Background and Objective:Secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD) is a major challenge in the context of patients awaiting renal transplantation. Optimal timing of parathyroidectomy (PTX) for these patients remains controversial, particularly to prevent tertiary hyperparathyroidism (THPT) and minimize postoperative complications such as hungry bone syndrome (HBS). The aim of this study is to evaluate current evidence on optimal timing of PTX in renal transplant candidates. Methods:To review the current evidence regarding the optimal timing of PTX in patients with SHPT undergoing renal transplantation, a systematic search of PubMed/MEDLINE, Scopus, and Web of Science was performed using the following keywords: hyperparathyroidism; renal transplant; parathyroidectomy timing; secondary hyperparathyroidism; tertiary hyperparathyroidism; hungry bone syndrome; CKD-MBD; graft survival; cinacalcet; cost-effectiveness. Biochemical outcomes, graft survival, and risk of THPT were assessed. Studies in English language from 2017-2025 were included. Study selection followed PRISMA criteria. Outcomes analyzed included biochemical control, graft function, recurrence rates, and postoperative complications. Key Content and Findings:Fifteen studies met inclusion criteria, including one systematic review, two narrative reviews, three cost-effectiveness analyses, eight retrospective studies and one randomized controlled trial. Early PTX (pre-transplant or within 12-18 months post-transplant) was associated with lower rates of persistent hyperparathyroidism (HPT), better biochemical control, reduced vascular calcifications, and decreased hospitalization rates. Delayed PTX (>18-24 months post-transplant) was linked to higher rates of THPT, bone loss, nephrocalcinosis, and reduced graft function. HBS occurred more frequently in pre-transplant PTX but was manageable with structured calcium/vitamin D replacement. Conclusions:PTX remains the most effective treatment for persistent HPT in renal transplant candidates. Current evidence supports pre-transplant PTX in severe SHPT or within 12-18 months after transplant if HPT persists. A multidisciplinary approach and early biochemical surveillance are essential for optimal outcomes.

BACKGROUND AND AIMS:Current evidence on catheter ablation for patients with congenital heart disease (CHD) is derived from small, retrospective studies. This study aims to provide insights from a nationwide contemporary registry. METHODS:This prospective study included all CHD patients referred for catheter ablation from 2020 to July 2024 across 28 French centres. The primary outcome was the rate of per-procedural acute success. Secondary outcomes included complications as well as freedom from arrhythmia recurrence. RESULTS:A total of 1135 consecutive catheter ablation procedures were performed in 998 patients (mean age 46.1 ± 16 years, 55.5% male). The main primary clinical arrhythmias targeted were atrial flutter/tachycardia in 677 (59.6%), atrial fibrillation in 195 (17.2%), ventricular arrhythmia in 188 (16.6%), and atrioventricular reentrant tachycardia in 38 (3.3%), with significant variations in patterns observed based on the underlying substrate. Clinical arrhythmia was successfully ablated in 1071 patients (94.4%). The mean number of arrhythmias targeted per procedure was 1.5 ± 0.7, with overall acute success rates exceeding 90% for all arrhythmias except for ventricular arrhythmias (86.7%). Acute complication occurred in 43 procedures (3.8%), including 1 (0.1%) death. The overall 1- and 2-year recurrence-free rates were 77.3% (95% confidence interval 74.2%-80.4%) and 68.4% (95% confidence interval 64.7%-72.3%), respectively. Significant variations in recurrence rates were noted based on the type of arrhythmia and the underlying CHD. CONCLUSIONS:Catheter ablation in patients with CHD demonstrates highly favourable acute outcomes and a low complication rate. Recurrence rates during follow-up vary depending on the targeted arrhythmia and the underlying CHD. These findings should be considered in the benefit-risk assessment.

