Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa
-
Upload
ahmed-albeyaly -
Category
Documents
-
view
212 -
download
16
description
Transcript of Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa
![Page 1: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/1.jpg)
![Page 2: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/2.jpg)
Ahmed HalawaMSc PGCE FRCS MD FRCS(Gen)
Consultant SurgeonSheffield Teaching Hospitals
Senior LecturerUniversity of SheffieldUniversity of Liverpool
![Page 3: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/3.jpg)
Failed medical treatment to control the hyperparathyroidism in a well dialysed patient indicated by: High PTH High Ca with normal PTH.Hyperphosphataemia. Vit D level 25(OH)D is >50 nmol/l (20 ng/ml).
![Page 4: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/4.jpg)
![Page 5: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/5.jpg)
3 glands 3% 4 glands 84% 5 or more 13%
Superior glands are posterior to the nerve (more consistent)
Inferior glands are anterior to the nerve (less consistent)
![Page 6: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/6.jpg)
![Page 7: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/7.jpg)
PTH Due to bone resistance, level above 3-5 times
the absolute value is considered abnormal
Ca (Normal or high)
Hyperphosphataemia
Vit D level
No radiological investigations are required
![Page 8: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/8.jpg)
High-resolution ultrasoundSensitivity 65-85%65-85% for adenoma; 30-90%30-90% for enlarged glandResults suboptimal in pts with multinodular thyroid disease, pts with short thick neck, ectopic glands (15-20%)(15-20%)May be useful in detecting Sestamibi scan negative adenomas
CT with contrast/thin section
Sensitivity of 46-87%46-87%Good for ectopic glands in the chest
MRI
Sensitivity of 65-80%65-80%Good for ectopic glands
Sestamibi
85-95%85-95% accurate in localizing adenoma in primary HPT Sestamibi-SPECT
Sensitivity 60%60% for enlarged gland and 98%98% for solitary adenomas
![Page 9: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/9.jpg)
Only Required for Redo Parathyroidectomy
![Page 10: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/10.jpg)
![Page 11: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/11.jpg)
![Page 12: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/12.jpg)
![Page 13: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/13.jpg)
Sensitivity (%)Sensitivity (%) 95% CI95% CI
Solitary Solitary adenomaadenoma
88.488.4 87 - 8987 - 89
HyperplasiaHyperplasia 44.444.4 41 - 4841 - 48
Double Double adenomaadenoma
3030 -2 - 62-2 - 62
CarcinomaCarcinoma 3333 3333Johnson N, AJR Am J Roentgenol. 2007 Jun;188(6):1706-15.
Tc-SestamibiTc-SestamibiSensit ivity Meta-analysisSensit ivity Meta-analysis
![Page 14: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/14.jpg)
67-year-old woman with hyperparathyroidism and left tracheoesophageal groove adenoma that could easily be
mistaken for posterior thyroid nodule.
![Page 15: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/15.jpg)
LEFT- 99mTc-sestamibi SPECT image shows physiologic uptake in salivary glands and thyroid gland, with focus of more intense uptake overlying superior pole of right thyroid lobe ( arrow). RIGHT-52-year-old woman with hyperparathyroidism and right superior parathyroid adenoma. Two-hour delayed SPECT image shows radiotracer retention in adenoma ( arrow) but clearing of tracer from overlying thyroid.
Tc-SestamibiTc-SestamibiSensit ivity Meta-analysisSensit ivity Meta-analysis
![Page 16: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/16.jpg)
40-year-old woman who presented with recurrent hypercalcaemia and hyperparathyroidism after
resection of both left-sided glands.
![Page 17: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/17.jpg)
39-year-old woman with left superior adenoma showing typical MRI signal characteristics .
![Page 18: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/18.jpg)
No place for a “Cowboy Surgeon”
![Page 19: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/19.jpg)
![Page 20: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/20.jpg)
Previous dialysis line generates fibrosis (damage) Vascular calcification (bleeding) Engorged neck veins (bleeding) Anticoagulation on dialysis (bleeding) Anaemia and platelet abnormality (bleeding) The glands are closely related to RLN (damage) Inconstancy of the inferior glands (recurrence) Supernumerary gland(s) (recurrence) Thymectomy (bleeding into the chest)
![Page 21: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/21.jpg)
Only 5-10% will come to surgery
Bilateral Neck Exploration If 4 glands found, minimum 3 ½ glands
removed and thymectomy
![Page 22: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/22.jpg)
Total parathyroidectomy
Thymectomy
No auto-transplantation
![Page 23: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/23.jpg)
Total parathyroidectomy
Thymectomy
No auto-transplantation?
![Page 24: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/24.jpg)
Undescended thymus is associated with undescended inferior para thyroid gland
The inferior parathyroid glands may be higher that the superior glands, but stays anterior to the RLN
![Page 25: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/25.jpg)
Fat
![Page 26: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/26.jpg)
PTH should be >100 pm/ml to prevent the disease, but no guarantee
Reduced osteoblasts and osteoclasts, no accumulation of osteoid and markedly low bone turnover
Induced by overtreatment of secondary hyperparathyroidism and not a disease
Fractures
![Page 27: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/27.jpg)
No adequately powered RCT
Recurrence
Adynamic bone disease (ABD)
![Page 28: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/28.jpg)
Develops from third pharyngeal pouch like the inferior parathyroid
Has some parathyroid rests that become active by persistent stimulation (CKD), they may develop into a full gland.
![Page 29: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/29.jpg)
![Page 30: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/30.jpg)
![Page 31: Surgery for CKD-MBD Parathyroidectomy Prof. Ahmed Halawa](https://reader031.fdocuments.us/reader031/viewer/2022020105/5599e9071a28abd8448b45ea/html5/thumbnails/31.jpg)