Application of Endoscopic Total Parathyroidectomy with Autotransplantation in the Treatment of Secondary Hyperparathyroidism in Chronic Renal Failure

Application of Endoscopic Total Parathyroidectomy with Autotransplantation in the Treatment of Secondary Hyperparathyroidism in Chronic Renal Failure | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Application of Endoscopic Total Parathyroidectomy with Autotransplantation in the Treatment of Secondary Hyperparathyroidism in Chronic Renal Failure Hong Xu, LIQUAN YU This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8684891/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 13 You are reading this latest preprint version Abstract Objective To study the clinical efficacy of endoscopic total parathyroidectomy with autotransplantation (ETPTX + AT) in the treatment of secondary hyperparathyroidism (SHPT) in chronic renal failure. Methods A total of 433 patients who underwent ETPTX + AT in our hospital from March 2019 to March 2024 were collected. The intraoperative conditions, postoperative complications, and changes in preoperative and postoperative biochemical indicators were observed by comparing the preoperative and postoperative serum calcium, serum phosphorus, and parathyroid hormone (PTH) levels of the patients. Results Among the patients, 412 (95.2%) had postoperative PTH < 100 pg/ml. The postoperative PTH, serum calcium, and serum phosphorus of the patients were significantly lower than those before surgery, and the differences were statistically significant (P < 0.05). During the perioperative period, 1 patient (0.23%) died of cardiac insufficiency, 4 patients (0.9%) had transient recurrent laryngeal nerve injury, 69 patients (15.9%) developed postoperative hypocalcemia (< 2.1 mmol/L), 1 patient (0.23%) was converted to open surgery, 7 patients (1.6%) had upper extremity vascular fistula occlusion after surgery, and 1 patient (0.23%) had cervical hematoma. Conclusion ETPTX is a very effective method for the treatment of SHPT, which can significantly reduce the patient's PTH, serum calcium, and serum phosphorus levels. Endoscopic total parathyroidectomy with autotransplantation (ETPTX + AT) Secondary hyperparathyroidism in chronic renal failure (SHPT) Parathyroid hormone (PTH) Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Research Data and Methods 1.1 Research Data A total of 433 patients who underwent ETPTX+AT in the Department of General Surgery, the Second Affiliated Hospital of Anhui Medical University from March 2019 to March 2024 were selected (Table 1). The surgical inclusion criteria were summarized according to relevant guidelines [1] and years of clinical experience in our department: 1. No severe cardiopulmonary or other functional disorders and able to tolerate general anesthesia surgery; 2. PTH ≥ 500 pg/ml (reference value 15-65 pg/ml); 3. Obvious elevation of serum calcium or phosphorus; 4. Patients with severe osteoarticular pain, skeletal deformity, pathological fractures, skin itching, etc., affecting the quality of life; 5. Poor effect of standardized internal medicine treatment; 6. Recent kidney transplantation and expected risk of severe hypercalcemia after transplantation. Patients who met the above inclusion criteria were re-evaluated for their ability to tolerate the establishment of a CO 2 pneumoperitoneum. For example, those with a history of neck surgery or neck intubation dialysis underwent ETPTX according to their own wishes. All patients were treated by the same team of surgeons.This study was approved by the Ethics Committee of the Second Affiliated Hospital of Anhui Medical University, and informed consent was obtained from the patients and their families. 1.2 Preoperative Preparation SHPT patients with surgical indications were first admitted to the Department of Nephrology of our hospital for preoperative examination and internal medicine treatment. Patients who wished to undergo laparoscopic surgery were fully evaluated, and consultations with relevant departments were completed to rule out surgical contraindications. They were transferred to the department for surgical treatment on the basis of full communication of surgical risks. All patients could receive emergency dialysis treatment if necessary. 1.3 Surgical Methods After successful anesthesia, the patient was placed in a supine position with a pillow under the shoulders and the head tilted back. Routine disinfection and draping were performed, and the surgeon and assistant stood on both sides of the patient. The anterior sternal approach was adopted. An expansion fluid was prepared with 250 ml of 0.9% NS + 1 mg of epinephrine. 50-100 ml of the expansion fluid was injected by infiltration in the pre-created space area under the anterior chest wall and platysma muscle. An incision of about 1 cm was made about 4 cm below the jugular notch, reaching the deep fascia layer. A dissector was used for blunt subcutaneous dissection, and an observation port was inserted. Incisions of 5 mm and 5 mm for operation ports were made about 4 cm above the bilateral nipples respectively (Figure 1). CO 2 gas was injected, and the pressure was maintained at 6-8 mmHg. The operation ports were inserted under direct vision. After establishing the operation space by ultrasonic scalpel dissection, the ultrasonic scalpel was used to dissect the skin flap superficially in the deep subcutaneous fascia, extending upward to the midpoint of the thyroid cartilage and bilaterally to the near lateral edge of the sternocleidomastoid muscle. The cervical white line was incised to the thyroid capsule, and then the space between the anterior cervical muscles was dissected along the superficial surface of the thyroid capsule. One side of the thyroid gland was fully dissected and flipped to the opposite side. The hyperplastic parathyroid glands were explored on the dorsal side of the thyroid gland, dissected by a combination of sharp and blunt dissection, the blood vessels of the parathyroid glands were treated with an ultrasonic scalpel, and the parathyroid glands were resected (Figure 2). Efforts were made to preserve the cervical blood vessels, and the recurrent laryngeal nerve was routinely dissected and protected. After the operation, the surgical field was irrigated, hemostasis was confirmed, and a drainage tube was placed in the surgical field and led out through the 5 mm operation port. The wound was sutured, and the surgical field was bandaged with compression (Figure 3). A part of the resected parathyroid tissue was taken for intraoperative frozen pathological examination, and the remaining parathyroid tissue was preserved in ice saline for transplantation. After pathological confirmation, the selected parathyroid tissue was cut into 2 mm × 2 mm particles. A straight incision was made on the lateral side of the right thigh, and after incision, the specimen was transplanted close to the dermis, with 1 particle implanted at each site, totaling 4 particles (Figure 4). 1.4 Postoperative Management Electrocardiographic monitoring was performed for 24 hours after the operation to monitor the patient's vital signs. The amount and color of drainage from the surgical area were observed, as well as the presence of hoarseness, choking when drinking water, dyspnea, convulsions of the limbs and corners of the mouth, etc. A tracheotomy kit and a negative pressure aspirator were routinely prepared at the bedside. Patients received routine intravenous calcium supplementation immediately after returning to the ward, and serum calcium was monitored every 6 hours after the operation. If the patient developed hypocalcemic symptoms, calcium supplementation by intravenous pump was added, and the pump speed was adjusted according to the serum calcium level to maintain the patient's serum calcium at 2.1 mmol/L. 1.5 Observation Indicators and Effect Evaluation The operation time, intraoperative blood loss, postoperative drainage volume, postoperative complications, and hospital stay of the patients were observed. The preoperative and postoperative PTH, serum calcium, and phosphorus results were collected to evaluate the surgical success rate. The criteria for judging surgical success adopted the standards of the 2021 Chinese Expert Consensus on Surgical Clinical Practice for Secondary Hyperparathyroidism in Chronic Kidney Disease [2] , that is, the minimum postoperative PTH < 100 pg/ml. 1.6 Statistics All data were analyzed using SPSS 23.0 statistical software package, and t-test was performed. The results were expressed as ±s, and P<0.05 was considered statistically significant. 