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👉4D-CT scans are more sensitive than sestamibi scans or ultrasound for tumor localization in recurrent parathyroid disease.

👉CheckYourCalcium (realízate un calcio total ensangre).

#CheckYourCalcium #Arrangoiz #ParathyroidExpert #ParathyroidSurgeon #Hiperparatiroidism #Hipercalcemia #CheckYourCalcium #HeadandNeckSurgeon #MountSinaiMedicalCenter #MSMC #Miami #Mexico #Hyperparathyroidism

👉Find more info at http://www.hiperparatiroidismo.info and https://www.ncbi.nlm.nih.gov/pubmed/29484563

👉The overproduction of parathyroid hormone (PTH), termed hyperparathyroidism (HPT), can be categorized as primary, secondary, or tertiary.

👉Primary hyperparathyroidism (PHPT) arises from an unregulated overproduction of PTH from an abnormal parathyroid gland.

👉Increased PTH levels may also occur as a compensatory response to hypocalcemic states resulting from chronic renal failure or gastrointestinal (GI) malabsorption of calcium. This secondary HPT can be reversed by correction of the underlying problem (e.g., kidney transplantation for chronic renal failure).

👉However, chronically stimulated parathyroid glands may occasionally become autonomous, resulting in persistence or recurrence of the hypercalcemia after successful renal transplantation, resulting in tertiary HPT. This review paper will focus on PHTP

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👉The changes in calcium and phosphate that result from renal hyperparathyroidism may increase calcification of the arteries leading to heart attacks and strokes.

👉Learn more at https://www.atherosclerosis-journal.com/article/S0021-9150(18)31349-2/fulltext

👉CheckYourCalcium (realízate un calcio total en sangre).

👉Para más información: http://www.hiperparatiroidismo.info

#CheckYourCalcium #Arrangoiz #ParathyroidExpert #ParathyroidSurgeon #Hiperparatiroidism #Hipercalcemia #CheckYourCalcium #HeadandNeckSurgeon #MountSinaiMedicalCenter #MSMC #Miami #Mexico #Hyperparathyroidism

• Focused parathyroidectomy:
  • Is the preferred approach in patients who have a solitary lesion:
    • That is imaged conclusively by:
      • Ultrasound, sestamibi, or other appropriate imaging modalities
• If the surgeon is not attempting to visualize all four glands:
  • The use of IOPTH:
    • To determine whether all hyperfunctioning tissue has been removed and to document an appropriate drop in PTH levels after the removal of the suspected gland:
      • Is the standard of care
• The most common criterion used:
  • Is a 50% or greater reduction in the PTH level from the baseline 10 minute after parathyroidectomy
• The best clinical marker of single-gland disease:
  • Is concordant preoperative imaging:
    • In combination with an appropriate correction of IOPTH levels
• Previous neck surgery or lack of concordant imaging on two types of studies:
  • Is not a contraindication to attempting focused parathyroidectomy
• Patients suspected of having multigland disease are managed by four-gland exploration via a smaller incision

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #Hypercalcemia #PHPT #Hyperparathyroidism #PrimaryHyperparathyroidism #EndocrineSurgery #HeadandNeckSurgeon #CancerSurgeon #Surgeon #Teacher #Miami #Mexico #MountSinaiMedicalCenter #MSMC

👉Per American Association of Endocrine Surgeons (AAES) Guidelines, parathyroidectomy is recommended for all patients under 50 with a diagnosis of primary hyperparathyroidism, regardless of the presence of symptoms or physical findings – Dr. Rodrigo Arrangoiz

👉https://jamanetwork.com/journals/jamasurgery/fullarticle/2542667

👉For more information: http://www.hiperparatiroidismo.info

#Arrangoiz #ParathyroidExpert #ParathyroidSurgeon #Hyperparathyroidism #Hipercalcemia #HeadandNeckSurgeon #MountSInaiMedicalCenter #MSMC #Miami #Mexico #Hiperparatiroidismo #ExpertoenParatiroides #CirujanodeParatiroides