Les modalités de traitement de l’hyperparathyroïdie primaire doivent prendre en compte le bénéfice attendu et les risques de chaque traitement envisagé, avant de pouvoir choisir la ou les options thérapeutiques définitives qui seront proposées au patient. Dans ce chapitre, un avant-propos mettra en perspectives les difficultés du choix du ou des critère(s) de jugement utilisé(s) pour argumenter l’utilisation de tel ou tel moyen de traitement. Les moyens de traitement seront envisagés les uns après les autres en commençant par la chirurgie, la destruction locale, pour finir par les moyens médicaux. Ce chapitre n’envisage pas les indications thérapeutiques qui sont traitées dans un chapitre spécifique.

Objective To describe surgical indications, procedures and outcomes in patients operated for Zollinger-Ellison syndrome (ZES) in multiple endocrine neoplasia type 1 (MEN1) using a large nationwide cohort. Background Management of ZES in MEN1 remains controversial. Methods All patients with ZES diagnosed through the MEN1 AFCE/GTE network from 1985 to 2015.Results Among 233 ZES patients, 66 (28%) were operated for ZES-related gastrinomas. Thirty-three (51%) procedures aimed to remove gastrinomas and associated pancreatic neuroendocrine tumors (pNET(s)) with appropriate resection. Thirty-two procedures (49%) aimed to remove gastrinomas alone (ZES group). Survival was decreased in patients metastatic at ZES diagnosis (p < 0.001). Fifteen-year survival among non-metastatic patients was not significantly better in operated patients (82% vs. 70%, p = 0.2). Perioperative mortality was nil. Metastatic lymph nodes were found in 30/42 lymphadenectomies (71%). The choice between pancreaticoduodenectomy versus duodenal focused surgery in the ZES group was associated with pre-operative detection of adenopathies (p > 0.001), leading to more frequent lymphadenectomies (p < 0.01). Previous pancreatic surgeries (30%) may have influenced the choice of ZES procedures. Gastrin levels were more frequently normalized when the duodenum and the head of pancreas were removed versus more localized duodenal surgeries (p < 0.01). Conclusion The high rate of invaded nodes in lymphadenectomies in MEN1 patients operated for ZES, the absence of operative mortality, and the decreased survival in metastatic patients are indirect arguments for surgery. Pancreaticoduodenectomy may be indicated in young and fit individuals to better control hypergastrinemia and to prevent metastatic progression in the ZES group. Gastrinoma removal is justified when associated with large pNETs.

Treatment modalities for primary hyperparathyroidism must take account of the expected benefits and risks of each treatment envisaged, before choosing the definitive option to be proposed to the patient. In this section, a Foreword puts in perspective the difficulties involved in choosing the criteria for a particular treatment method. Treatments are then considered one after the other: surgery, local destruction and medical management. This section does not consider therapeutic indications.

A catecholamine-induced hypertensive crisis in patients with pheochromocytoma has recently been defined as systolic/diastolic blood pressure ≥ 180/120 mmHg. However, the consequences of observing blood pressure values above these thresholds during laparoscopic adrenalectomy have never been evaluated. The aim of this study was to identify factors associated with intraoperative catecholamine-induced hypertensive crisis (main objective) and postoperative cardiovascular complications (secondary objective). A multi-institutional retrospective cohort study from 01/01/2000 to 12/31/2016 was performed in eight university hospitals to identify independent factors associated with catecholamine-induced hypertensive crisis while adjusting for the clustering of patients within hospitals (generalized linear mixed model for hierarchical analysis). Logistic regression analysis was used to analyze postoperative cardiovascular complications on day 30. A total of 1056 patients underwent adrenalectomy for pheochromocytoma, of whom 894 were included in the final analysis. During adrenalectomy, 122 patients (13.6

Long standing persistent atrial fibrillation has a complex physiopathology with limited effective therapeutic options. We describe an alternative approach to the convergent hybrid ablation that is effective and allows an extended ablation with left atrial appendage exclusion through one access. We present the details of this surgical technique.

Treatment modalities for primary hyperparathyroidism must take account of the expected benefits and risks of each treatment envisaged, before choosing the definitive option to be proposed to the patient. In this section, a Foreword puts in perspective the difficulties involved in choosing the criteria for a particular treatment method. Treatments are then considered one after the other: surgery, local destruction and medical management. This section does not consider therapeutic indications, which are dealt with in a section 9.