2. Results 2.1 Intraoperative Surgical Indicators (see Table 2) 2.2 Surgery and Postoperative Complications Among the 433 patients who underwent ETPTX+AT in this study, 412 patients had postoperative PTH < 100 pg/ml, with a surgical success rate of 95.2%. Among the 421 patients with complete resection of 4 parathyroid glands, 9 still had high postoperative PTH. 11 patients had 3 parathyroid glands resected, and 1 patient had 2 resected. 1 patient was converted to open surgery due to severe cervical adhesion, unclear anatomical layers, and intraoperative bleeding caused by preoperative neck intubation dialysis. 1 patient died of cardiac insufficiency during the perioperative period. 4 patients developed hoarseness accompanied by choking when eating, which was significantly improved before discharge after symptomatic treatment with neurotrophic drugs. 69 patients developed early postoperative hypocalcemia (<2.1 mmol/L), and 2 patients developed intractable hypocalcemia. Postoperative upper extremity vascular fistula occlusion occurred in 7 patients, and cervical hematoma occurred in 1 patient. 2.3 Changes in Preoperative and Postoperative Biochemical Indicators The postoperative PTH, serum calcium, and serum phosphorus of the patients were significantly lower than those before surgery (see Table 3), and the differences were statistically significant (P<0.05). 3. Discussion Secondary hyperparathyroidism (SHPT) in chronic renal failure is one of the most common complications in patients with chronic kidney disease [ 3 ] . It is a pathophysiological state of compensatory hyperplasia of the parathyroid glands and excessive secretion of parathyroid hormone (PTH) caused by the body's attempt to correct calcium and phosphorus metabolism disorders [ 4 ] . The symptoms of SHPT mostly involve multiple systems such as the skeleton, neuromuscular system, and cardiovascular system, which seriously affect the patient's lifespan and quality of life [ 5 ] . Common clinical treatment methods for SHPT include internal medicine drug treatment and surgical treatment [ 6 ] . For refractory SHPT that is ineffective to drug treatment, surgical treatment is recommended by domestic and foreign treatment guidelines [ 7 – 8 ] . With the continuous improvement of technical level, laparoscopic parathyroid surgery has become a routinely performed surgical method in recent years [ 9 ] . Benefiting from the early cooperation between our department and the Department of Nephrology, we have accumulated a lot of open parathyroid surgery skills. After a mature learning curve, our department has routinely carried out ETPTX + AT since 2019. Laparoscopic surgery benefits from the good field of vision and magnification provided by the endoscope, which is easy to identify the small blood vessels on the surface of the thyroid gland, making the intraoperative operation of the chief surgeon more precise. The use of ultrasonic scalpel in laparoscopic surgery is also significantly better than that of traditional electrosurgical knife, mainly reflected in the good hemostatic effect and less smoke generated during the operation, which reduces the impact on the surgical field of vision. Since laparoscopic surgery is performed in a closed cavity, the contact between internal tissues and external air is reduced, the chance of surgical site infection is reduced, and the small incision of laparoscopic surgery has a relatively lower infection rate compared with the large transverse incision of open surgery. In this study, only 1 case of superficial infection of the chest incision occurred, and the wound healed well after routine dressing change. Seven patients developed vascular fistula occlusion after surgery. Except for the patients' own fistula vascular conditions, the possible causes were local vascular compression caused by intraoperative posture and excessive fluctuation of intraoperative blood pressure. Through communication with operating room nurses and anesthesiologists, proper posture and stable intraoperative blood pressure control have greatly reduced this situation. Recurrent laryngeal nerve injury is one of the common complications during parathyroid surgery. Most of them are caused by improper intraoperative operation, and a few can also be caused by compression or traction of hematoma or scar tissue. The recurrent laryngeal nerve ascends along the tracheoesophageal groove, and the parathyroid glands are mostly located near the recurrent laryngeal nerve. The upper pole parathyroid gland is adjacent to the entry of the recurrent laryngeal nerve into the larynx, and improper operation here is likely to damage the recurrent laryngeal nerve. The relationship between the recurrent laryngeal nerve and the inferior thyroid artery is relatively complex near the lower pole of the lateral lobe. Therefore, when performing resection of the lower pole parathyroid gland, sufficient space should be reserved to avoid damaging the recurrent laryngeal nerve. With the upgrading and updating of medical equipment, the routine use of 4K high-definition and 3D lenses provides the chief surgeon with more magnified, clear, and three-dimensional images, making it relatively simple to identify the recurrent laryngeal nerve and blood vessels, and the probability of accidental surgical injury is greatly reduced. In this study, 4 patients developed hoarseness accompanied by choking when eating, which was significantly improved before discharge after symptomatic treatment with neurotrophic drugs. Intraoperative bleeding is one of the main reasons for converting laparoscopic surgery to open surgery. Postoperative bleeding is a serious complication that may lead to asphyxia. The incidence of bleeding after thyroid and parathyroid surgery is 0.07%~5% [ 10 ] . How to avoid bleeding and quickly resolve bleeding is the key to carrying out laparoscopic parathyroid surgery. Most of the blood vessels of the parathyroid glands originate from the thyroid blood vessels and are relatively slender. In addition, abnormal calcium and phosphorus metabolism in dialysis patients will lead to vascular calcification, reducing vascular elasticity and narrowing the lumen. Moreover, hypertension is very common in uremic patients. These are all unfavorable factors for intraoperative bleeding. Therefore, during operation, excessive traction of blood vessels leading to laceration and bleeding should be avoided. Secondly, the thyroid gland should be turned up gently when exposing the parathyroid glands to avoid damaging the blood vessels on the surface of the thyroid gland [ 11 – 12 ] . Once vascular rupture and bleeding occur, gauze compression can be used to stop bleeding first, and then treatment can be performed when the field of vision is clear. According to the daily experience of our department, most bleeding can be stopped with an ultrasonic scalpel. If necessary, suture ligation can be used to ensure hemostasis, and drainage should be routinely placed. In this study, only 1 patient was converted to open surgery due to intraoperative bleeding. Different from the previous autotransplantation of parathyroid glands into the patient's upper arm, our ward has changed the transplantation site to the lateral side of the patient's thigh through years of experience summary. Firstly, the factors causing hyperplasia of parathyroid function in patients with uremia still exist [ 13 ] , so even if the graft is transferred to the lower extremities, the survival rate is still very high. Secondly, vascular fistulas for renal dialysis are mostly located in the upper arm blood vessels of patients. Once the vascular fistula is occluded after