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Obesity Surgery

, Volume 25, Issue 4, pp 700–704 | Cite as

Primary Hyperparathyroidism After Roux-en-Y Gastric Bypass

  • Yufei Chen
  • Carrie C. Lubitz
  • Scott A. Shikora
  • Richard A. Hodin
  • Randall D. Gaz
  • Francis D. MooreJr
  • Travis J. McKenzie
Original Contributions

Abstract

Background

Primary hyperparathyroidism (PHPT) in the setting of previous roux-en-Y gastric bypass (RYGBP) is not well described. The diagnosis can be difficult, as secondary hyperparathyroidism (SHPT) commonly occurs in patients after RYGBP due to calcium malabsorption and vitamin D deficiency.

Methods

All patients from 2000 to 2012 who underwent cervical exploration for diagnosis of primary hyperparathyroidism with history of preceding RYGBP were identified and analyzed retrospectively.

Results

Ten patients were identified. The average age was 58.4 and all patients were female. Time interval between RYGBP and cervical exploration was 67 months with median follow-up of 19 months. Average preoperative calcium was 10.8 mg/dL, PTH 155 pg/mL, and 25-vitamin-D 32 ng/mL. Eighty percent of patients presented with symptoms and 90 % underwent preoperative imaging. Seventy percent underwent initial focused parathyroidectomy with 20 % being converted to four-gland exploration. Seventy percent of patients had a single adenoma with two patients having multi-gland disease. Intraoperative PTH was used in seven patients with successful drop to 50 % of baseline in all. Ninety percent of patients had greater then 6-month follow-up without evidence of persistent or recurrent PHPT. Average 6-month calcium was 9.3 mg/dL, PTH 73 pg/mL, and 25-vitamin-D 44 ng/ML. Four patients had evidence of persistently elevated PTH despite normalization of calcium.

Conclusions

PHPT after RYGBP is rare but surgery with either a focused approach following successful localization or four-gland exploration is indicated when the biochemical diagnosis holds true. The presence of SHPT can make diagnosis and follow-up difficult and may predispose them to severe post-operative hypocalcemia.

Keywords

Hyperparathyroidism Primary hyperparathyroidism Gastric bypass Roux-en-Y Hypercalcemia 

Notes

Conflict of Interest

Yufei Chen, M.D., Carrie C. Lubitz, M.D., MPH, Scott A. Shikora, M.D., FACS, Richard A. Hodin, M.D., Randall D. Gaz, M.D., Francis D. Moore Jr, M.D., and Travis J. McKenzie, M.D., have no conflicts of interest to disclose.

Statement of Informed Consent

For this type of retrospective study, formal informed consent is not required.

Statement of Human and Animal Rights

This article does not contain any studies with human participants or animals performed by any of the authors.