• Exposure of the Prevertebral Fascia:
  • The first step in identifying the superior gland:
    • Is to locate the inferior thyroid artery (ITA)
  • The ITA is a crucial reference point for the location of the superior parathyroid gland:
    • The superior parathyroid gland is usually found in an area 1 cm cranial to the ITA
  • Once the ITA has been identified, blunt dissection cranial to the artery and directly posterior is performed down to the shiny prevertebral fascia
  • The prevertebral fascia defines the posterior extent of the dissection, and the most posterior location possible for a superior parathyroid gland
• Visual:
  • Although it is tempting to dive straight in and attempt to dissect the first piece of tissue that resembles parathyroid tissue, considerable time and effort can be saved by slowly and deliberately confirming the key landmarks and looking for some of the morphological features described in section “Pearls for Identification of Parathyroid Glands” (published in a previous Blog)
  • The identification of a parathyroid gland begins withcareful visual inspection:
    • Start by looking for a gland or fat pad in a 1 to 2-cm area cranial to the ITA on the posterior surface of the thyroid lobe (Figure 1)
• Digital
  • The superior glands can be found in a number of positions in association with structures from the fourth branchial arch, including:
    • Retropharyngeal
    • Retroesophageal
    • Para-esophageal
    • Adjacent the hyoid bone
  • Further, when a superior gland enlarges:
    • It tends to do so in a posterior and caudal direction and can pass behind the ITA to lie below the inferior gland
  • After careful visual inspection in the area 1 cm cranial tothe ITA, these potential positions are digitally palpatedfor using five maneuvers (Fig. 1.4):
    • The index finger is introduced into the space previously created above the ITA and directly down to the prevertebral fascia / retroesophageal space and then swept along the esophagus to feel in the retroesophageal / retropharyngeal positions
    • The finger is then swung caudally until the finger lies vertically with the tip below the ITA
    • The tissue over the tip of the finger is gently balloted, feeling for an enlarged superior gland to contact the tip of the posterior index finger
    • The finger is then swung back to a horizontal position
    • The finger is withdrawn slowly while the tip remain in contact with the esophagus and trachea, deliberately feeling for the trachea-esophageal groove

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #Hyperparathyroidism #Hypercalcemia #HeadandNeckSurgeon #MSMC #MountSinaiMedicalCenter #Miami #Mexico #Surgeon #Teacher

👉Normocalcemic hyperparathyroidism (HPT) is characterized by normal calcium, high PTH levels, and may be a distinct entity that behaves differently than classical HPT.

👉Rodrigo Arrangoiz MS, MD, FACS cirujano de tumores de cabeza y cuello / cirugia endocrina es experto en el manejo del hiperparatiroidismo primario.

👉Introdujo a su país (Mexico) la técnica de exploración bilateral de cuello con valoración de la funcionalidad de las glándulas paratiroides con paratiroidectomia radioguiada:

https://m.youtube.com/watch?v=AgvQmtz1gnA&time_continue=127

👉Su entrenamiento fue el siguiente:

• Cirugia general y gastrointestinal:
• Michigan State University:
• 2004 al 2010• Cirugia oncológica / tumores de cabeza y cuello / cirugia endocrina:
• Fox Chase Cancer Center (Filadelfia):
• 2010 al 2012• Maestria en ciencias (Clinical research for healthprofessionals):
• Drexel University (Filadelfia):
• 2010 al 2012• Cirugia de tumores de cabeza y cuello / cirugiaendocrina
• IFHNOS / Memorial Sloan Kettering Cancer Center:
• 2014 al 2016

#Arrangoiz

#CirugiadeTumoresdeCabezayCuello

#CirugiaEndocrina

#CirugiaOncologica

#HeadandNeckSurgery

#EndocrineSurgery

#SurgicalOncology

#Hyperparathyroidism

#Hiperparatiroidism

#MountSinaiMedicalCenter

#MSMC

#Miami

#Mexico

• Primary hyperparathyroidism (PHPT) is seen in 0.1% to 0.5% of the adult population:
  • It is the most common cause of hypercalcemia (high calcium level) in the general population
  • It is about three times to four times more common in women than men
  • Patients are usually older, with an average age at presentation of 65 years:Most cases are over 45 years
• Learn more at:https://collectedmed.com/index.php/article/article/demo_article_display/7545/83/2/1