long-term dialysis, a new vascular fistula needs to be performed, so the transplantation area is bound to have an impact on the vascular fistula. Thirdly, a few patients have postoperative recurrence. Transplantation to the thigh may facilitate surgical resection and have less impact on the patient's vascular fistula. Due to the large range of skin flap dissection in laparoscopic surgery, the incidence of postoperative skin ecchymosis or subcutaneous hematoma may increase. Secondly, dialysis patients have poor coagulation function, and the skin is prone to ecchymosis when slightly squeezed. In addition, the instability of dialysis effect and tissue interstitial edema are also likely to aggravate the formation of subcutaneous hematoma. When dissecting the skin flap to establish the surgical operation space, the correct anatomical plane should be mastered, and an appropriate pressure of CO 2 gas should be used to maintain the operation cavity. Adequate gasification plays a crucial role in the separation of skin flaps by ultrasonic scalpel. When CO 2 is perfused at high pressure for a long time, severe intracranial hypertension, extensive subcutaneous emphysema, and mediastinal emphysema may occur, which may affect respiratory and circulatory functions in severe cases. Our department has summarized that maintaining the pressure at 6–8 mmHg is a very safe limit, and none of the 433 laparoscopic surgeries performed had the above situations. The incidence of hypocalcemia in dialysis patients is 27% [ 14 ] , while patients with ETPTX + AT are more likely to develop hypocalcemia due to rapid bone calcium uptake after surgery, which is often called "hungry bone syndrome" [ 15 ] . In view of the fact that the patient's preoperative dry weight and serum PTH level are independent risk factors for severe hypocalcemia in SHPT patients after surgery, in addition, the patient's age, dialysis time, serum calcium, etc. should be combined to predict the degree of postoperative hypocalcemia and formulate an individualized calcium supplementation plan [ 16 – 17 ] . In this study, 69 patients developed early postoperative hypocalcemia (serum calcium below 2.1 mmol/L), which was quickly corrected after routine calcium supplementation. Among them, 2 patients developed intractable hypocalcemia, and the serum calcium of these 2 patients was basically stable after nearly 4 weeks of calcium supplementation treatment before discharge. Among the 421 patients with complete resection of 4 parathyroid glands, 9 still had high postoperative PTH, 11 patients had 3 parathyroid glands resected, and 1 patient had 2 resected. Ectopic parathyroid glands are considered, which may be located in the sternum, mediastinum, thymus, etc [ 18 ] . Inaccurate preoperative localization, multiple parathyroid glands, and ectopic parathyroid glands can all lead to difficulty in complete surgical resection. Through the analysis of this study, ETPTX + AT significantly reduces the blood PTH level in SHPT patients and maintains the patient's serum calcium and phosphorus at normal levels. It has a high surgical success rate and low complication rate, and is a safe and effective method for the treatment of SHPT. However, due to the short follow-up time, the advantages of this surgical method still need to be further verified. Abbreviations [Endoscopic total parathyroidectomy with autotransplantation (ETPTX+AT); Secondary hyperparathyroidism in chronic renal failure (SHPT); Parathyroid hormone (PTH)] Declarations 2 . Ethics approval and consent to participate [I affirm that this study complies with the principles of the Declaration of Helsinki.This study was approved by the Ethics Committee of the Second Affiliated Hospital of Anhui Medical University, and informed consent was obtained from the patients and their families.] 3. Consent for publication [All authors have agreed to the publication of this manuscript.] 4. Availability of data and materials [by collecting the examination data of patients treated at our hospital] 5. Competing Interests [All authors declare that they have no competing interests.] 6 . Funding [ No funding was received for this study] 7. Authors' contributions [First, we are grateful to Professors Yu Liquan and Li Peikun from the Department of General Surgery, the Second Affiliated Hospital of Anhui Medical University, whose meticulous guidance, rigorous supervision and valuable suggestions throughout the study—from protocol design to manuscript revision—greatly improved the research quality. We also thank Dr. Yu Zhongshan and our research team for their full collaboration and technical support in experiments and data collection, laying a solid foundation for the completion of this study. ] 8. Acknowledgements [Finally, we thank Shu Xiaoxia, our families and friends for their understanding, tolerance and emotional support that motivated us to move forward.] References Dream S, Kuo LE, Kuo JH, et al. The American association of endocrine surgeons guidelines for the definitive surgical management of secondary and tertiary renal hyperparathyroidism[J]. Ann Surg, 2022, 276(3): e141-176. He Qingqing, Tian Wen. Chinese Expert Consensus on Surgical Clinical Practice for Secondary Hyperparathyroidism in Chronic Kidney Disease (2021 Edition)[J]. Chinese Journal of Practical Surgery, 2021, 41(8): 841–848. Levin A, Bakris GL, Molitch M, et al. Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: results of the study to evaluate early kidney disease[J]. Kidney Int, 2007, 71(1): 31–38. Rodzoń-Norwicz M, Norwicz S, Sowa-Kućma M, et al. Secondary hyperparathyroidism in chronic kidney disease: pathomechanism and current treatment possibilities[J]. Endokrynol Pol, 2023, 74(5): 490–498. doi: 10.5603/ep.95820 . Hiramitsu T, Hasegawa Y, Futamura K, et al. Treatment for secondary hyperparathyroidism focusing on parathyroidectomy[J]. Front Endocrinol(Lausanne), 2023, 14: 1169793. doi: 10.3389/fendo.2023.1169793 . Zhou Li, Li Zhihui. Interpretation of the American Association of Endocrine Surgeons' "Guidelines for the Surgical Management of Secondary and Tertiary Hyperparathyroidism"[J]. Chinese Journal of Bases and Clinics in General Surgery, 2023, 30(02): 160–166. Kidney Disease: Improving Global Outcomes CKD-MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD)[J]. Kidney Int Suppl, 2009, 76(113): S1-130. doi: 10.1038/ki.2009.188 . He Q, Zhu J, Zhuang D, et al. Robotic total parathyroidectomy by the axillo-bilateral-breast approach for secondary hyperparathyroidism: a feasibility study[J]. J Laparoendosc Adv Surg Tech A, 2015, 25(4): 311–313. Zhou Peng, Zhuang Dayong, He Qingqing, et al. Da Vinci robotic total parathyroidectomy plus partial gland autotransplantation for renal hyperparathyroidism[J]. Chinese Journal of General Surgery, 2018, 33(1): 49–52. Edafe O, Cochrane E, Balasubramanian SP. Reoperation for Bleeding After Thyroid and Parathyroid Surgery: Incidence, Risk Factors, Prevention, and Management[J]. World J Surg, 2020, 44(4): 1156–1162. doi: 10.1007/s00268-019-05322-2 . PMID: 31822944. He Q, Zhuang D, Zheng L, et al. Harmonic focus compared with classic hemostasis during total parathyroidectomy in secondary hyperparathyroidism: a prospective randomized trial[J]. AMERICAN SURGEON, 2014, 80(12): E342-345. Tian Wen, Zhang Hao. Expert Consensus on the Application of Energy Instruments in Thyroid Surgery (2017 Edition)[J]. Chinese Journal of Practical Surgery, 2017, (9): 992–997. Wang Yongfei, Liu Yihao, Wang Guan, et al. Clinical analysis of 26 cases of refractory secondary hyperparathyroidism treated with total parathyroidectomy and forearm autotransplantation[J]. Chinese Journal of Experimental Surgery, 2023, 40(6): 1109–1112. doi: 10.3760/cma.j.cn421213-20221122-01373 . Lau WL, Obi Y, Kalantar-Zadeh K. Parathyroidectomy in the Management of Secondary Hyperparathyroidism[J]. Clin J Am Soc Nephrol, 2018, 13(6): 952–961. doi: 10.2215/CJN.10390917 . Epub 2018 Mar 9. PMID: 29523679; PMCID: PMC5989682. Jain N, Reilly RF. Hungry bone syndrome[J]. Curr Opin Nephrol Hypertens, 2017, 26(4): 250–255. doi: 10.1097/MNH.0000000000000327 . PMID: 28375869. Liu J, Huang