- Email: [email protected]
Response to “Response to: Tertiary hyperparathyroidism: Is less than a subtotal resection ever appropriate? A study on long-term outcomes”
Letters to the Editors 1045
Surgery Volume 148, Number 5
4. Triponez F, Dosseh D, Hazzan M, Noel C, Vanhille P, Proye CA. Subtotal parathyroidectomy with thymectomy for autonomous hyperparathyroidism after renal transplantation. Br J Surg 2005;92:1282-7. 5. Evenepoel P, Claes K, Kuypers DR, Debruyne F, Vanrenterghem Y. Parathyroidectomy after successful kidney transplantation: a single centre study. Nephrol Dial Transplant 2007;22:1730-7. 6. Akerstrom G, Stalberg P. Surgical management of MEN-1 and -2: state of the art. Surg Clin North Am 2009;89:1047-68. 7. Tominaga Y, Katayama A, Sato T, Matsuoka S, Goto N, Haba T, et al. Re-operation is frequently required when parathyroid glands remain after initial parathyroidectomy for advanced secondary hyperparathyroidism in uraemic patients. Nephrol Dial Transplant 2003;18(Suppl 3):iii65-70. doi:10.1016/j.surg.2010.03.026
Response to ‘‘Response to: Tertiary hyperparathyroidism: Is less than a subtotal resection ever appropriate? A study on long-term outcomes’’ To the Editors: We have read the letter by Triponez et al1 and appreciate their thoughtful response. We would like to respond to some of the concerns they raised. The appropriate operative management of patients with tertiary hyperparathyroidism is debated and, unfortunately, owing to its relative clinical rarity, we have limited data to utilize to determine the best treatment option. As with any operative intervention, we must define the goal of our intervention, and we must carefully balance the risks with the benefits of our intervention. At our institution, the goal of operative intervention for tertiary hyperparathyroidism is to achieve long-term normocalcemia. This end point was achieved in 94% of patients and 100% of those treated with a limited resection. The goal of our operation is not necessarily to obtain long-term normal parathyroid hormone (PTH) levels. Therefore, PTH levels are not obtained routinely in patients postoperatively. Vitamin D deficiency is prevalent in our region of the country, and this population is also at risk for the development of graft dysfunction leading to secondary hyperparathyroidism; both of these conditions can lead to increased PTH levels in the postoperative period, yet in no limited resection case was this mildly increased PTH level associated with hypercalcemia to suggest disease recurrence or the need for a reoperation.
Triponez et al1 state that we had lost up to 52% of patients to follow-up. This statement is not accurate; we had >6 months of follow-up on 92% of the patients with a mean follow-up of 7 years. We did not have PTH data on all of our patients, not because they were lost to follow-up, but because they were normocalcemic, and there was no clinical indication to check a PTH level. In our study, 29 patients operated on by an experienced endocrine surgeon underwent limited resection. All these patients have remained cured with a mean of 7 years of follow-up, and none suffered a postoperative complication. This cohort only accounts for 20% of our patients, and, therefore, represents only a portion of patients with tertiary hyperparathyroidism. As with most surgical diseases, 1 operation is not applicable to all patients. With our approach, we suggest that we treat patients based on the findings at the time of operation, using experienced operative judgment. We think that this is particularly relevant when examining the risks of operation, which in our series included a 7% incidence of permanent hypoparathyroidism in those patients treated with a subtotal resection in comparison with a 0% incidence in the limited resection group. This area of debate will likely continue for years, but it is our hope that as we continue to gain experience and extend the long-term follow-up of our patients, we will be able to continue to shed some light on how to best manage this complex and diverse subset of patients. Rebecca S. Sippel, MD Susan C. Pitt, MD Herbert Chen, MD Department of Surgery Section of Endocrine Surgery University of Wisconsin Madison, WI E-mail: [email protected]
Reference 1. Triponez F, Clark OH, Evenepoel P. Response to: Tertiary hyperparathyroidism: is less than a subtotal resection ever appropriate? A study on long-term outcomes. Surgery 2010;148: 1042-3. doi:10.1016/j.surg.2010.04.028
