2. 2
Course Faculty
1. Ahmed Halawa MD FRCS
Consultant Transplant Surgeon, Sheffield Teaching Hospital, UK.
2. Osama El Shahat MD
Consultant Nephrologist, Head of Nephrology dept. Mansoura International Hospital,
Mansoura, Egypt
3. Gamal Metwally MD
Consultant General Surgeon, Head of Surgery dept. Mansoura International Hospital,
Mansoura, Egypt.
4. Ashraf Hamed MD
Consultant Surgeon, Mansoura International Hospital, Mansoura, Egypt.
5. Ibrahim Shalaby MD
Consultant Surgeon. Mansoura International Hospital, Mansoura, Egypt.
6. Ahmed Lotfy MD
Lecturer of Endocrine Surgery, University of Mansoura, Mansoura, Egypt.
7. Hussein Sheashaa MD
Professor of Nephrology and Transplantation, Nephrology and Urology Centre,
University of Mansoura, Mansoura, Egypt.
8. Zaghloul Goada MD
Consultant Nephrologist, Damanhour Medical National Institute, General
Organization of Teaching Hospitals and Institutes, Ministry of Health, Egypt.
9. Osama El Belky MD
Consultant Surgeon, Damanhour Medical National Institute, General Organization of
Teaching Hospitals and Institutes, Ministry of Health, Egypt.
3. 3
Background
Renal hyperparathyroidism is quite a common disease affecting the vast majority of chronic
kidney disease (CKD) patients. With effective medical treatment, only 5-10% of CKD
patients require surgical treatment. The medical treatment includes a wide variety of
medications to replace the inactive vitamin D, suppress the hyperactive parathyroid glands
and also to counteract the hyperphosphatemia. Based on my previous visits to Egypt and also
supported by publications from this country, the financial difficulties the CKD patients are
suffering from does not allow the delivery of a successful medical treatment mainly due to
the inability to use an effective and more expensive phosphate binder and active vitamin D.
This has led to an increased prevalence of the florid disease compared to developed countries.
The situation was made worse by lack of understanding of the principles of diagnosis and
surgical treatment of renal hyperparathyroidism among many clinicians. Surgeons rely
mainly on imaging in localization of the hyperplastic glands which is well known to be not
sensitive enough in this multigland disease. This often has led to inadequate management of
this disease. Also the multicentric nature of this condition (multigland, rather than a single
gland disease) is often undermined. The published reports from Egypt demonstrated only few
centres dealing with this disease; however the number of patients reported is quite small with
variable outcomes. The final outcome demonstrates more patients require surgery for the
poorly controlled hyperparathyroidism that unmasks the lack of appropriate surgical
experience in many district areas of Egypt.
Aims and objectives of the course
This module has been specifically developed for surgeons in districts areas of Egypt to
increase the awareness of this disabling disease and also to popularize the standard surgical
management of renal hyperparathyroidism. The choice is between total parathyroidectomy
with auto-transplantation of 50 mg of relatively normal parathyroid tissues into sternomastoid
pockets and subtotal parathyroidectomy (removing 3½ glands), both combined with
thymectomy. The choice between these two approaches depends primarily on the availability
of histopathologist trained in frozen section of the parathyroid glands.
4. 4
The course also emphasises the value and the implementation of evidenced-based peri-
operative management of this disease including the indication of imaging and the selection of
the imaging modality when indicated.
“Training the trainers” is another objective of the course, where already trained surgeons are
trained to pass the skills, information, attitudes and values to other colleagues.This strategy
creates an educational culture that allows autonomy and continuity of the training process.
Teaching strategy
This course will be taught using an interactive style utilising key examples of where theory
links to practice. The overall teaching strategy will be a blended approach (theoretical and
practical) with a major focus on problem solving, reflective practice and critical thinking
supported by tutorials on key concepts and self-study appropriate for postgraduate students.
The course encourages the trainers to analyse the current practice against the best available
evidence with strong emphasis on professionalism, ethics and clinical governance.
The course will be delivered over 6 days (one full study day and 5 full days surgical training).
The delegates (maximum 5) will be taught the theoretical background of renal
hyperparathyroidism and CKD - mineral bone disease with emphasis on the pre and post-
operative management. Audit presentations and also case scenarios are discussed during this
study day. The lectures will be given by experienced surgeons and nephrologists covering
both the surgical and medical aspects. The delegates are required to attend the whole 6 days
(100% attendance is essential) to achieve the learning objectives.
