What would result from the total surgical removal of the parathyroid gland?
Parathyroidectomy is the surgery to remove one or more of the parathyroid glands in the patient who has hyperparathyroidism. This activity reviews the technique and complications of parathyroidectomy and highlights the role of the interprofessional team in evaluating and managing the patients undergoing parathyroidectomy perioperatively. Show
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IntroductionParathyroidectomy is the surgery to remove one or more of the parathyroid glands in the patient who has hyperparathyroidism. Parathyroidectomy is the only definitive treatment for primary hyperparathyroidism. Most patients with primary hyperparathyroidism have a single parathyroid adenoma, though a significant minority (up to 10%) may have double adenomas, and a small minority will have hyperplasia of all four glands.[1] The traditional parathyroidectomy technique explores all four glands and removes the adenoma(s) based on clinical observation of gland size. With the development of the preoperative localization technique, the minimally invasive surgery using the radio-guided technique, ultrasound imaging, high-resolution endoscopic technique, rapid intraoperative parathyroid hormone (IOPTH) monitoring has been used by many surgeons to avoid exploration of all glands. The traditional parathyroidectomy still has its advantages and is still routine practice for some surgeons. For completeness' sake, this standard surgery is the operation reviewed in this article.[2][3][4][5] Anatomy and PhysiologyThe parathyroid glands are four glands located posterior to the thyroid, with a normal weight ranging from 30 to 50 mg. The two superior parathyroid glands are derived from the fourth pharyngeal pouch and are classically located posterior to the plane of the recurrent laryngeal nerve. Their location is more consistent than the inferior parathyroid glands. The two inferior parathyroid glands are derived from the third pharyngeal pouch as well as thymus; they are classically located inferior to the thyroid and anterior to the plane of the recurrent laryngeal nerve, but sometimes can be located in very aberrant locations in the lower neck, in the parenchyma of the thyroid gland or thymus remnant, in the carotid sheath, the retro-esophageal space, or the mediastinum. There can also exist true ectopic glands, including supra-numerary glands. These may also be located in the carotid sheath, paraesophageal or retro-esophageal space, or intrathyroidal or mediastinal positions. The four parathyroid glands are supplied by the inferior thyroid artery from the thyrocervical trunk. The superior parathyroid glands may be supplied by the superior thyroid artery in 20% of cases, or more commonly by an anastomotic branch between the inferior thyroid and the superior thyroid artery. Parathyroid glands regulate calcium by secreting parathyroid hormone (PTH). When the serum calcium level decreases, the chief cells in the parathyroid release PTH. In the kidney, PTH increases calcium reabsorption in the loop of Henle (as well as in the distal tubule and collecting duct), excretion of phosphate, and promotes 25-hydroxy vitamin D converting to active 1,25-dihydroxy vitamin D3. PTH stimulates osteoclast activity in the bone, releases calcium into the blood, and elevates serum calcium levels. In the intestine, activated Vitamin D increases the absorption of calcium. Hyperparathyroidism is a disorder with excessive production of PTH due to the overactivity of the parathyroid gland(s). Primary hyperparathyroidism results from autonomous hypersecretion of PTH from the abnormal parathyroid gland. The majority of patients with primary hyperparathyroidism have a single enlarged parathyroid gland, usually an adenoma, though hypercellular parathyroid is also possible. In up to 10% of patients with primary hyperparathyroidism, there will be two abnormal glands. Multiple endocrine neoplasia (MEN) type 1, type 2A, or parathyroid carcinoma can cause primary hyperparathyroidism in rare cases. The high calcium level due to hypersecretion of PTH can lead to neuromuscular symptoms, osteoporosis and bone loss, and kidney stones. Secondary hyperparathyroidism is due to high PTH levels from the physiological response to hypocalcemia. Vitamin D deficiency and chronic renal failure are the most common causes of secondary hyperparathyroidism. Tertiary hyperparathyroidism occurs in patients with secondary hyperparathyroidism from chronic renal failure and persistent secretion of PTH after renal transplant. IndicationsPrimary Hyperparathyroidism Parathyroidectomy is indicated for all patients with symptomatic primary hyperparathyroidism.