References

  1. 1.
    Ogden CL, Yanovski SZ, Carroll MD, et al. The epidemiology of obesity. Gastroenterology. 2007;132:2087–102. eng.CrossRefPubMedGoogle Scholar
  2. 2.
    Nguyen NT, Masoomi H, Magno CP, et al. Trends in use of bariatric surgery, 2003–2008. J Am Coll Surg. 2011;213:261–6. eng.CrossRefPubMedGoogle Scholar
  3. 3.
    Jin J, Robinson AV, Hallowell PT, et al. Increases in parathyroid hormone (PTH) after gastric bypass surgery appear to be of a secondary nature. Surgery. 2007;142:914–20. discussion 914–20. eng.CrossRefPubMedGoogle Scholar
  4. 4.
    Avgerinos DV, Leitman IM, Martínez RE, et al. Evaluation of markers for calcium homeostasis in a population of obese adults undergoing gastric bypass operations. J Am Coll Surg. 2007;205:294–7. eng.CrossRefPubMedGoogle Scholar
  5. 5.
    Johnson JM, Maher JW, DeMaria EJ, et al. The long-term effects of gastric bypass on vitamin D metabolism. Ann Surg. 2006;243:701–4. discussion 704–5. eng.CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    Carlin AM, Rao DS, Yager KM, et al. Effect of gastric bypass surgery on vitamin D nutritional status. Surg Obes Relat Dis. 2006;2:638–42. eng.CrossRefPubMedGoogle Scholar
  7. 7.
    Johnson JM, Maher JW, Samuel I, et al. Effects of gastric bypass procedures on bone mineral density, calcium, parathyroid hormone, and vitamin D. J Gastrointest Surg. 2005;9:1106–10. discussion 1110–1. eng.CrossRefPubMedGoogle Scholar
  8. 8.
    Sipponen P, Härkönen M. Hypochlorhydric stomach: a risk condition for calcium malabsorption and osteoporosis? Scand J Gastroenterol. 2010;45:133–8. eng.CrossRefPubMedGoogle Scholar
  9. 9.
    Malone M, Alger-Mayer SA. Medication use patterns after gastric bypass surgery for weight management. Ann Pharmacother. 2005;39:637–42. eng.CrossRefPubMedGoogle Scholar
  10. 10.
    Crowley LV, Seay J, Mullin G. Late effects of gastric bypass for obesity. Am J Gastroenterol. 1984;79:850–60. eng.PubMedGoogle Scholar
  11. 11.
    Grant CS, Thompson G, Farley D, et al. Primary hyperparathyroidism surgical management since the introduction of minimally invasive parathyroidectomy: Mayo Clinic experience. Arch Surg. 2005;140:472–8. discussion 478–9. eng.CrossRefPubMedGoogle Scholar
  12. 12.
    Bilezikian JP, Khan AA, Potts JT. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the third international workshop. J Clin Endocrinol Metab. 2009;94:335–9. eng.CrossRefPubMedCentralPubMedGoogle Scholar
  13. 13.
    Ahmad R, Hammond JM. Primary, secondary, and tertiary hyperparathyroidism. Otolaryngol Clin N Am. 2004;37:701–13. vii-viii. eng.CrossRefGoogle Scholar
  14. 14.
    Corlew DS, Bryda SL, Bradley EL, et al. Observations on the course of untreated primary hyperparathyroidism. Surgery. 1985;98:1064–71. eng.PubMedGoogle Scholar
  15. 15.
    Nilsson I, Yin L, Lundgren E, et al. Clinical presentation of primary hyperparathyroidism in Europe—nationwide cohort analysis on mortality from nonmalignant causes. J Bone Miner Res. 2002;17(2):N68–74. eng.PubMedGoogle Scholar
  16. 16.
    Allendorf J, DiGorgi M, Spanknebel K, et al. 1112 consecutive bilateral neck explorations for primary hyperparathyroidism. World J Surg. 2007;31:2075–80. eng.CrossRefPubMedGoogle Scholar
  17. 17.
    Lee NC, Norton JA. Multiple-gland disease in primary hyperparathyroidism: a function of operative approach? Arch Surg. 2002;137:896–9. discussion 899–900. eng.CrossRefPubMedGoogle Scholar
  18. 18.
    Singer MC, Pucar D, Mathew M, et al. Improved localization of sestamibi imaging at high-volume centers. Laryngoscope. 2013;123:298–301. eng.CrossRefPubMedGoogle Scholar
  19. 19.
    Adkisson CD, Koonce SL, Heckman MG, et al. Predictors of accuracy in preoperative parathyroid adenoma localization using ultrasound and Tc-99m-sestamibi: a 4-quadrant analysis. Am J Otolaryngol. 2013;34:508–16. eng.CrossRefPubMedGoogle Scholar
  20. 20.
    Garner SC, Leight GS. Initial experience with intraoperative PTH determinations in the surgical management of 130 consecutive cases of primary hyperparathyroidism. Surgery. 1999;126:1132–7. discussion 1137–8. eng.CrossRefPubMedGoogle Scholar
  21. 21.
    Lupoli GA, Fonderico F, Panico A, et al. Stricter criteria increase the validity of a quick intraoperative parathyroid hormone assay in primary hyperparathyroidism. Med Sci Monit. 2009;15:CR111–6. eng.PubMedGoogle Scholar
  22. 22.
    Reiher AE, Schaefer S, Chen H, et al. Does the final intraoperative PTH level really have to fall into the normal range to signify cure? Ann Surg Oncol. 2012;19:1862–7. eng.CrossRefPubMedGoogle Scholar
  23. 23.
    McKenzie TJ, Chen Y, Hodin RA, et al. Recalcitrant hypocalcemia after thyroidectomy in patients with previous Roux-en-Y gastric bypass. Surgery. 2013;154:1300–6. discussion 1306. eng.CrossRefPubMedCentralPubMedGoogle Scholar
  24. 24.
    Witteveen JE, van Thiel S, Romijn JA, et al. Hungry bone syndrome: still a challenge in the post-operative management of primary hyperparathyroidism: a systematic review of the literature. Eur J Endocrinol. 2013;168:45–53. eng.CrossRefGoogle Scholar
  25. 25.
    Mittendorf EA, Merlino JI, McHenry CR. Post-parathyroidectomy hypocalcemia: incidence, risk factors, and management. Am Surg. 2004;70:114–9. discussion 119–20. eng.PubMedGoogle Scholar
  26. 26.
    Palal B, Sinsakul M, Reutrakul S. Life-threatening hypocalcemia following subtotal parathyroidectomy in a patient with renal failure and previous Roux-en-Y gastric bypass surgery. Case Rep Endocrinol 2011;2011:370583. eng.Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Yufei Chen
    • 1
  • Carrie C. Lubitz
    • 1
  • Scott A. Shikora
    • 2
  • Richard A. Hodin
    • 1
  • Randall D. Gaz
    • 1
  • Francis D. MooreJr
    • 2
  • Travis J. McKenzie
    • 1
  1. 1.Massachusetts General HospitalBostonUSA
  2. 2.Brigham and Women’s HospitalBostonUSA

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