The study aims to evaluate the long-term incidence of cardiovascular events (CVE) and compare the effectiveness of medical and surgical interventions using a combined cardiovascular endpoint in individuals diagnosed with primary aldosteronism (PA). The authors carried out a multicentric, retrospective study in Marseille on a total of 106 inpatients divided into two samples with biologically proven primary aldosteronism, of whom 55 underwent surgical treatment and 51 received medical therapy between January 2014 and December 2022. The mean age of the sample was 53 years. Over a 54-month follow-up period, five patients in the medical group (10.64%) and three in the surgical group (5.45%) experienced a CVE (p = 0.46). Although the difference was not statistically significant, the surgical group had more cardiovascular morbidity at baseline. At the end of the follow-up, the surgical group demonstrated a significant reduction in blood pressure (BP) (mean 126/74 mmHg) compared to the medical group (mean 136/81 mmHg) (p = 0.02), with a significantly lower number of antihypertensive medications (1.23 ± 1.5 vs. 2.83 ± 1.8, p < 0.01). Additionally, the surgical group had a significantly higher serum potassium level at the end of follow-up despite similar potassium supplementation. The long-term incidence of CVE in PA did not significantly differ between medical and surgical treatment. However, there appears to be a trend toward reduced CVE over the long term in surgically treated patients who had excess cardiovascular morbidity at baseline. In addition, surgical treatment significantly improved BP control, with patients requiring fewer and demonstrating better serum potassium regulation.

Background/Objectives: Adrenalectomy for pheochromocytoma presents a risk due to catecholamine discharge, leading to perioperative hemodynamic instability and potential fatality. Recommendations stress surgical caution and care in referral centers. Laparoscopic and robotic adrenalectomy advancements have decreased perioperative risks, with robotic access deemed advantageous for larger tumors. This study aimed to assess if surgical technique and a new clevidipine-based perioperative protocol could improve hemodynamic stability. Methods: All robotic adrenalectomies treated in recent years (50) were included (Group A). A control group of 50 laparoscopic adrenalectomies (Group B) was also included. Results: In Group A, 7 patients had a BMI > 30 (14%), and 20 patients (40%) had pheochromocytomas > 5 cm in size. During surgery, 22 patients (44%) had systolic blood pressure/SBP ≥ 160 mmHg, and 18 patients (36%) had heart rate/HR ≥ 110 bpm. A total of 44 patients (88%) were treated perioperatively with clevidipine, 32 (64%) required amines perioperatively, and 8 (16%) did not require transfer to intensive care. In Group B, 2 patients had BMI > 30 (4%), 12 (24%) had pheochromocytomas > 5 cm in size, 35 (70%) had SBP ≥ 160 mmHg, 16 patients (32%) had HR ≥ 110 bpm, 23 (46%) patients required amines perioperatively, and all were transferred to intensive care after surgery. In addition, 11 (22%) patients were treated with clevidipine. In both groups, MAP < 60 mmHg was equivalent (62% vs. 60%). Conclusions: The clevidipine-based protocol, combined with robotic adrenalectomy, notably for larger tumors, potentially improves perioperative hemodynamic stability, reducing postoperative intensive care needs. This combination could represent an advancement in managing those patients.

In 2024, the French Society of Endocrinology, the French-speaking Association of Endocrine Surgery, and the French Society of Nuclear Medicine have elaborated a joint consensus statement on primary hyperparathyroidism, which was presented at the last congress of the French Society of Endocrinology, in October 2024, and subsequently published as 15 individual chapters in the Annals of Endocrinology. This consensus statement is a fruit of a joint effort by over 80 French-speaking experts in the field, including adult and pediatric endocrinologists, endocrine and pediatric surgeons, radiologists, nuclear medicine specialists, biologists and geneticists, and has been endorsed by the Belgian and Swiss endocrine societies. This document summarizes the recommendations, subdivided into 15 sections each preceded by a brief introduction. It aimed at covering systematically all areas of diagnosis and management of primary hyperparathyroidism throughout life in a comprehensive way, that we hope could be useful in particular to our younger colleagues in training.