[6] The symptoms include polydipsia and polyuria, nephrolithiasis or nephrocalcinosis, hypercalciuria (24-hour urine calcium level >400 mg/dL), impaired renal function (glomerular filtration rate [GFR] <60 mL/minute), osteoporosis (bone density score <-2.5), fragility fracture or vertebral compression fracture, pancreatitis, peptic ulcer disease or gastroesophageal reflux and neurocognitive dysfunction or neuropsychiatric symptoms attributable to PHPT. Indications of Parathyroidectomy in Asymptomatic Hyperparathyroidism [7]
A recent study revealed normocalcemic and hypercalcemic primary hyperparathyroidism had similarly increased cardiovascular risk factors. Parathyroidectomy ameliorated the increased cardiovascular risk factors in both normocalcemic and hypercalcemic PHPT.[8] Secondary Hyperparathyroidism Patients with secondary hyperparathyroidism are usually managed medically. Parathyroidectomy is indicated in refractory hyperparathyroidism with hypercalcemia or hyperphosphatemia, or severe symptoms. About 15% of patients will need parathyroidectomy for medically refractory secondary hyperparathyroidism after 5 to 10 years on dialysis.[9] Tertiary Hyperparathyroidism Tertiary hyperparathyroidism with symptomatic hypercalcemia is the main indication for parathyroidectomy. Surgical treatment for tertiary HPT has higher cure rates than medical therapy.[10] Limited or subtotal parathyroidectomy is recommended. The goal is a normal calcium level at least six months postoperatively.[11] Parathyroidectomy is indicated if the hyperparathyroidism is a suspicion of parathyroid carcinoma, especially with significantly elevated calcium or PTH levels (which can be in the thousands of ng/mL), painful large neck mass, or inhomogeneous mass on imaging.[6] Other indications of parathyroidectomy include parathyroid cyst and parathyroid hypercalcemic crisis (severe hypercalcemia and central nervous system dysfunction).[12][13] ContraindicationsAbsolute Contraindication
Relative Contraindication
EquipmentThe following equipment is needed:
Personnel
PreparationSurgery Parathyroidectomy is the standard treatment for hyperparathyroidism. The goal is to remove the parathyroid gland or glands producing excess PTH. The standard procedure for patients with multi-gland disease, unsuccessful preoperative localization, is the traditional surgical approach of bilateral parathyroid exploration of 4 glands. Focused parathyroidectomy with a smaller incision and less dissection is used in patients with a well-localized solitary adenoma. Compared to bilateral parathyroid exploration, focused parathyroidectomy has similar clinical outcomes: including recurrence, persistence, and reoperation rates but significantly lower overall complication rates and shorter operative time.[17] Total parathyroidectomy and subtotal parathyroidectomy (a small remnant of gland left or auto-transplanted) are indicated in secondary or tertiary hyperparathyroidism with parathyroid hyperplasia. Total parathyroidectomy with auto-transplantation carries a higher risk of permanent hypocalcemia and cardiovascular events, whereas the risk of hyperparathyroidism recurrence is higher with subtotal parathyroidectomy.[9][18] Several new technologies, including ultrasound localization of hyperplastic parathyroid glands, radio-guided surgery, endoscopic-assisted parathyroidectomy, and intraoperative assessment of serum PTH levels, can be appropriately used in the practice of parathyroid surgery.[19] Preoperative Localization Preoperative localization is critical for focused, minimally invasive parathyroid surgery. The localization imaging studies include Sestamibi scintigraphy (technetium-99-sestamibi scanning), SPECT — sestamibi-single photon emission computed tomography (SPECT or MIBI-SPECT), SPECT and CT fusion, neck ultrasound, 4D-CT, MRI, and PET-CT.