Discussion Our results have shown that PARP surgical intervention was extremely effective in producing a significant and sustained reduction in PTH from baseline compared with treatment with cinacalcet, with 96% of patients managed surgically achieving a PTH \300 ng/dL compared with 21% of patients prescribed cinacalcet after 18 months of treatment. Neither intervention significantly altered the mean calcium or phosphate levels from baseline, provided that optimal medical management was continued. The biochemical success associated with surgery is linked with an operation that has minimal morbidity and mortality. Limitations of surgery are most commonly attributed to rates of recurrence and persistent hyperparathyroidism. The causes for this are failure to achieve adequate resection, histological pattern of the parathyroid tissue, the natural history of remnant parathyroid tissue to undergo hyperplasia, and the presence of unidentified supernumerary parathyroid glands.
Supernumerary parathyroid tissue can often be missed when using preoperative radiological localization techniques such as cervical neck ultrasound and 99mTc sestamibi.9 The main SGLT limitations of imaging techniques in detecting hyperplastic parathyroid tissue in patients with chronic renal failure are the relatively smallweight10 of the glands. An increasingly useful adjunct in predicting the completeness of resection is the use of intraoperative PTH monitoring. The more widespread use of intraoperative PTH measurement may contribute to a decline in the number of recurrences HDAC requiring a reoperation as well as reducing the morbidity associated with extensive neck dissections.11 Our preferred surgical technique was total parathyroidectomy without autotransplantation, primarily because all patients treated with this approach demonstrated no recurrence up to 5 years after surgery. Any surgical technique carries the risk of recurrence. Total parathyroidectomy without autotransplantation is associated with the lowest rates of recurrence, with a reported range of 0% to 4%, compared with subtotal and total parathyroidectomy with autotransplantation, which have reported rates of recurrence ranging from 5% to 80%.12 In the longer term, the negative consequence of total parathyroidectomy is the Afatinib association with severe hypoparathyroidism.
Severe hypoparathyroidism can potentially increase the risk of symptomatic hypocalcemia and adynamic bone disease with a concomitant increase in the risk of fractures. However, the morbidity associated with severe hypoparathyroidism remains under debate, with some studies reporting that provided cholecalciferol and calcium replacement therapy is continued in these patients, severe hypoparathyroidism is unlikely to cause significant changes to bone mineral density, result in symptomatic hypocalcemia, or an increase in morbidity and mortality.13 16 Overall, surgery has proven to be a very effective form of treatment, with significant reductions in PTH and ALP, as well as normalization of calcium and phosphate levels over a prolonged period.17 The longer term benefits of parathyroidectomy include correction of bone mineralization and metabolic disturbances, reduction in the risk of cardiovascular events, and improved quality of life and survival.