalcaemia is the most common adverse effect after total thyroidectomy. It recovers in about two-thirds of the patients within the first postoperative month. Little is known, however, about recovery of the parathyroid function (RPF) after this time period.

Short and Long-Term Outcomes After Surgical Procedures Lasting for More Than Six Hours.

Long-term all-cause mortality and dependency after complex surgical procedures have not been assessed in the framework of value-based medicine. The aim of this study was to investigate the postoperative and long-term outcomes after surgical procedures lasting for more than six hours. Retrospective cohort study of patients undergoing a first elective complex surgical procedure between 2004 and 2013.

Failure of fragmented parathyroid gland autotransplantation to prevent permanent hypoparathyroidism after total thyroidectomy.

Purpose: Parathyroid autotransplantation during total thyroidectomy leads to higher rates of postoperative hypocalcaemia. It has been argued, however, that it prevents permanent hypoparathyroidism. The impact of autografted normal parathyroid gland fragments on long-term parathyroid status has not been assessed properly.

Compliance with recommendations on surgery for primary hyperparathyroidism-from guidelines to real practice: results from an Iberian survey.

Purpose: Knowledge about compliance with recommendations derived from the positional statement of the European Society of Endocrine Surgeons on modern techniques in primary hyperparathyroidism surgery and the Third International Workshop on management of asymptomatic primary hyperparathyroidism is scarce. Our purpose was to check it on a bi-national basis and determine whether management differences may have impact on surgical outcomes.

Methods: An online survey including questions about indications, preoperative workup, surgical approach, intraoperative adjuncts, and outcomes was sent to institutions affiliated to the endocrine surgery divisions of the National Surgical Societies from Spain and Portugal.

Inadvertent parathyroidectomy during total thyroidectomy and central neck dissection for papillary thyroid carcinoma.

Background: The main drawback of central neck lymph node dissection is postoperative parathyroid failure. Little information is available concerning inadvertent resection of the parathyroid glands in this setting and its relationship to postoperative hypoparathyroidism. Our aim was to determine the prevalence of inadvertent parathyroidectomy during total thyroidectomy and central neck dissection for papillary thyroid cancer and its impact on short-and long-term parathyroid function.

Current dilemmas in the diagnosis and management of follicular thyroid tumors.

Follicular carcinoma (FTC) is a relatively uncommon type of differentiated thyroid carcinoma. Guidelines have often dealt with FTC and papillary thyroid cancer as a single disease. Over the last decade, however, a better understanding of these two types of thyroid cancer indicates that they cannot be analysed together.

Esophageal recurrence of medullary thyroid carcinoma.

Medullary thyroid carcinoma (MTC) metastasizes to the regional lymph nodes and to the lungs, liver and bones. Only one case of recurrence of MTC involving the upper gastrointestinal tract has been reported so far. We describe the case of a 38-year-old woman with MTC, who developed an upper esophageal submucosal recurrence after two previous local recurrences treated surgically and one ethanol injection.

Undescended parathyroid adenomas as cause of persistent hyperparathyroidism.

Background: Undescended glands are a rare cause of primary and secondary hyperparathyroidism (HPT), but they are more common, however, among patients with recurrent HPT or those who have undergone a failed initial cervical exploration. The currently development of more precise noninvasive imaging techniques has improved the results of preoperative diagnosis of these ectopic lesions.

Methods: The operative reports of patients undergoing parathyroidectomy at our institution were reviewed to identify patients with an undescended parathyroid gland adenomas.