[20][21] In the cases with a history of neck surgery, unsuccessful radio-image localization, invasive localization such as selective venous sampling.[22][23] Pre-op Preparation Anesthesia General anesthesia is preferred for parathyroidectomy, especially for patients who need sternotomy, neck dissection. Most surgeons prefer to use general anesthesia with intubation for single gland, focused parathyroidectomy.[24] Recent studies showed local anesthesia with the cervical block is feasible and significantly reduces the cost.[25] Local anesthesia in minimally invasive parathyroidectomy was associated with significantly lower postoperative pain, nausea, and vomiting.[26] General anesthesia is preferred for parathyroidectomy, especially for patients who need sternotomy, neck dissection. Positioning The patient is placed on the operating table supine with the neck extended and both arms tucked at the sides. A shoulder roll can be placed to improve the exposure of the neck. The operating table is slightly in reverse Trendelenburg position. Patients with cervical spine disease should be assessed for the safety of neck extension. TechniqueProcedure
Intraoperative Decision Making
ComplicationsPostoperative Bleeding and Hematoma Postoperatively life-threatening hematoma is rare but is a serious complication; the incidence reported was 0.6%.[30] The hematoma compresses the trachea, causes venous congestion of airway structures and subsequent airway compromise. Immediate wound opening and surgical hematoma evacuation or re-exploration are indicated to alleviate airway compression. Intubation should not be delayed. Recurrent Laryngeal Nerve Injury Recurrent laryngeal nerve injury is one of the most feared complications of parathyroid surgery. Injury to the recurrent laryngeal nerve results in paresis or palsy of the vocal cord, causing hoarseness (unilateral damage) or stridor, airway occlusion (bilateral damage), and an increased risk of aspiration, may need immediate reintubation or occasionally tracheostomy. Most recurrent laryngeal nerve injuries are transient. 1.1% of the patient presented a permanent postoperative vocal cord paresis after thyroid and parathyroid surgery due to recurrent laryngeal nerve injury. Injuries after parathyroidectomy are less frequent compared to thyroid surgery. Most patients with transient postoperative recurrent laryngeal nerve injury recovered normal vocal cord mobility within six months.[31] Identifying the recurrent laryngeal nerve during thyroid dissection is the gold standard to avoid nerve injury.[32] Intraoperative nerve monitoring during parathyroidectomy is a promising adjunct to visualization alone in detecting nerve structures during neck dissection, which may decrease the likelihood of recurrent laryngeal nerve injury.[33] A reinnervation procedure should be attempted When recurrent laryngeal nerve transection is recognized during parathyroidectomy.[6] Hypoparathyroidism and Hypocalcemia The symptoms of postoperative hypocalcemia include perioral numbness, fingertip paresthesia, Chvostek’s sign, Trousseau’s sign, and severe symptoms including tetany, cardiac dysrhythmia, seizures. Most hypocalcemia is transient, and permanent hypocalcemia is reported in only 0.5% to 3.8% of cases.[34] One of the most common causes of postsurgical hypoparathyroidism and hypocalcemia is inadvertent removal of, damage to, or inadvertent devascularization of the parathyroid glands. Postoperative hypocalcemia may be due to “Hungry bone syndrome” with low serum calcium levels resulting from remineralization of the bone as the stimulus of PTH for high bone turnover is removed after parathyroid surgery.[35] As the American Association of Endocrine Surgeons Guidelines recommends, patients with transient postoperative hypoparathyroidism should be treated with calcium and, if necessary, calcitriol supplements, which should be weaned as tolerated. Patients with prolonged hypoparathyroidism may be considered for recombinant PTH therapy.[6] Persistent or Recurrent Hyperparathyroidism Persistent/recurrent hyperparathyroidism occurs in 2% to 5% of patients with sporadic primary hyperparathyroidism.