Surgery Volume 148, Number 5
4. Triponez F, Dosseh D, Hazzan M, Noel C, Vanhille P, Proye CA. Subtotal parathyroidectomy with thymectomy for autonomous hyperparathyroidism after renal transplantation. Br J Surg 2005;92:1282-7. 5. Evenepoel P, Claes K, Kuypers DR, Debruyne F, Vanrenterghem Y. Parathyroidectomy after successful kidney transplantation: a single centre study. Nephrol Dial Transplant 2007;22:1730-7. 6. Akerstrom G, Stalberg P. Surgical management of MEN-1 and -2: state of the art. Surg Clin North Am 2009;89:1047-68. 7. Tominaga Y, Katayama A, Sato T, Matsuoka S, Goto N, Haba T, et al. Re-operation is frequently required when parathyroid glands remain after initial parathyroidectomy for advanced secondary hyperparathyroidism in uraemic patients. Nephrol Dial Transplant 2003;18(Suppl 3):iii65-70. doi:10.1016/j.surg.2010.03.026
Response to ‘‘Response to: Tertiary hyperparathyroidism: Is less than a subtotal resection ever appropriate? A study on long-term outcomes’’ To the Editors: We have read the letter by Triponez et al1 and appreciate their thoughtful response. We would like to respond to some of the concerns they raised. The appropriate operative management of patients with tertiary hyperparathyroidism is debated and, unfortunately, owing to its relative clinical rarity, we have limited data to utilize to determine the best treatment option. As with any operative intervention, we must define the goal of our intervention, and we must carefully balance the risks with the benefits of our intervention. At our institution, the goal of operative intervention for tertiary hyperparathyroidism is to achieve long-term normocalcemia. This end point was achieved in 94% of patients and 100% of those treated with a limited resection. The goal of our operation is not necessarily to obtain long-term normal parathyroid hormone (PTH) levels. Therefore, PTH levels are not obtained routinely in patients postoperatively. Vitamin D deficiency is prevalent in our region of the country, and this population is also at risk for the development of graft dysfunction leading to secondary hyperparathyroidism; both of these conditions can lead to increased PTH levels in the postoperative period, yet in no limited resection case was this mildly increased PTH level associated with hypercalcemia to suggest disease recurrence or the need for a reoperation.
Triponez et al1 state that we had lost up to 52% of patients to follow-up. This statement is not accurate; we had >6 months of follow-up on 92% of the patients with a mean follow-up of 7 years. We did not have PTH data on all of our patients, not because they were lost to follow-up, but because they were normocalcemic, and there was no clinical indication to check a PTH level. In our study, 29 patients operated on by an experienced endocrine surgeon underwent limited resection. All these patients have remained cured with a mean of 7 years of follow-up, and none suffered a postoperative complication. This cohort only accounts for 20% of our patients, and, therefore, represents only a portion of patients with tertiary hyperparathyroidism. As with most surgical diseases, 1 operation is not applicable to all patients. With our approach, we suggest that we treat patients based on the findings at the time of operation, using experienced operative judgment. We think that this is particularly relevant when examining the risks of operation, which in our series included a 7% incidence of permanent hypoparathyroidism in those patients treated with a subtotal resection in comparison with a 0% incidence in the limited resection group. This area of debate will likely continue for years, but it is our hope that as we continue to gain experience and extend the long-term follow-up of our patients, we will be able to continue to shed some light on how to best manage this complex and diverse subset of patients. Rebecca S. Sippel, MD Susan C. Pitt, MD Herbert Chen, MD Department of Surgery Section of Endocrine Surgery University of Wisconsin Madison, WI E-mail: [email protected]
Reference 1. Triponez F, Clark OH, Evenepoel P. Response to: Tertiary hyperparathyroidism: is less than a subtotal resection ever appropriate? A study on long-term outcomes. Surgery 2010;148: 1042-3. doi:10.1016/j.surg.2010.04.028