OBJECTIVE:To quantify the association between surgeon age and intraoperative hemodynamic instability (IHI) occurrence during pheochromocytoma surgery. BACKGROUND:Surgeons must master technical and nontechnical skills to limit IHI occurrence during pheochromocytoma resection, a rare, complex surgery. METHODS:This retrospective cohort study included data from adult patients who underwent pheochromocytoma surgery undertaken by surgeons aged 30 to 65 in 8 high-referral university hospitals in France from 01/01/2000 to 12/31/2016. Surgeon experience was quantified using surgeon's age at the time of surgery, and performance was evaluated using IHI occurrence. GEE logistic regression models, adjusted for potential confounders related to the patient and surgical procedure, were used to determine the probability of IHI according to surgeon age, independently of the surgeon-anesthesiologist duo and each surgeon's annual surgical volume. RESULTS:Nine hundred ninety pheochromocytoma surgeries performed by 44 surgeons were analyzed. There was a concave relationship between surgeon age and IHI (P=0.012). Standardized rates of IHI were 71.7% (95% CI: 60.9%-82.6%) at 30 years, reached a minimum of 50.4% (45.9%-54.7%) at 48 years, and were 70.2% (55.7%-80.2%) at 65 years. Among low-volume surgeons, IHI occurrence was more likely in those aged 55 to 65 compared with those aged 45 to 55 [adjusted odds ratios=1.71 (1.04 to 2.80)]. Among high-volume surgeons, IHI was more likely to occur in surgeons aged 30 to 44 compared with those aged 45-55 [2.05 (1.10 to 3.83)]. CONCLUSIONS:Our results suggest that in pheochromocytoma surgery surgeon performance could peak at mid-career, and then plateau and decline. Solutions that help surgeons maintain performance throughout their careers might be beneficial.

Primary hyperparathyroidism (PHPT) presents diverse phenotypic variations. Few studies have investigated potential peculiarities of non-localized PHPT. This retrospective study aimed to compare renal and skeletal outcomes in patients with non-localized PHPT subjected to medical versus surgical treatment. Patients with non-localized PHPT from two European Tertiary Centers were divided into Group A (medical treatment, 42 patients) and Group B (Surgery, 45 patients). Biochemical markers, renal function, and bone mineral density (BMD) were assessed at baseline and 18–24 months post-treatment. At initial univariate analysis, Student's t test, Fisher's exact test, Wilcoxon test, and Friedman's non-parametric test were utilized. The two groups displayed significant differences in age and vitamin D levels. Group B exhibited notable post-operative reductions in serum calcium (p value < 0.00001, versus p < 0.001 for group A), PTH (p < 0.00001 versus 0.078 for group A), and calciuria (p < 0.05 versus 0.3657 for group A). Surgical intervention yielded significant improvements in BMD (group B: p < 0.0001; group A: p = 0.3359) at femoral and lumbar sites, with no post-treatment fractures in Group B, contrasting with Group A (4 new fractures). The GFR of group A showed a statistically non-significant change with a p value of 0.631. Conversely, for the group B, the GFR displayed a statistically significant change (p < 0.001.). Surgical intervention in non-localized PHPT showcased distinct advantages in normalizing calcemia and PTH levels and improving skeletal metabolism. Although few significant differences in renal function were observed post-surgery, the apparent advantage of group B should be interpreted taking into account the different average ages of the two cohorts.