Q, Yang M, et al. Risk factors predicting severe hypocalcemia after total parathyroidectomy without autotransplantation in patients with secondary hyperparathyroidism[J]. International Journal of Endocrinology, 2023, 48(1): 1–9. Yang Guang, Wang Ningning, Zha Xiaoming, et al. Influencing factors of hungry bone syndrome after parathyroidectomy in maintenance hemodialysis patients[J]. Chinese Journal of Nephrology, 2019, 35(8): 568–574. Park HS, Hong N, Jeong JJ, et al. Update on preoperative parathyroid localization in primary hyperparathyroidism[J]. Endocrinology and Metabolism (Seoul, Korea), 2022, 37(5): 744–755. Tables Table 1 Comparison of baseline characteristics of patients Gender Male/ Female（n/n） Age (x̄±s, yr) Dialysis duration （x̄±s，yr） Preoperative PTH (x̄±s, pg/mL) Preoperative serum calcium (x̄±s, mmol/L) Preoperative serum phosphorus (x̄±s, mmol/L) 235/198 48.6±10.2 8.1±4.6 1473.5±60.1 2.33±0.24 2.07±0.49 Table 2 Comparison of Perioperative Surgical Indices in Patients Operative time (x̄±s,min) Intraoperative blood loss (x̄±s,ml) 1st postoperative day drainage volume (x̄±s，ml) 2nd postoperative day drainage volume (x̄±s，ml) 3rd postoperative day drainage volume (x̄±s，ml) Postoperative hospital stay (x̄±s，d) 97.5±30.5 25.6±4.5 30±7 75±10 15±4 11.3±2.9 Table 3 Comparison of Biochemical Indices in Patients serum calcium mmol/L serum phosphorus mmol/L Pth pg/ml Preoperative postoperative t p Preoperative postoperative t p Preoperative postoperative t p 2.332±0.235 2.13±0.29 8.374 <0.001 2.06±0.63 1.15±0.48 21.464 <0.001 1527±205 3(1.48) 26.007 <0.001 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 10 May, 2026 Reviews received at journal 31 Mar, 2026 Reviews received at journal 27 Mar, 2026 Reviews received at journal 22 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviewers agreed at journal 14 Mar, 2026 Reviews received at journal 14 Mar, 2026 Reviewers agreed at journal 12 Mar, 2026 Reviewers invited by journal 12 Mar, 2026 Editor assigned by journal 17 Feb, 2026 Submission checks completed at journal 16 Feb, 2026 First submitted to journal 15 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8684891","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":606218714,"identity":"63d1bc98-06f9-4e07-8aed-2020356dba8d","order_by":0,"name":"Hong Xu","email":"","orcid":"","institution":"Anhui Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Xu","suffix":""},{"id":606218715,"identity":"9eb92a4b-7a36-4691-b849-70155b2789f9","order_by":1,"name":"LIQUAN YU","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYBACNmb2ww8+GEjIMTYzH3zwgcFOzuAAAS187D1phjMqLIyZ29mSDWcwJBtbEtIix3PAQJrnTEViez+PmTQPw8HE/YS0sEkkJBjObJMw5m3m+QbUciBxG2EtiQcefGyTkJNs5t1GrBaoLYakaDGQ5m2TSNx/mOfZ7Ryglg0EtUC8L5HY2MzDVm0D9D5hLZBAljBmbGYzNpxhkGxMMF7km8FRWSfH2H/44YsvFUREJRowIE35KBgFo2AUjAIcAAAD4kiT17HfaAAAAABJRU5ErkJggg==","orcid":"","institution":"Anhui Medical University","correspondingAuthor":true,"prefix":"","firstName":"LIQUAN","middleName":"","lastName":"YU","suffix":""}],"badges":[],"createdAt":"2026-01-24 08:10:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8684891/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8684891/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104874168,"identity":"3f98c344-8d12-440e-a227-f4ec40b81cb1","added_by":"auto","created_at":"2026-03-18 08:29:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":632741,"visible":true,"origin":"","legend":"\u003cp\u003eTrocar Placement for Laparoscopic Surgery\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8684891/v1/c2fd20e5e8a1876ced151080.png"},{"id":104874152,"identity":"c8b1470b-818c-4dfb-b50c-bf8ca74fa4ba","added_by":"auto","created_at":"2026-03-18 08:29:16","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":412180,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative Resection of the Parathyroid Gland\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8684891/v1/25c65b5d62df3e824331a8dd.png"},{"id":104874213,"identity":"36ec0f87-04f5-4f31-a7a1-cc98c191962f","added_by":"auto","created_at":"2026-03-18 08:29:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":502800,"visible":true,"origin":"","legend":"\u003cp\u003eIndwelling Drainage Tube Placement at the Wound Site\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8684891/v1/623d6103fb87919eea8e0338.png"},{"id":104874105,"identity":"6497f4d9-b124-4e2c-a0ee-ee95823151a3","added_by":"auto","created_at":"2026-03-18 08:29:00","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":746176,"visible":true,"origin":"","legend":"\u003cp\u003eSubcutaneous Autologous Transplantation\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8684891/v1/96bc114f42d5159969aca2a3.png"},{"id":105034279,"identity":"d28a7c88-9022-4713-a065-175bfefe99cb","added_by":"auto","created_at":"2026-03-20 07:23:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3602233,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8684891/v1/166d375a-3dc7-4a3a-b793-5a4d32b072bb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Application of Endoscopic Total Parathyroidectomy with Autotransplantation in the Treatment of Secondary Hyperparathyroidism in Chronic Renal Failure","fulltext":[{"header":"1. Research Data and Methods","content":"\u003ch3\u003e1.1 Research Data\u003c/h3\u003e\n\u003cp\u003eA total of 433 patients who underwent ETPTX+AT in the Department of General Surgery, the Second Affiliated Hospital of Anhui Medical University from March 2019 to March 2024 were selected (Table 1). The surgical inclusion criteria were summarized according to relevant guidelines \u003csup\u003e[1]\u0026nbsp;\u003c/sup\u003eand years of clinical experience in our department: 1. No severe cardiopulmonary or other functional disorders and able to tolerate general anesthesia surgery; 2. PTH ≥ 500 pg/ml (reference value 15-65 pg/ml); 3. Obvious elevation of serum calcium or phosphorus; 4. Patients with severe osteoarticular pain, skeletal deformity, pathological fractures, skin itching, etc., affecting the quality of life; 5. Poor effect of standardized internal medicine treatment; 6. Recent kidney transplantation and expected risk of severe hypercalcemia after transplantation. Patients who met the above inclusion criteria were re-evaluated for their ability to tolerate the establishment of a CO\u003csub\u003e2\u003c/sub\u003e pneumoperitoneum. For example, those with a history of neck surgery or neck intubation dialysis underwent ETPTX according to their own wishes. All patients were treated by the same team of surgeons.This study was approved by the Ethics Committee of the Second Affiliated Hospital of Anhui Medical University, and informed consent was obtained from the patients and their families.\u003c/p\u003e\n\u003ch3\u003e1.2 Preoperative Preparation\u003c/h3\u003e\n\u003cp\u003eSHPT patients with surgical indications were first admitted to the Department of Nephrology of our hospital for preoperative examination and internal medicine treatment. Patients who wished to undergo laparoscopic surgery were fully evaluated, and consultations with relevant departments were completed to rule out surgical contraindications. They were transferred to the department for surgical treatment on the basis of full communication of surgical risks. All patients could receive emergency dialysis treatment if necessary.\u003c/p\u003e\n\u003ch3\u003e1.3 Surgical Methods\u003c/h3\u003e\n\u003cp\u003eAfter successful anesthesia, the patient was placed in a supine position with a pillow under the shoulders and the head tilted back. Routine disinfection and draping were performed, and the surgeon and assistant stood on both sides of the patient. The anterior sternal approach was adopted. An expansion fluid was prepared with 250 ml of 0.9% NS + 1 mg of epinephrine. 