Surgical Treatment of Secondary Hyperparathyroidism in Surgery B of Chu of Point G

Purpose: To describe the epidemiological, clinical and therapeutic aspects of 
secondary hyperparathyroidism inrenal failure chronic. Patients and methods: 
We collected 11 cases of hyperparathyroidism secondary to renal failure 
terminal operated in the Service of surgery B of the Central Hospital 
University of Point G between December 2016 and November 2018. Results: 
The sex ratio was 0.22 in favor of women. The average age of the patients was 
43 or 27 years with extremes of 63 and 25 years. Secondary hyperparathyroidism 
in renal failure chronic represented 1.9% of interventions to cold in 
the Service of surgery B. 100% of patients (11/11) were haemodialysis. 100% 
of the patients had clinical and biological signs. 45.5% (5/11) had radiological 
signs. The average rate of parathyroid hormone was 2413.51 pg/ml with extremes 
of 1264 pg/ml and 3616 pg/ml. The reference value was 15 - 65 pg/ml. 
The surgical technique of choice was the 7/8th parathyroidectomy in 100% of 
cases. The postoperative were simple in 81.8%, and complicated in 18.2%. 
There were no death. The average duration of postoperative follow-up was 6 
months. After surgery, 50% of patients (5/10) had normal levels of parathyroid 
hormone and 50% (5/10) made a persistent hyperparathyroidism. Conclusion: 
Secondary hyperparathyroidism is a frequent complication in renal 
insufficient chronic in hemodialysis. Surgery is indicated in the resistant cases 
of medical treatment. The 7/8th parathyroidectomy is the surgical technique 
of choice. The rate of post operative complications is higher in our context.


Introduction
Hyperparathyroidism is the set of clinical, biological and anatomical demonstrations as a result of hyper secretion of parathyroid hormone (PTH) by the parathyroid glands.
Hyperparathyroidism can be primary (parathyroid adenoma in 80% -85%, primitive hyperplasia in 14% -15% and carcinoma < 1%), secondary (compensatory hyperplasia due to a decline in the rate of calcium in the renal insufficient chronic), or tertiary (autonomous hyperactivity of the parathyroid). Secondary hyperparathyroidism is a common complication in chronic renal failure [1]. It is an inevitable condition in chronic renal insufficient patients at the stage of hemodialysis; because it is the result of an alteration extended responsible for kidney function of phosphocalcic metabolism disorder. The increase in the secretion of PTH trained parathyroid hormone, a hypocalcemie, a hyperphosphoremie, a deficiency in vitamin D [1].
The diagnosis is mentioned before the clinical and radiological components but the confirmation is based on the immunoassay of the serum of parathyroid hormone (PTH serum). The hearing is before any medical; however these therapies are limited by their lack of effectiveness in the long term. The morbi-mortality is linked to osteo-articular and cardiovascular complications. When the hyperparathyroidism becomes uncontrolled, the parathyroidectomy remains the reference. The purpose of this work was to describe the epidemiological, clinical and therapeutic aspects of hyperparathyroidism secondary to chronic renal failure in the Service of surgery B of the Central Hospital University of Point G.

Patients and Methods
It was a retro-prospective descriptive and analytical study which took place in the Service of surgery B of CHU of Point G from December 2016 to November 2018 or a duration of 24 months. We have included all patients who have been operated for secondary hyperparathyroidism confirmed by dosage of the parathyroid hormone in the Service of surgery B of the Point G Academic Hospital Center.
Have not been included in this study: − Patients with non-exploitable records; − Other hyperparathyroidism (primary and tertiary); − Secondary hyperparathyroidism medically treated (not operated).
Judging criteria: We have defined secondary hyperparathyroidism in chronic renal failure according to the international recommendations of Kidney Disease Improving Global Outcome (KDIGO).
At the terminal stage of chronic renal failure, we target to maintain between 2 to 9 times the upper limit of the standard of the dosage used ( Table 1).
The reference value of the Parathyroid hormone in the blood was 15 -65 To make the diagnosis we relied on the clinical, radiological and biological arguments.
Cervical ultrasound has allowed us to objectify the pathological glands.
The surgical indication was asked before the failure of medical treatment with a rate of PTH over 1000 pg/ml.
All patients were dialyzed 24 hours before surgery and immediately after surgery.
Post operative follow-up was based on the dosage of the parathyroid hormone and standardization in the range of 2 to 9 times (the reference value of the parathyroid hormone in the blood of the laboratory was 15 -65 pg/ml) either 130 -585 pg/ml ( Table 2).
The postoperative follow-up of the patients was done immediately Postoperatively, at 1 week, 1 month, 3 months, 6 months, 1 year, 2 years as shown in Table   3.
The minimum duration of patient follow-up was 6 months:

Results
We have collected 11 cases of secondary hyperparathyroidism in renal failure terminal operated in the service.
100% of patients were made for FAV once or twice.
Hemodialysis has been the type of dialysis performed in 100% of patients.
The echo heart was carried out in 18.2% of cases (2/11), cervical scanner in 18.2% of cases (2/11), the chest radiography in 18.2% of cases (2/11). We did neither the scintigraphy nor the extemporaneous examination of the operating room nor the per operative dosage of the parathyroid hormone.
In pre-operative the average rate of PTH was 2413.51 pg/ml and ranged from 1257 and 3616 as shown in Table 2.
The previous cervicotomy transversal type Kocher has been the path of surgical first performed in 100% of cases.
The surgical technique performed was the subtotal parathyroidectomy or the 7/8th at 100% of the patients. It consisted of the complete removal of the 3 parathyroid glands (of pathological aspect) and half of the last (of healthy appearance) parathyroid gland. We have not conducted any total parathyroidectomy according to Wells.
The postoperative were simple in 81.8% of cases (9/11), complicated in 18.2% (2/11). These 2 complications were a compressive cervical hematoma that was evacuated in emergency by a drain (Redon) and a surgical site infection. We have not recorded lesion of the lower laryngeal nerve.
There has been no death (mortality zero). After 6 months postoperative the rate of PTH has been dosed in 10 patients. He was in the standard desired in 50% of cases (5/10), superior in 50% of cases (5/10).

Discussion
Limitations of the study: We didn't the scintigraphy, surgery was performed on the basis of knowledge in anatomy.
We did neither the extemporaneous examination of the operating room nor the per operative dosage of the parathyroid hormone.
The sex ratio for women in our study (7.2) is consistent with the data in the literature [2] [3] [4].
The female is a risk factor in the occurrence of secondary hyperparathyroidism in chronic renal insufficient patients [1]. The relative risk is multiplied by 2 due to a hypersensitivity to the action of PTH associated with ovarian dysfunction (anovulation and amenorrhea) predisposing to bone consequences rise in hyperparathyroidism secondary [5].
All patients in our study conducted a hemodialysis. Hemodialysis has been practiced in 90% -100% by the authors [1] [2] [5]. The reference value of PTH in this study was 15 -65 pg/ml, and the average rate parathyroid hormone was 2413.51 pg/ml as shown in Table 2.