[36] Persistent hyperparathyroidism should be defined as a failure to achieve normocalcemia within6months of parathyroidectomy. Recurrent hyperparathyroidism is defined by the recurrence of hypercalcemia after a normocalcemic interval at more than six months after parathyroidectomy.[6] The most common causes of persistent/recurrent hyperparathyroidism include unrecognized four gland hyperplasia, ectopic location of the hyperfunctioning parathyroid gland(s), or operations performed by inexperienced or low-volume parathyroid surgeons.[37][38] A final intraoperative PTH level greater than 40 pg/mL was associated with an increased risk of persistent and recurrent disease irrespective of the number of glands resected.[36] The subsequent operation for persistent or recurrent hyperparathyroidism is often recommended to achieve a biochemical cure. But the indication is stricter than initial surgery due to lower cure rates and higher risks in the subsequent operation. Preop evaluation should be made by an experienced parathyroid surgeon, including confirmation of biochemical diagnosis, assessment of indications for surgery, review of prior records if available, and evaluation of RLN function.[6] Clinical SignificanceParathyroidectomy is the definitive therapy for primary hyperparathyroidism but may also be necessary in secondary or tertiary hyperparathyroidism. Bilateral neck exploration is the standard operation, especially optimal for patients who have multiple gland disease or non-localizing preoperative imaging studies. With improved preoperative localization techniques and intraoperative PTH monitoring, minimally invasive parathyroidectomy is widely used in unilateral exploration. Even a four-gland exploration can be performed in a minimally invasive fashion.[39] Enhancing Healthcare Team OutcomesParathyroidectomy involves a multidisciplinary team to achieve the best clinical outcome. The team includes surgeons, radiologists, pathologists, anesthesiologists, operating room nursing staff. This joint patient management minimizes the delay from diagnosing to operation decision, leading to efficient pre-operative imaging localization, ensuring patient suitability for surgery, managing intraoperative nerve monitoring and PTH level monitor, and optimizing postoperative care. Nursing, Allied Health, and Interprofessional Team InterventionsNurses have an important role in the support, education, and care of patients undergoing parathyroidectomy. Preoperative nursing interventions involve routing nursing physiological observations, offering patients psychological support, and education about disease and surgery. Nursing, Allied Health, and Interprofessional Team MonitoringNurses are especially crucial in postoperative patient safety involving hemodynamical monitoring, fluid balance, and electrolyte measurement. In particular, nurses must be aware of potential postoperative complications, including signs of recurrent laryngeal nerve injury, signs of hypocalcemia, neck hematoma. If the patient is discharged with medication, especially opioids, the nurse needs to review these medications with the patient for safety purposes. References1.Shalaby M, Hadedeya D, Lee GS, Toraih E, Kandil E. Impact of Surgeon-Performed Ultrasound on Treatment of Thyroid Cancer Patients. Am Surg. 2020 Sep;86(9):1148-1152. [PubMed: 32853031] 2.Lee WJ, Ruda J, Stack BC. Minimally invasive radioguided parathyroidectomy using intraoperative sestamibi localization. Otolaryngol Clin North Am. 2004 Aug;37(4):789-98, ix. [PubMed: 15262516] 3.Meilstrup JW. Ultrasound examination of the parathyroid glands. Otolaryngol Clin North Am. 2004 Aug;37(4):763-78, ix. [PubMed: 15262514] 4.Lo CY, Chan WF, Luk JM. Minimally invasive endoscopic-assisted parathyroidectomy for primary hyperparathyroidism. 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Focused Parathyroidectomy Under Local Anesthesia - A Feasibility Study. Indian J Endocrinol Metab. 2019 Jan-Feb;23(1):67-71. [PMC free article: PMC6446694] [PubMed: 31016156] 26.Black MJ, Ruscher AE, Lederman J, Chen H. Local/cervical block anesthesia versus general anesthesia for minimally invasive parathyroidectomy: what are the advantages? Ann Surg Oncol. 