50-100 ml of the expansion fluid was injected by infiltration in the pre-created space area under the anterior chest wall and platysma muscle. An incision of about 1 cm was made about 4 cm below the jugular notch, reaching the deep fascia layer. A dissector was used for blunt subcutaneous dissection, and an observation port was inserted. Incisions of 5 mm and 5 mm for operation ports were made about 4 cm above the bilateral nipples respectively (Figure 1). CO\u003csub\u003e2\u003c/sub\u003e gas was injected, and the pressure was maintained at 6-8 mmHg. The operation ports were inserted under direct vision. After establishing the operation space by ultrasonic scalpel dissection, the ultrasonic scalpel was used to dissect the skin flap superficially in the deep subcutaneous fascia, extending upward to the midpoint of the thyroid cartilage and bilaterally to the near lateral edge of the sternocleidomastoid muscle. The cervical white line was incised to the thyroid capsule, and then the space between the anterior cervical muscles was dissected along the superficial surface of the thyroid capsule. One side of the thyroid gland was fully dissected and flipped to the opposite side. The hyperplastic parathyroid glands were explored on the dorsal side of the thyroid gland, dissected by a combination of sharp and blunt dissection, the blood vessels of the parathyroid glands were treated with an ultrasonic scalpel, and the parathyroid glands were resected (Figure 2). Efforts were made to preserve the cervical blood vessels, and the recurrent laryngeal nerve was routinely dissected and protected. After the operation, the surgical field was irrigated, hemostasis was confirmed, and a drainage tube was placed in the surgical field and led out through the 5 mm operation port. The wound was sutured, and the surgical field was bandaged with compression (Figure 3). A part of the resected parathyroid tissue was taken for intraoperative frozen pathological examination, and the remaining parathyroid tissue was preserved in ice saline for transplantation. After pathological confirmation, the selected parathyroid tissue was cut into 2 mm × 2 mm particles. A straight incision was made on the lateral side of the right thigh, and after incision, the specimen was transplanted close to the dermis, with 1 particle implanted at each site, totaling 4 particles (Figure 4).\u003c/p\u003e\n\u003ch3\u003e1.4 Postoperative Management\u003c/h3\u003e\n\u003cp\u003eElectrocardiographic monitoring was performed for 24 hours after the operation to monitor the patient's vital signs. The amount and color of drainage from the surgical area were observed, as well as the presence of hoarseness, choking when drinking water, dyspnea, convulsions of the limbs and corners of the mouth, etc. A tracheotomy kit and a negative pressure aspirator were routinely prepared at the bedside. Patients received routine intravenous calcium supplementation immediately after returning to the ward, and serum calcium was monitored every 6 hours after the operation. If the patient developed hypocalcemic symptoms, calcium supplementation by intravenous pump was added, and the pump speed was adjusted according to the serum calcium level to maintain the patient's serum calcium at 2.1 mmol/L.\u003c/p\u003e\n\u003ch3\u003e1.5 Observation Indicators and Effect Evaluation\u003c/h3\u003e\n\u003cp\u003eThe operation time, intraoperative blood loss, postoperative drainage volume, postoperative complications, and hospital stay of the patients were observed. The preoperative and postoperative PTH, serum calcium, and phosphorus results were collected to evaluate the surgical success rate. The criteria for judging surgical success adopted the standards of the 2021 Chinese Expert Consensus on Surgical Clinical Practice for Secondary Hyperparathyroidism in Chronic Kidney Disease \u003csup\u003e[2]\u003c/sup\u003e, that is, the minimum postoperative PTH \u0026lt; 100 pg/ml.\u003c/p\u003e\n\u003ch3\u003e1.6 Statistics\u003c/h3\u003e\n\u003cp\u003eAll data were analyzed using SPSS 23.0 statistical software package, and t-test was performed. The results were expressed as ±s, and P\u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"2. Results","content":"\u003ch3\u003e2.1 Intraoperative Surgical Indicators (see Table 2)\u003c/h3\u003e\n\u003ch3\u003e2.2 Surgery and Postoperative Complications\u003c/h3\u003e\n\u003cp\u003eAmong the 433 patients who underwent ETPTX+AT in this study, 412 patients had postoperative PTH \u0026lt; 100 pg/ml, with a surgical success rate of 95.2%. Among the 421 patients with complete resection of 4 parathyroid glands, 9 still had high postoperative PTH. 11 patients had 3 parathyroid glands resected, and 1 patient had 2 resected. 1 patient was converted to open surgery due to severe cervical adhesion, unclear anatomical layers, and intraoperative bleeding caused by preoperative neck intubation dialysis. 1 patient died of cardiac insufficiency during the perioperative period. 4 patients developed hoarseness accompanied by choking when eating, which was significantly improved before discharge after symptomatic treatment with neurotrophic drugs. 69 patients developed early postoperative hypocalcemia (\u0026lt;2.1 mmol/L), and 2 patients developed intractable hypocalcemia. Postoperative upper extremity vascular fistula occlusion occurred in 7 patients, and cervical hematoma occurred in 1 patient.\u003c/p\u003e\n\u003ch3\u003e2.3 Changes in Preoperative and Postoperative Biochemical Indicators\u003c/h3\u003e\n\u003cp\u003eThe postoperative PTH, serum calcium, and serum phosphorus of the patients were significantly lower than those before surgery (see Table 3), and the differences were statistically significant (P\u0026lt;0.05).\u003c/p\u003e"},{"header":"3. Discussion","content":"\u003cp\u003eSecondary hyperparathyroidism (SHPT) in chronic renal failure is one of the most common complications in patients with chronic kidney disease\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. It is a pathophysiological state of compensatory hyperplasia of the parathyroid glands and excessive secretion of parathyroid hormone (PTH) caused by the body's attempt to correct calcium and phosphorus metabolism disorders \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. The symptoms of SHPT mostly involve multiple systems such as the skeleton, neuromuscular system, and cardiovascular system, which seriously affect the patient's lifespan and quality of life \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Common clinical treatment methods for SHPT include internal medicine drug treatment and surgical treatment \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. For refractory SHPT that is ineffective to drug treatment, surgical treatment is recommended by domestic and foreign treatment guidelines \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. With the continuous improvement of technical level, laparoscopic parathyroid surgery has become a routinely performed surgical method in recent years \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBenefiting from the early cooperation between our department and the Department of Nephrology, we have accumulated a lot of open parathyroid surgery skills. After a mature learning curve, our department has routinely carried out ETPTX\u0026thinsp;+\u0026thinsp;AT since 2019. Laparoscopic surgery benefits from the good field of vision and magnification provided by the endoscope, which is easy to identify the small blood vessels on the surface of the thyroid gland, making the intraoperative operation of the chief surgeon more precise. The use of ultrasonic scalpel in laparoscopic surgery is also significantly better than that of traditional electrosurgical knife, mainly reflected in the good hemostatic effect and less smoke generated during the operation, which reduces the impact on the surgical field of vision. Since laparoscopic surgery is performed in a closed cavity, the contact between internal tissues and external air is reduced, the chance of surgical site infection is reduced, and the small incision of laparoscopic surgery has a relatively lower infection rate compared with the large transverse incision of open surgery. In this study, only 1 case of superficial infection of the chest incision occurred, and the wound healed well after routine dressing change.