Abstract
Total parathyroidectomy with autotransplantation is frequently used in the treatment of hyperparathyroidism associated with renal osteodystrophy because of the high incidence of recurrent disease following subtotal resection. A similar argument has been made to support the application of this technique to cases of recurrent or persistent hyperparathyroidism and to familial polyendocrine syndromes with parathyroid hyperplasia. We have recently had occasion to apply this approach in a new clinical setting of metabolic bone disease. Three patients with congenital hypophosphatemic rickets and 1 with pseudohypoparathyroidism were treated with total parathyroidectomy and autotransplant into the forearm. All 4 had developed secondary hyperparathyroidism with hypercalcemia while being treated with 1,25(OH) 2 D 3 (with or without inorganic phosphate). Each had a history of previous vitamin D intoxication. Reduction of parathyroid mass permitted effective treatment of severe bone disease in each case. Two patients developed graft-dependent hypercalcemia which required resection of graft tissue from the forearm under local anesthesia. Both have shown a further recurrence. Total parathyroidectomy and autotransplantation may be useful in the management of selected patients with metabolic bone disease due to familial hyophosphatemic rickets or pseudohypoparathyroidism.
Résumé
La parathyroïdectomie totale suivie d'autotransplantation est souvent employée pour traiter l'hyperthyroïdisme associé avec une ostéodystrophie rénale en raison de la fréquence de la récidive après parathyroïdectomie subtotale. Il en est de même en présence d'hyperparathyroïdisme persistant ou récidivant et des syndromes endocriniens familiaux s'accompagnant d'hyperplasie hyperthyroïdienne. Ce choix thérapeutique a été appliqué récemment à une nouvelle entité clinique répondant à une affection osseuse métabolique. Trois malades qui présentaient un rachitisme congénital avec hypophosphatase et un sujet qui était atteint de pseudo-hypoparathyroïdisme ont été traités par parathyroïdectomie totale avec autotransplantation au niveau de l'avant-bras. Tous les quatre avaient développé un hyperparathyroïdisme secondaire avec hypercalcémie alors qu'ils recevaient du 1,25 OH2D3 (avec ou sans phosphate inorganique). Chacun présentait des antécédents d'intoxication par la vitamine D. La réduction de la masse parathyroïdienne donna lieu à un traitement efficace de tous les cas. Deux malades cependant accusèrent une hypercalcémie liée à la présence du greffon autotransplanté, hypercalcémie qui fut traitée par l'ablation de celui-ci sous anesthésie locale. En conclusion, la parathyroïdectomie totale avec autotransplantation peut être utile pour traiter certains malades qui présentent une maladie osseuse métabolique due à un rachitisme familial avec hypophosphatasémie ou un pseudo-hypoparathyroïdisme.
Resumen
La paratiroidectomía total con autotransplante es un procedimiento frecuentemente asociado con osteodistrofia renal debido a la elevada incidencia de hiperparatiroidismo recurrente cuando sólo se realiza resección subtotal. Una argumentación similar se usa en apoyo de la aplicación de este procedimiento en casos de hiperparatiroidismo recurrente o persistente y de síndromes poliendocrinos familiares con hiperplasia paratiroidea. Recientemente tuvimos oportunidad de utilizar este enfoque en una nueva condición clínica de enfermedad ósea metabólica. Tres pacientes con raquitismo hipofosfatémico congénito y uno con pseudohipoparatiroidismo fueron tratados con paratiroidectomía y autotransplante en el antebrazo. Todos los cuatro habían desarrollado hiperparatiroidismo secundario con hipercalcemia en el curso de tratamiento con 1,25 (OH)2D3 (con o sin fosfato inorgánico). Cada uno tenía historia de intoxicación previa con vitamina D. La reducción de la masa paratiroidea hizo posible la realización de tratamiento efectivo de la severa enfermedad ósea en cada caso. Dos pacientes desarrollaron hipercalcemia transplante-dependiente, lo cual exigió la resección del tejido transplantado al antebrazo bajo anestesia local. Ambos han exhibido una nueva recurrencia. La paratiroidectomía total con autotransplante puede ser útil en el manejo de pacientes seleccionados que sufren de enfermedad ósea metabólica debida a raquitismo hipofosfatémico familiar o pseudohipoparatiroidismo.
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Supported by a grant (RR125) from the National Institutes of Health and by the Pediatric and Adult Clinical Research Centers of the Yale-New Haven Hospital.
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Kinder, B.K., Rasmussen, H. New applications of total parathyroidectomy and autotransplantation: Use in proximal renal tubular dysfunction. World J. Surg. 9, 156–164 (1985). https://doi.org/10.1007/BF01656271
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DOI: https://doi.org/10.1007/BF01656271