Optimising the Surgical Management of Secondary and Tertiary Hyperparathyroidism: A Meta-analysis and Examination of Management and Outcomes in the Western Sydney Local Health District (WSLHD)

Abstract

Secondary hyperparathyroidism (SHPT) and tertiary hyperparathyroidism (THPT) are common sequalae of chronic kidney disease associated with significant morbidity and mortality, due to their metabolic and cardiovascular effects. When refractory to medical treatment, surgical parathyroidectomy is the treatment of choice. Due to their multi-gland disease nature, success in surgery can be challenging. Failure to identify and remove all pathological parathyroid glands may result in persistent or recurrent hyperparathyroidism, which is difficult to manage. Reoperative surgery is challenging due to increased perioperative morbidity. Preoperative localisation imaging help identify locations of pathological parathyroid glands. However, there is no strong evidence for the diagnostic test accuracy (DTA) of localisation imaging for SHPT and THPT to guide clinical decision- making.

WSLHD serves a large cohort of renal dialysis and renal transplant patients and the referral for parathyroidectomy for SHPT and THPT are centralised to two of the major hospitals within the health district. There are currently no local guidelines for the indications and timing of referral for parathyroidectomy. There have also been no studies assessing the local performance of preoperative localisation imaging, rate of persistent or recurrent disease and other surgical outcomes. An understanding of the WSLHD experience in surgical management and outcomes would provide insight into how we can optimise the quality of care for SHPT and THPT patients in WSLHD.

The aim of this thesis is to systematically review and meta-analyse the DTA of preoperative localisation imaging for SHPT and THPT, and to provide evidence for the clinical choice of preoperative localisation imaging.

We also aim to evaluate the WSLHD experience of referral practice, choice and performance of preoperative localisation imaging, and other aspects of surgical management and outcomes for patients with SHPT and THPT.