2007 Feb;14(2):744-9. [PubMed: 17122989] 27.Jason DS, Balentine CJ. Intraoperative Decision Making in Parathyroid Surgery. Surg Clin North Am. 2019 Aug;99(4):681-691. [PubMed: 31255199] 28.Casella C, Galani A, Totaro L, Ministrini S, Lai S, Dimko M, Portolani N. Total Parathyroidectomy with Subcutaneous Parathyroid Forearm Autotransplantation in the Treatment of Secondary Hyperparathyroidism: A Single-Center Experience. Int J Endocrinol. 2018;2018:6065720. [PMC free article: PMC6079428] [PubMed: 30123263] 29.Ippolito G, Palazzo FF, Sebag F, De Micco C, Henry JF. Intraoperative diagnosis and treatment of parathyroid cancer and atypical parathyroid adenoma. Br J Surg. 2007 May;94(5):566-70. [PubMed: 17380564] 30.Rosenbaum MA, Haridas M, McHenry CR. Life-threatening neck hematoma complicating thyroid and parathyroid surgery. Am J Surg. 2008 Mar;195(3):339-43; discussion 343. [PubMed: 18241836] 31.Joliat GR, Guarnero V, Demartines N, Schweizer V, Matter M. Recurrent laryngeal nerve injury after thyroid and parathyroid surgery: Incidence and postoperative evolution assessment. Medicine (Baltimore). 2017 Apr;96(17):e6674. [PMC free article: PMC5413231] [PubMed: 28445266] 32.Steurer M, Passler C, Denk DM, Schneider B, Niederle B, Bigenzahn W. Advantages of recurrent laryngeal nerve identification in thyroidectomy and parathyroidectomy and the importance of preoperative and postoperative laryngoscopic examination in more than 1000 nerves at risk. Laryngoscope. 2002 Jan;112(1):124-33. [PubMed: 11802050] 33.Ghani U, Assad S, Assad S. Role of Intraoperative Nerve Monitoring During Parathyroidectomy to Prevent Recurrent Laryngeal Nerve Injury. Cureus. 2016 Nov 15;8(11):e880. [PMC free article: PMC5161260] [PubMed: 28003944] 34.Steen S, Rabeler B, Fisher T, Arnold D. Predictive factors for early postoperative hypocalcemia after surgery for primary hyperparathyroidism. Proc (Bayl Univ Med Cent). 2009 Apr;22(2):124-7. [PMC free article: PMC2666856] [PubMed: 19381311] 35.Witteveen JE, van Thiel S, Romijn JA, Hamdy NA. Hungry bone syndrome: still a challenge in the post-operative management of primary hyperparathyroidism: a systematic review of the literature. Eur J Endocrinol. 2013 Mar;168(3):R45-53. [PubMed: 23152439] 36.Mazotas IG, Yen TWF, Doffek K, Shaker JL, Carr AA, Evans DB, Wang TS. Persistent/Recurrent Primary Hyperparathyroidism: Does the Number of Abnormal Glands Play a Role? J Surg Res. 2020 Feb;246:335-341. [PubMed: 31635835] 37.Chen H, Wang TS, Yen TW, Doffek K, Krzywda E, Schaefer S, Sippel RS, Wilson SD. Operative failures after parathyroidectomy for hyperparathyroidism: the influence of surgical volume. Ann Surg. 2010 Oct;252(4):691-5. [PubMed: 20881776] 38.Gough I. Reoperative parathyroid surgery: the importance of ectopic location and multigland disease. ANZ J Surg. 2006 Dec;76(12):1048-50. [PubMed: 17199687] 39.Sosa JA, Udelsman R. Minimally invasive parathyroidectomy. Surg Oncol. 2003 Aug;12(2):125-34. [PubMed: 12946483] What happens if you surgically remove the parathyroid glands?After parathyroid glands are removed, the remaining parathyroid glands may take some time to work properly again. This, along with uptake of calcium into bones, can lead to low levels of calcium — a condition called hypocalcemia. You may have of numbness, tingling or cramping if your calcium level gets too low.
What happens to parathyroid gland in total thyroidectomy?These glands frequently get bruised during surgery and mild hypoparathyroidism is rather common after surgery but usually resolves after a few days to weeks. While rare, permanent hypoparathyroidism continues to be a real, clinical problem after thyroid surgery.
What is a total parathyroidectomy?In a total parathyroidectomy, all 4 glands are removed. In some cases, the surgeon will implant parathyroid tissue in the forearm muscle of the patient to provide residual parathyroid function.
What happens after parathyroid adenoma removal?It will take about 1 to 3 weeks for you to fully heal. The surgery area must be kept clean and dry. You may need to drink liquids and eat soft foods for a day. Call your surgeon if you have any numbness or tingling around your mouth in the 24 to 48 hours after surgery.
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