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #Hyperparathyroidism #PrimaryHyperparathyroidism #CancerSurgeon #EndocrineSurgery #Teacher #Surgeon #HeadandNeckSurgeon #SurgicalOncologist #ParathyroidAdenoma #Hypercalcemia #ElevatedCalciumLevels #Miami #MountSinaiMedicalCenter #MSMC #Mexico #Hialeah

• Primary Hyperparathyroidism (PHPT):
  • Is a common disorder:
    • Affecting 100,000 individuals annually in the United States
  • PHPT occurs in 0.1% to 0.3% of the general population
  • Is more common in women (1:500) than in men (1:2000)
  • Increased PTH production leads to hypercalcemia via:
    • Increased GI absorption of calcium, increased production of vitamin D3, and reduced renal calcium clearance
  • PHPT is characterized by increased parathyroid cell proliferation and PTH secretion:
    • That is independent of calcium levels

• Atypical presentations of PHPT include a spectrum of disturbances in calcium homeostasis, ranging from:
  • Symptomatic severe hypercalcemia (parathyroid crisis) to normocalcemic PHPT
• Laboratory testing often can distinguish atypical presentations of PHPT from other diseases, such as:
  • Malignancy
  • Familial hypocalciuric hypercalcemia (FHH)
  • Secondary hyperparathyroidism
• In PHPT and FHH:
  • The calcium and PTH levels:
    • Are usually simultaneously elevated
• Nonparathyroid-mediated causes of hypercalcemia, including milk-alkali syndrome, granulomatous disease, and hypervitaminosis D:
  • Are associated with suppressed rather than elevated PTH concentrations
• Malignancy:
  • PHPT and malignancy are the most common causes of hypercalcemia:
    • Accounting for more than 90% of the cases:
      • It is usually not difficult to differentiate between them
  • Malignancy is often evident clinically by the time it causes hypercalcemia:
    • Patients with hypercalcemia of malignancy have higher calcium concentrations and are more symptomatic from hypercalcemia than individuals with PHPT
    • However, it may be difficult to differentiate the two problems clinically when the presentation is less typical:
      • As an example, some patients with occult malignancy may present with mild hypercalcemia
      • Alternatively, patients with hyperparathyroidism can occasionally have acute onset of severe, symptomatic hypercalcemia (parathyroid crisis):
        • In these cases, measurement of intact PTH will usually distinguish the two diseases:
          • Intact PTH concentrations are generally:
            • Undetectable or very low in hypercalcemia of malignancy
            • Elevated or high-normal in PHPT
        • It is uncommon for patients with hypercalcemia of malignancy to have elevated PTH levels:
          • But this finding may occur rarely in individuals with:
            • Hypercalcemia of malignancy and concomitant PHPT or
            • In individuals with PTH-secreting tumors:
              • Which are also rare
    • Patients with parathyroid carcinomas:
      • Have severe hypercalcemia and PTH levels in the hundreds to thousands pg/mL range
• Familial hypocalciuric hypercalcemia (FHH):
  • An autosomal dominant disorder characterized by:
    • Longstanding, mild hypercalcemia:
      • Normal or mildly elevated PTH levels
      • Low urinary calcium excretion:
        • Less than 100 mg/24 hours
  • In most cases, it is due to:
    • An inactivating mutation in the calcium-sensing receptor in the parathyroid glands and the kidneys
  • A family history of hypercalcemia:
    • Especially in young children
    • And the absence of symptoms and signs of hypercalcemia are characteristic of this disorder
  • 15% to 20% of patients with FHH:
    • May have a mildly elevated PTH concentration:
      • In these individuals, it may be difficult to distinguish asymptomatic PHPT from FHH:
        • It is important to make this distinction, however, because FHH is a benign inherited condition:
          • That typically does not require parathyroidectomy and will not be cured by it
  • The major feature that distinguishes FHH from PHPT is:
    • A low urine calcium excretion and calcium/creatinine (Ca/Cr) clearance ratio
  • In contrast, in the absence of hypovitaminosis D, most patients with PHPT have either normal or elevated urinary calcium excretion. Because the calcium-sensing receptor is a cation receptor, urinary magnesium excretion parallels calcium excretion and is therefore low in FHH, in contrast with PHPT. Measurement of urinary magnesium is not, however, recommended in the evaluation of PHPT or FHH.
• Drugs — Two drugs deserve special consideration when evaluating a patient for hyperparathyroidism: thiazide diuretics and lithium.
• Thiazide diuretics, including chlorthalidone, reduce urinary calcium excretion and therefore can cause mild hypercalcemia (up to 11.5 mg/dL [2.9 mmol/L). In addition, some patients with hyperparathyroidism may be prescribed thiazides, which may elevate the serum calcium further and thereby unmask the hyperparathyroidism. Following discontinuation of the drug, these individuals remain hypercalcemic, although perhaps less so, and are found to have surgically proven hyperparathyroidism. Thus, if a patient taking a thiazide is found to be hypercalcemic, the drug should be withdrawn, if possible, and calcium and PTH assessed three months later. Persistent hypercalcemia (with elevated or high-normal PTH) after drug withdrawal suggests that the thiazide has unmasked PHPT.
• Lithium decreases parathyroid gland sensitivity to calcium, shifting the calcium-PTH curve to the right. Lithium may also reduce urinary calcium excretion. Lithium is thought to affect calcium-PTH dynamics through an action downstream of the calcium-sensing receptor, but the exact locus is still unknown. Some patients taking lithium develop hypercalcemia and hypocalciuria, and a subset of these individuals have high serum PTH concentrations. If the lithium can be stopped without exacerbating the psychiatric condition, the hypercalcemia may resolve. Following discontinuation, the serum calcium concentration is more likely to normalize if the duration of lithium use had been relatively short (eg, less than a few years), but less likely if it had been longer (eg, more than 10 years).
• Secondary hyperparathyroidism — Occasionally, patients with PHPT have consistently normal total and ionized calcium concentrations (normocalcemic PHPT). These patients typically come to medical attention in the setting of an evaluation for low bone mineral density (BMD). In these cases, it may be difficult to distinguish secondary hyperparathyroidism from early PHPT because the biochemical findings may be similar.
• Secondary hyperparathyroidism occurs when the parathyroid gland appropriately responds to a reduced level of extracellular calcium. PTH concentrations rise, and calcium is mobilized by increasing intestinal absorption (via increase in calcitriol) and by increasing bone resorption. Thus, it is characterized biochemically by elevated PTH and normal or low serum calcium concentrations.
• Secondary hyperparathyroidism may occur in patients with renal insufficiency or failure and impaired calcitriol (1,25 dihydroxyvitamin D) production, as well as in individuals with inadequate calcium intake or absorption, as can occur with vitamin D deficiency or with gastrointestinal diseases causing malabsorption. Assessment of renal function (serum creatinine), vitamin D status (25-hydroxyvitamin D [25(OH)D]), and calcium sufficiency (urinary calcium excretion) may help differentiate normocalcemic primary and secondary hyperparathyroidism. Further assessment and work-up for specific gastrointestinal disorders is generally undertaken only when the clinical suspicion is high.
• Some patients may have more than one condition leading to increased PTH secretion. Co-existing PHPT and vitamin D deficiency is not uncommon. When this occurs, the serum calcium level in the primary hyperparathyroid patient may be reduced (into the normal range in some cases) due to vitamin D deficiency.

#Arrangoiz #ParathyroidSurgeon #EndocrineSurgery #CancerSurgeon #HeadandNeckSurgeon #SurgicalOncologist #MountSinaiMedicalCenter #MSMC #Miami #Mexico