\u003c/p\u003e \u003cp\u003eSeven patients developed vascular fistula occlusion after surgery. Except for the patients' own fistula vascular conditions, the possible causes were local vascular compression caused by intraoperative posture and excessive fluctuation of intraoperative blood pressure. Through communication with operating room nurses and anesthesiologists, proper posture and stable intraoperative blood pressure control have greatly reduced this situation.\u003c/p\u003e \u003cp\u003eRecurrent laryngeal nerve injury is one of the common complications during parathyroid surgery. Most of them are caused by improper intraoperative operation, and a few can also be caused by compression or traction of hematoma or scar tissue. The recurrent laryngeal nerve ascends along the tracheoesophageal groove, and the parathyroid glands are mostly located near the recurrent laryngeal nerve. The upper pole parathyroid gland is adjacent to the entry of the recurrent laryngeal nerve into the larynx, and improper operation here is likely to damage the recurrent laryngeal nerve. The relationship between the recurrent laryngeal nerve and the inferior thyroid artery is relatively complex near the lower pole of the lateral lobe. Therefore, when performing resection of the lower pole parathyroid gland, sufficient space should be reserved to avoid damaging the recurrent laryngeal nerve. With the upgrading and updating of medical equipment, the routine use of 4K high-definition and 3D lenses provides the chief surgeon with more magnified, clear, and three-dimensional images, making it relatively simple to identify the recurrent laryngeal nerve and blood vessels, and the probability of accidental surgical injury is greatly reduced. In this study, 4 patients developed hoarseness accompanied by choking when eating, which was significantly improved before discharge after symptomatic treatment with neurotrophic drugs.\u003c/p\u003e \u003cp\u003eIntraoperative bleeding is one of the main reasons for converting laparoscopic surgery to open surgery. Postoperative bleeding is a serious complication that may lead to asphyxia. The incidence of bleeding after thyroid and parathyroid surgery is 0.07%~5% \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. How to avoid bleeding and quickly resolve bleeding is the key to carrying out laparoscopic parathyroid surgery. Most of the blood vessels of the parathyroid glands originate from the thyroid blood vessels and are relatively slender. In addition, abnormal calcium and phosphorus metabolism in dialysis patients will lead to vascular calcification, reducing vascular elasticity and narrowing the lumen. Moreover, hypertension is very common in uremic patients. These are all unfavorable factors for intraoperative bleeding. Therefore, during operation, excessive traction of blood vessels leading to laceration and bleeding should be avoided. Secondly, the thyroid gland should be turned up gently when exposing the parathyroid glands to avoid damaging the blood vessels on the surface of the thyroid gland \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Once vascular rupture and bleeding occur, gauze compression can be used to stop bleeding first, and then treatment can be performed when the field of vision is clear. According to the daily experience of our department, most bleeding can be stopped with an ultrasonic scalpel. If necessary, suture ligation can be used to ensure hemostasis, and drainage should be routinely placed. In this study, only 1 patient was converted to open surgery due to intraoperative bleeding.\u003c/p\u003e \u003cp\u003eDifferent from the previous autotransplantation of parathyroid glands into the patient's upper arm, our ward has changed the transplantation site to the lateral side of the patient's thigh through years of experience summary. Firstly, the factors causing hyperplasia of parathyroid function in patients with uremia still exist \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e, so even if the graft is transferred to the lower extremities, the survival rate is still very high. Secondly, vascular fistulas for renal dialysis are mostly located in the upper arm blood vessels of patients. Once the vascular fistula is occluded after long-term dialysis, a new vascular fistula needs to be performed, so the transplantation area is bound to have an impact on the vascular fistula. Thirdly, a few patients have postoperative recurrence. Transplantation to the thigh may facilitate surgical resection and have less impact on the patient's vascular fistula.\u003c/p\u003e \u003cp\u003eDue to the large range of skin flap dissection in laparoscopic surgery, the incidence of postoperative skin ecchymosis or subcutaneous hematoma may increase. Secondly, dialysis patients have poor coagulation function, and the skin is prone to ecchymosis when slightly squeezed. In addition, the instability of dialysis effect and tissue interstitial edema are also likely to aggravate the formation of subcutaneous hematoma. When dissecting the skin flap to establish the surgical operation space, the correct anatomical plane should be mastered, and an appropriate pressure of CO\u003csub\u003e2\u003c/sub\u003e gas should be used to maintain the operation cavity. Adequate gasification plays a crucial role in the separation of skin flaps by ultrasonic scalpel. When CO\u003csub\u003e2\u003c/sub\u003e is perfused at high pressure for a long time, severe intracranial hypertension, extensive subcutaneous emphysema, and mediastinal emphysema may occur, which may affect respiratory and circulatory functions in severe cases. Our department has summarized that maintaining the pressure at 6\u0026ndash;8 mmHg is a very safe limit, and none of the 433 laparoscopic surgeries performed had the above situations.\u003c/p\u003e \u003cp\u003eThe incidence of hypocalcemia in dialysis patients is 27% \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e, while patients with ETPTX\u0026thinsp;+\u0026thinsp;AT are more likely to develop hypocalcemia due to rapid bone calcium uptake after surgery, which is often called \"hungry bone syndrome\" \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. In view of the fact that the patient's preoperative dry weight and serum PTH level are independent risk factors for severe hypocalcemia in SHPT patients after surgery, in addition, the patient's age, dialysis time, serum calcium, etc. should be combined to predict the degree of postoperative hypocalcemia and formulate an individualized calcium supplementation plan \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. In this study, 69 patients developed early postoperative hypocalcemia (serum calcium below 2.1 mmol/L), which was quickly corrected after routine calcium supplementation. Among them, 2 patients developed intractable hypocalcemia, and the serum calcium of these 2 patients was basically stable after nearly 4 weeks of calcium supplementation treatment before discharge.\u003c/p\u003e \u003cp\u003eAmong the 421 patients with complete resection of 4 parathyroid glands, 9 still had high postoperative PTH, 11 patients had 3 parathyroid glands resected, and 1 patient had 2 resected. Ectopic parathyroid glands are considered, which may be located in the sternum, mediastinum, thymus, etc\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Inaccurate preoperative localization, multiple parathyroid glands, and ectopic parathyroid glands can all lead to difficulty in complete surgical resection.\u003c/p\u003e \u003cp\u003eThrough the analysis of this study, ETPTX\u0026thinsp;+\u0026thinsp;AT significantly reduces the blood PTH level in SHPT patients and maintains the patient's serum calcium and phosphorus at normal levels. It has a high surgical success rate and low complication rate, and is a safe and effective method for the treatment of SHPT. However, due to the short follow-up time, the advantages of this surgical method still need to be further verified.