Assessment of ultrasound guided percutaneous ethanol injection and parathyroidectomy in patients with tertiary hyperparathyroidism

Background. Tertiary hyperparathyroidism continues to cause significant mor bidity in patients with chronic renal failure. This is frequently resistant to medical management and may ultimately require a surgical parathyroidect omy. Recent studies have reported upon the technique of percutaneous ethano l ablation for both primary and tertiary hyperparathyroidism. In this study we report on a 5 year experience using ethanol injection and compare the r esults with surgical parathyroidectomy. Methods. A prospective study in 39 patients with tertiary hyperparathyroidi sm, 25 were dialysis dependent and 14 had a functioning renal allograft. Tw enty-two patients underwent percutaneous fine needle ethanol injection (PFN EI) and 17 underwent surgical parathyroidectomy. Results. A > 30% reduction in intact parathyroid hormone (iPTH) was achieve d in Il of 22 patients undergoing PFNEI after a mean of 1.8+/-1.4 injection s per gland. In four patients, symptomatic hyperparathyroidism recurred and they required further PFNEI or surgical parathyroidectomy at 17, 28, 46, a nd 48 months later. There was no significant reduction in iPTH in 11 patien ts following PFNEI after a mean of 2.5+/-1.3 injections per gland. They all required a subsequent surgical parathyroidectomy for symptomatic hyperpara thyroidism. Four patients developed a laryngeal nerve palsy following PFNEI , two of which were permanent. Seventeen patients underwent successful surg ical parathyroidectomy as a primary procedure. Conclusion. Whilst PFNEI is successful in primary hyperparathyroidism, when typically only one adenoma is present, the effectiveness of PFNEI is unpre dictable and the long term results are poor compared with those of surgical parathyroidectomy in tertiary hyperparathyroidism. The procedure is not wi thout complications and makes subsequent surgery more difficult. Therefore it can only be recommended for patients with a known single parathyroid gla nd such as patients in whom hyperparathyroidism has recurred following a pr evious surgical subtotal parathyroidectomy and who are unsuitable for furth er surgery.