Abstract Background Management of ZES in MEN1 remains controversial. The objective was to describe surgical indications, procedures and outcome in patients operated for Zollinger-Ellison syndrome (ZES) in Multiple Endocrine Neoplasia type 1 (MEN1) using a large nationwide cohort. Methods All patients with ZES diagnosed through the MEN1 AFCE/GTE network during the 1985-2015 period. Results Among 233 ZES patients, 66 (28%) were operated for ZES-related gastrinoma(s). Thirty-three (51%) procedures aimed at removing gastrinoma(s) and associated pancreatic neuroendocrine tumor(s) (pNET(s)) by appropriate resection(s). Thirty-two procedures (49%) aimed at removing gastrinoma(s) alone (ZES group). Survival was decreased in metastatic patients at ZES diagnosis (p<0.001). Fifteen-year survival among non-metastatic patients was not significantly better in operated patients (82% (95% CI:67-90) versus 70% (95% CI:60-78)) (p=0.2). Operative mortality was nil. Metastatic lymph nodes were found in 30/42 lymphadenectomies (71%). The choice between duodenopancreatectomy versus duodenal focused surgery in the ZES group was associated with pre-operative detection of adenopathies (p>0.001), leading to more frequent lymphadenectomies (p<0.01). Previous pancreatic surgeries (30%) may have influenced the choice of ZES procedures. Conclusions The high rate of invaded nodes in lymphadenectomies in MEN1 patients operated for ZES, the absence of operative mortality, and the decreased survival in metastatic patients are indirect arguments for surgery. Duodenopancreatectomy was chosen more frequently than duodenal focused surgery in case of suspected lymph nodes in the ZES group. Duodenopancreatectomy may be indicated in young and fit patients to prevent metastatic evolution in the ZES group. Removing gastrinoma(s) when associated with large pNET(s) is justified.

Abstract Background Laparoscopic adrenalectomy (LA) is the standard of care for the management of pheochromocytoma after preoperative medical preparation (PMP) using antihypertensive medications. Catecholamine-induced hypertensive crisis (CIHC) was recently defined by an international consortium as blood pressure > 180/120 mmHg. However, the impact of PMP on intraoperative CIHC and perioperative complications remains controversial. The aim of this study was to evaluate the impact of PMP on the incidence of intraoperative CIHC and perioperative complications. Methods Multi-institutional retrospective cohort study including data from all patients who underwent LA for pheochromocytoma in 8 high-volume surgical departments from 01/01/2000 to 12/31/2016. Patients who underwent emergency surgery, bilateral or open adrenalectomy were excluded (n=140). Results Data were available for 922 patients (female n=520, 56.4%). Long-term antihypertensive treatment prior surgery and specific PMP were recorded in 479 (51.9%) and 604 patients (65.5%), respectively. During LA, at least one episode of CIHC was observed in 123 patients (13.7%). Perioperative mortality rate was 0.3% (3 patients). Thirty-day postoperative complication rate was 20.4% (188 patients). In multivariable analysis, tumor size (0.99, 0.98-1.00; p=0.04) remained the only independent predictor for intraoperative CIHC incidence (ASA score, long-term antihypertensive treatment, and PMP had no significant impact). ASA score (2.17, 1.56-3.01; p<0.001), tumor size (1.01, 1.00-1.02; p<0.01), long-term antihypertensive treatment (1.59, 1.11-2.28; p=0.01), and intraoperative CIHC incidence (0.62, 0.39-0.97; p=0.03) remained independent predictors for perioperative complications, but not PMP. Conclusions The use of PMP had no significant impact on intraoperative CIHC incidence and perioperative complications in this multi-institutional cohort study.

Adult and paediatric patients with pathogenic variants in the gene encoding succinate dehydrogenase (SDH) subunit B ( SDHB ) often have locally aggressive, recurrent or metastatic phaeochromocytomas and paragangliomas (PPGLs). Furthermore, SDHB PPGLs have the highest rates of disease-specific morbidity and mortality compared with other hereditary PPGLs. PPGLs with SDHB pathogenic variants are often less differentiated and do not produce substantial amounts of catecholamines (in some patients, they produce only dopamine) compared with other hereditary subtypes, which enables these tumours to grow subclinically for a long time. In addition, SDHB pathogenic variants support tumour growth through high levels of the oncometabolite succinate and other mechanisms related to cancer initiation and progression. As a result, pseudohypoxia and upregulation of genes related to the hypoxia signalling pathway occur, promoting the growth, migration, invasiveness and metastasis of cancer cells. These factors, along with a high rate of metastasis, support early surgical intervention and total resection of PPGLs, regardless of the tumour size. The treatment of metastases is challenging and relies on either local or systemic therapies, or sometimes both. This Consensus statement should help guide clinicians in the diagnosis and management of patients with SDHB PPGLs.