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e[Endoscopic total parathyroidectomy with autotransplantation (ETPTX+AT); Secondary hyperparathyroidism in chronic renal failure (SHPT); Parathyroid hormone (PTH)]\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e2\u003cstrong\u003e. Ethics approval and consent to participate\u003c/strong\u003e [I affirm that this study complies with the principles of the Declaration of Helsinki.This study was approved by the Ethics Committee of the Second Affiliated Hospital of Anhui Medical University, and informed consent was obtained from the patients and their families.]\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp;\u003cstrong\u003eConsent for publication\u003c/strong\u003e [All authors have agreed to the publication of this manuscript.]\u003c/p\u003e\n\u003cp\u003e4.\u0026nbsp;\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e [by collecting the examination data of patients treated at our hospital]\u003c/p\u003e\n\u003cp\u003e5.\u0026nbsp;\u003cstrong\u003eCompeting Interests\u0026nbsp;\u003c/strong\u003e[All authors declare that they have no competing interests.]\u003c/p\u003e\n\u003cp\u003e6\u003cstrong\u003e. Funding\u0026nbsp;\u003c/strong\u003e\u0026nbsp; [ No funding was received for this study] \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003cbr\u003e7.\u0026nbsp;\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e [First, we are grateful to Professors Yu Liquan and Li Peikun from the Department of General Surgery, the Second Affiliated Hospital of Anhui Medical University, whose meticulous guidance, rigorous supervision and valuable suggestions throughout the study—from protocol design to manuscript revision—greatly improved the research quality. We also thank Dr. Yu Zhongshan and our research team for their full collaboration and technical support in experiments and data collection, laying a solid foundation for the completion of this study. ]\u003cbr\u003e8.\u0026nbsp;\u003cstrong\u003eAcknowledgements\u003c/strong\u003e [Finally, we thank Shu Xiaoxia, our families and friends for their understanding, tolerance and emotional support that motivated us to move forward.]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDream S, Kuo LE, Kuo JH, et al. The American association of endocrine surgeons guidelines for the definitive surgical management of secondary and tertiary renal hyperparathyroidism[J]. Ann Surg, 2022, 276(3): e141-176.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe Qingqing, Tian Wen. Chinese Expert Consensus on Surgical Clinical Practice for Secondary Hyperparathyroidism in Chronic Kidney Disease (2021 Edition)[J]. Chinese Journal of Practical Surgery, 2021, 41(8): 841\u0026ndash;848.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevin A, Bakris GL, Molitch M, et al. Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: results of the study to evaluate early kidney disease[J]. Kidney Int, 2007, 71(1): 31\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodzoń-Norwicz M, Norwicz S, Sowa-Kućma M, et al. Secondary hyperparathyroidism in chronic kidney disease: pathomechanism and current treatment possibilities[J]. Endokrynol Pol, 2023, 74(5): 490\u0026ndash;498. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5603/ep.95820\u003c/span\u003e\u003cspan address=\"10.5603/ep.95820\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHiramitsu T, Hasegawa Y, Futamura K, et al. Treatment for secondary hyperparathyroidism focusing on parathyroidectomy[J]. Front Endocrinol(Lausanne), 2023, 14: 1169793. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fendo.2023.1169793\u003c/span\u003e\u003cspan address=\"10.3389/fendo.2023.1169793\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou Li, Li Zhihui. Interpretation of the American Association of Endocrine Surgeons' \"Guidelines for the Surgical Management of Secondary and Tertiary Hyperparathyroidism\"[J]. Chinese Journal of Bases and Clinics in General Surgery, 2023, 30(02): 160\u0026ndash;166.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKidney Disease: Improving Global Outcomes CKD-MBD Work Group. KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD)[J]. Kidney Int Suppl, 2009, 76(113): S1-130. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/ki.2009.188\u003c/span\u003e\u003cspan address=\"10.1038/ki.2009.188\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe Q, Zhu J, Zhuang D, et al. Robotic total parathyroidectomy by the axillo-bilateral-breast approach for secondary hyperparathyroidism: a feasibility study[J]. J Laparoendosc Adv Surg Tech A, 2015, 25(4): 311\u0026ndash;313.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou Peng, Zhuang Dayong, He Qingqing, et al. Da Vinci robotic total parathyroidectomy plus partial gland autotransplantation for renal hyperparathyroidism[J]. Chinese Journal of General Surgery, 2018, 33(1): 49\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdafe O, Cochrane E, Balasubramanian SP. Reoperation for Bleeding After Thyroid and Parathyroid Surgery: Incidence, Risk Factors, Prevention, and Management[J]. World J Surg, 2020, 44(4): 1156\u0026ndash;1162. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00268-019-05322-2\u003c/span\u003e\u003cspan address=\"10.1007/s00268-019-05322-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 31822944.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHe Q, Zhuang D, Zheng L, et al. Harmonic focus compared with classic hemostasis during total parathyroidectomy in secondary hyperparathyroidism: a prospective randomized trial[J]. AMERICAN SURGEON, 2014, 80(12): E342-345.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTian Wen, Zhang Hao. Expert Consensus on the Application of Energy Instruments in Thyroid Surgery (2017 Edition)[J]. Chinese Journal of Practical Surgery, 2017, (9): 992\u0026ndash;997.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Yongfei, Liu Yihao, Wang Guan, et al. Clinical analysis of 26 cases of refractory secondary hyperparathyroidism treated with total parathyroidectomy and forearm autotransplantation[J]. Chinese Journal of Experimental Surgery, 2023, 40(6): 1109\u0026ndash;1112. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3760/cma.j.cn421213-20221122-01373\u003c/span\u003e\u003cspan address=\"10.3760/cma.j.cn421213-20221122-01373\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLau WL, Obi Y, Kalantar-Zadeh K. Parathyroidectomy in the Management of Secondary Hyperparathyroidism[J]. Clin J Am Soc Nephrol, 2018, 13(6): 952\u0026ndash;961. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2215/CJN.10390917\u003c/span\u003e\u003cspan address=\"10.2215/CJN.10390917\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2018 Mar 9. PMID: 29523679; PMCID: PMC5989682.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJain N, Reilly RF. Hungry bone syndrome[J]. Curr Opin Nephrol Hypertens, 2017, 26(4): 250\u0026ndash;255. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MNH.0000000000000327\u003c/span\u003e\u003cspan address=\"10.1097/MNH.0000000000000327\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 28375869.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu J, Huang Q, Yang M, et al. Risk factors predicting severe hypocalcemia after total parathyroidectomy without autotransplantation in patients with secondary hyperparathyroidism[J]. International Journal of Endocrinology, 2023, 48(1): 1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang Guang, Wang Ningning, Zha Xiaoming, et al. Influencing factors of hungry bone syndrome after parathyroidectomy in maintenance hemodialysis patients[J]. Chinese Journal of Nephrology, 2019, 35(8): 568\u0026ndash;574.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark HS, Hong N, Jeong JJ, et al. Update on preoperative parathyroid localization in primary hyperparathyroidism[J]. Endocrinology and Metabolism (Seoul, Korea), 2022, 37(5): 744\u0026ndash;755.