Abstract
Multichannel autoanalyzers have diagnosed many unsuspected, largely asymptomatic cases of primary hyperparathyroidism. The age of onset of the disease and its rate of progression are not well understood. Surgical restoration of the eucalcemic state is associated with the healing of bone pathology, but many patients are not relieved of hypertensive or renal disease, and sometimes these problems continue to develop in the postoperative period, resulting in continued morbidity and mortality despite “successful” surgery. Conflicting opinions regarding the differentiation between parathyroid adenomas, hyperplasia, and normal glands appear to be resolving as newer data, both retrospective and prospective, reemphasize the pathologic importance of the clinically enlarged or abnormal glands. Parathyroid surgery for renal osteodystrophy of secondary hyperparathyroidism and for persisting hypercalcemia of tertiary hyperparathyroidism may be modified by autotransplantation. Carcinoma of the parathyroid glands is rare, but operative findings merit review. A variety of surgical approaches have been proposed. The surest method for restoring normal calcium levels with minimal permanent hypocalcemia is identification of 4 parathyroid glands and removal of those which are grossly abnormal. For patients with multiple endocrine adenomatosis or familial hyperparathyroidism, subtotal parathyroidectomy is preferred. Additional surgical guidelines are reviewed and the development of a parathyroid registry to ensure closer follow-up is suggested.
Résumé
Les autoanalyseurs multi-canaux ont permis le diagnostic de nombreux cas d'hyperparathyroïdie pauci—si pas asymptomatique. Le moment de début de la maladie et sa rapidité d'évolution restent des inconnues. Le retour, après chirurgie, à un équilibre calcique normal est suivi d'une guérison des lésions osseuses. Mais il persiste, chez de nombreux opérés, de l'hypertension ou des lésions rénales, qui parfois continuent à évoluer après l'opération. Il peut donc y avoir des troubles et même des décès après une opération “réussie”. Au cours des dernières années, des opinions contradictoires ont été émises concernant la distinction entre adénome parathyroïdien, hyperplasie et glandes normales. Mais l'accumulation récente de données prospectives et rétrospectives a redémontré l'importance, au point de vue de la pathologie, des parathyroides augmentées de volume ou anormales. La chirurgie parathyroidienne pour l'ostéodystrophie rénale de l'hyperparathyroïdie secondaire et pour l'hypercalcémie persistante de l'hyperparathyroïdie tertiaire a été complètement transformée par l'autotransplantation. Le cancer des parathyroïdes est rare mais mérite une discussion des lésions trouvées à l'intervention; divers traitements ont été proposés. La façon la plus sûre de rétablir l'équilibre calcique avec un risque minime d'hypocalcémie persistante est d'identifier les 4 glandes parathyroïdes et d'enlever toutes celles qui paraissent macroscopiquement anormales. En cas d'adénomatose multiendocrinienne ou d'hyperparathyroïdie familiale, il faut préférer la parathyroïdectomie sub-totale. D'autres lignes de conduite sont discutées. Nous suggérons la création d'un registre parathyroïdien pour assurer une meilleure surveillance des malades.
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Esselstyn, C.B. Parathyroid pathology: Its relation to choice of operation for hyperparathyroidism. World J. Surg. 1, 701–706 (1977). https://doi.org/10.1007/BF01555918
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DOI: https://doi.org/10.1007/BF01555918