Each surgeon will have the opportunity to assess in many parathyroidectomy operations and
operate under the supervision “hands on” of experienced consultant surgeons from 3 leading
centres from Sheffield (UK), Mansoura (Egypt) and Damanhour (Egypt). Trainees will be
involved in post-operative care of these patients during the course.
Venue and Date
Mansoura International Hospital (Mansoura, Egypt) is hosting the course with provision of
the necessary facilities for the training staff and the delegates. The course will delivered in
October and April each year; however the exact date will be confirmed well in advance.
5. 5
Organizing Bodies
The Egyptian Medical Syndicate (Eldakahleyia branch) in association with Sheffield
Teaching Hospitals, UK.
Sponsoring Bodies and Course Fees
The course is designed to be a non-profit making training event sponsored by the “Egyptian
Medical Syndicate”. 300 US dollars (or equivalent in local currency) to be paid to the
Egyptian Medical Syndicate (Eldekahlyia branch) to cover administration and other
additional expenses. Sheffield Teaching Hospital, UK is supporting the course by providing
the necessary expertise.
Pre-requisite experience before taking this course:
The delegate should provide evidence of satisfactory experience in neck surgery particularly
thyroidectomy evidenced by reference letter from the head of the surgical department. Also a
supporting letter from the head of the nephrology department is required to demonstrate the
need to provide the parathyroidectomy service locally.
Assessment
The delegates will be assessed for their abilities to manage renal hyperparathyroidectomy
both medically and surgically (work-based assessment) by experienced faculty members.
Certificate of satisfactory performance will be awarded by the “Egyptian Medical Syndicate”
to successful candidates.
Mentoring
After successful completion of the core training, the course faculty will provide mentoring
facilities (free of charge) for the delegates in their work place on request. This mentoring
option allows continuing high standard of care and also helps to spread the learning
objectives of the course to many counties of Egypt.
Audit
The candidates are advised to audit their activities annually and present their results in
national nephrology meetings. Centres are invited to present their audits and discuss difficult
cases in the introductory days of the future courses.
6. 6
Future Development
The study (introductory) day will be developed to “CKD - Mineral Bone Disease Day” inviting
both parathyroid surgeons and nephrologists expert in the field to present their experience in
medical and surgical management of this disabling disease.
This training event can be held in other centres in Egypt and also in other emerging countries
(after mutual agreement with the ISN) in line with the ISN principles and procedures
including the declaration of Istanbul.
Course Enquiries
Tel:
Dr Osama El Shahat +201021031918, +201115633877
Dr Gamal Metwally +201223447285, +201028842232
Dr Ahmed Halawa +447787542128
Fax: +20502215760
E-mail address for enquiries and booking: parathyroidectomy.course@yahoo.com
Corresponding address:
Parathyroidectomy Course
Attention to: Dr Osama El Shahat
Nephrology Department - Mansoura International Hospital
Madinat El Salam - Mansoura - Egypt
Suggested Readings
1. Companion to Specialist Surgical Practice: Endocrine Surgery. 5th
Edition. Edited by
Tom W J Lennard. Elsevier Saunders.
2. British Society of Endocrine and Thyroid Surgeons (BSETS).
http://www.baets.org.uk/
3. British Renal Society (BRS).
http://www.britishrenal.org/
4. The American Association of Endocrine Surgeons.
https://www.endocrinesurgery.org/
5. Endocrine Surgery, an Issue of Surgical Clinics, 1e (The Clinics: Surgery) by Peter J.
Mazzaglia MD FACS (9 Aug 2014).
7. 7
References
1. Afifi A. Renal Osteodystrophy in Developing Countries. Artificial Organs. 2002:
26: 767–769. doi: 10.1046/j.1525-1594.2002.07068.x
2. Barsoum RS. Burden of chronic kidney disease: North Africa. Kidney International
Supplements. 2013: 3, 164–166.
3. Goodman WG. The consequences of uncontrolled secondary hyperparathyroidism
and its treatment in chronic kidney disease. Seminars in Dialysis. 2004;17:209-216.
4. Saafan HA, Salam MA, Elshafey IA, Kader AH, Hamza AH. Tertiary
Hyperparathyroidism in Children on Chronic Dialysis: Role of Surgery. Annals of
Pediatric Surgery. 2007; 3 (2) :69-74
5. Sturgeon CM, Sprague SM, Metcalfe W. Variation in parathyroid hormone
immunoassay Results - a critical governance issue in the management of chronic
kidney disease. Nephrol Dial Transplant. 2011;26:3440-3445.