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 Comparison of baseline characteristics of patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"98%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4948%;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003cp\u003eMale/ Female（n/n）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3402%;\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(x̄\u0026plusmn;s, yr)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4948%;\"\u003e\n \u003cp\u003eDialysis duration\u003c/p\u003e\n \u003cp\u003e（x̄\u0026plusmn;s，yr）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4948%;\"\u003e\n \u003cp\u003ePreoperative PTH\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(x̄\u0026plusmn;s, pg/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.5258%;\"\u003e\n \u003cp\u003ePreoperative serum calcium\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(x̄\u0026plusmn;s, mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.6495%;\"\u003e\n \u003cp\u003ePreoperative serum phosphorus\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(x̄\u0026plusmn;s, mmol/L)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4948%;\"\u003e\n \u003cp\u003e235/198\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3402%;\"\u003e\n \u003cp\u003e48.6\u0026plusmn;10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4948%;\"\u003e\n \u003cp\u003e8.1\u0026plusmn;4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16.4948%;\"\u003e\n \u003cp\u003e1473.5\u0026plusmn;60.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.5258%;\"\u003e\n \u003cp\u003e2.33\u0026plusmn;0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.6495%;\"\u003e\n \u003cp\u003e2.07\u0026plusmn;0.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2 Comparison of Perioperative Surgical Indices in Patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOperative time\u003c/p\u003e\n \u003cp\u003e(x̄\u0026plusmn;s,min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIntraoperative blood loss\u003c/p\u003e\n \u003cp\u003e(x̄\u0026plusmn;s,ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1st postoperative day drainage volume\u003c/p\u003e\n \u003cp\u003e(x̄\u0026plusmn;s，ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2nd postoperative day drainage volume\u003c/p\u003e\n \u003cp\u003e(x̄\u0026plusmn;s，ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3rd postoperative day drainage volume\u003c/p\u003e\n \u003cp\u003e(x̄\u0026plusmn;s，ml)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePostoperative hospital stay\u003c/p\u003e\n \u003cp\u003e(x̄\u0026plusmn;s，d)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e97.5\u0026plusmn;30.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.6\u0026plusmn;4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30\u0026plusmn;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75\u0026plusmn;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.3\u0026plusmn;2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3 Comparison of Biochemical Indices in Patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eserum calcium mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003eserum phosphorus mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003ePth pg/ml\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003epostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 5px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003epostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003ePreoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003epostoperative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003et\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 6px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e2.332\u0026plusmn;0.235\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e2.13\u0026plusmn;0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\n \u003cp\u003e8.374\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e2.06\u0026plusmn;0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1.15\u0026plusmn;0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e21.464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e1527\u0026plusmn;205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e3(1.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e26.007\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 6px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Endoscopic total parathyroidectomy with autotransplantation (ETPTX + AT), Secondary hyperparathyroidism in chronic renal failure (SHPT), Parathyroid hormone (PTH)","lastPublishedDoi":"10.21203/rs.3.rs-8684891/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8684891/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo study the clinical efficacy of endoscopic total parathyroidectomy with autotransplantation (ETPTX\u0026thinsp;+\u0026thinsp;AT) in the treatment of secondary hyperparathyroidism (SHPT) in chronic renal failure.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 433 patients who underwent ETPTX\u0026thinsp;+\u0026thinsp;AT in our hospital from March 2019 to March 2024 were collected. The intraoperative conditions, postoperative complications, and changes in preoperative and postoperative biochemical indicators were observed by comparing the preoperative and postoperative serum calcium, serum phosphorus, and parathyroid hormone (PTH) levels of the patients.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong the patients, 412 (95.2%) had postoperative PTH\u0026thinsp;\u0026lt;\u0026thinsp;100 pg/ml. The postoperative PTH, serum calcium, and serum phosphorus of the patients were significantly lower than those before surgery, and the differences were statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). During the perioperative period, 1 patient (0.23%) died of cardiac insufficiency, 4 patients (0.9%) had transient recurrent laryngeal nerve injury, 69 patients (15.9%) developed postoperative hypocalcemia (\u0026lt;\u0026thinsp;2.1 mmol/L), 1 patient (0.23%) was converted to open surgery, 7 patients (1.6%) had upper extremity vascular fistula occlusion after surgery, and 1 patient (0.23%) had cervical hematoma.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eETPTX is a very effective method for the treatment of SHPT, which can significantly reduce the patient's PTH, serum calcium, and serum phosphorus levels.\u003c/p\u003e","manuscriptTitle":"Application of Endoscopic Total Parathyroidectomy with Autotransplantation in the Treatment of Secondary Hyperparathyroidism in Chronic Renal Failure","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-18 08:26:58","doi":"10.21203/rs.3.rs-8684891/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-10T09:00:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-31T12:06:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-27T08:31:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-22T10:53:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190425575628899904835579191330680488905","date":"2026-03-14T18:39:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324808878255161078601153649621260982263","date":"2026-03-14T12:18:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36811808007978112579328169379128377710","date":"2026-03-14T10:27:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-14T10:11:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274554951687235349930877315910475177268","date":"2026-03-12T18:40:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-12T15:59:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-17T05:54:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-16T06:40:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Medical Research","date":"2026-02-16T03:19:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-medical-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejmr","sideBox":"Learn more about [European Journal of Medical Research](http://eurjmedres.biomedcentral.com)","snPcode":"40001","submissionUrl":"https://submission.nature.com/new-submission/40001/3","title":"European Journal of Medical Research","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"50b932b5-8e87-4d90-97c8-fab726e8f9c1","owner":[],"postedDate":"March 18th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-10T09:00:20+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-10T09:09:48+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-18 08:26:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8684891","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8684891","identity":"rs-8684891","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}