parathyroidectomy
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Introduction
Surgical removal of one or more of the 4 parathyroid glands.
Indications
- parathyroid adenoma resulting in hyperparathyroidism
- end-stage renal disease (ESRD) with
- severe hypercalcemia
- radiologic evidence of renal osteodystrophy
- refractory uremic pruritus
- calciphylaxis
- otherwise unexplained symptomatic myopathy
- parathyroidectomy for primary hyperparathyroidism seems to be beneficial for comormid hypertension[4]
* cure rate 97%[7]
Contraindications
- does not lower 8-year risk of symptomatic nephrolithiasis in patients with primary hyperparathyroidism[5]
- does not prevent progression of chronic renal failure in adults > 60 years with primary hyperparathyroidism[8]
Laboratory
- mean preoperative serum calcium = 10.9 mg/dL[7]
- mean postoperative serum calcium = 9.4 mg/dL[7]
- see hyperparathyroidism
* serum calcium reference interval = 8.1-10.9 mg/dL
Procedure
- subtotal parathyroidectomy
- removal of all identifiable parathyroid tissue except for 40-60 mg of least hyperplastic gland
- total parathyroidectomy with autotransplantation
- implantation into brachioradialis or sternocleidomastoid
- advantage: ease of removal of recurrent hyperplastic parathyroid tissue under local anesthesia
- disadvantage: implanted tissue may not be culprit in recurrence (50%); unidentified parathyroid tissue may have remained*
- implantation into brachioradialis or sternocleidomastoid
- intraoperoative PTH levels may help localize glands
- rapid turnaround (15 minutes)
- percutaneous techniques may be used[3]
* ectopic glands may occur in thorax
Complications
- hypoparathyroidism resulting from removal of all PTH-secreting tissue
- hypocalcemia resulting from hungry bone syndrome
Management
- hypocalcemia usually occurs following parathyroidectomy
- functional hypoparathyroidism
- transient release of calcitonin from thyroid
- hungry bone syndrome may result in prolonged hypocalcemia
- measurement of ionized Ca+2 2-4 time/day for 1st few postoperative days
- oral Ca+2 2-4 g/day as soon as patient able to swallow
- administer between meals to avoid phosphate binding
- IV calcium gluconate 1 ampule in 50 mL of D5W infused over 20 minutes for symptomatic hypocalcemia (i.e. (tetany); repeat as necessary
- follow IV calcium gluconate with 6-10 amupules of 10% calcium gluconate 540-720 mg Ca+2 in 1 liter D5W
- vitamin D supplementation: calcitriol up to 4 ug/day
- correct hypomagnesemia
- avoid phosphate replacement as this may bind Ca+2
- exception is severe hypophosphatemia (< 1 mg/dL)
- prognosis
- normal parathyroid tissue regains function within 1 week following long-term suppression
- bone disease is typically mild
Notes
- can be associated with improved & sustained quality of life in selected patients with primary hyperparathyroidism[6]
- screening of patients with 36-item Short Form Survey (SF-36) & disease-specific Parathyroidectomy Assessment of Symptoms tool recommended prior to surgery[6]
More general terms
References
- ↑ Stedman's Medical Dictionary 27th ed, Williams & Wilkins, Baltimore, 1999
- ↑ UpToDate 11.2 2003 http://www.uptodate.com
- ↑ 3.0 3.1 Udelsman R et al. The superiority of minimally invasive parathyroidectomy based on 1650 consecutive patients with primary hyperparathyroidism. Ann Surg 2011 Mar; 253:585 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21183844
- ↑ 4.0 4.1 Graff-Baker AN, Bridges LT, Chen Q et al Parathyroidectomy for Patients With Primary Hyperparathyroidism and Associations With Hypertension. JAMA Surg. Published online October 9, 2019. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31596437 https://jamanetwork.com/journals/jamasurgery/fullarticle/2752279
- ↑ 5.0 5.1 Seib CD et al. Kidney stone events following parathyroidectomy vs nonoperative management for primary hyperparathyroidism. J Clin Endocrinol Metab 2022 Jul; 107:e2801. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35363858 PMCID: PMC9202696 (available on 2023-04-01) https://academic.oup.com/jcem/article/107/7/e2801/6562390
Huang S-Y et al. Parathyroidectomy for nephrolithiasis in primary hyperparathyroidism: Beneficial but not a panacea. Surgery 2022 Jan; 171:29. PMID: https://www.ncbi.nlm.nih.gov/pubmed/34364687 https://www.surgjournal.com/article/S0039-6060(21)00659-0/fulltext
Seib CD et al. Association of parathyroidectomy with 5-year clinically significant kidney stone events in patients with primary hyperparathyroidism. Endocr Pract 2021 Sep; 27:948. PMID: https://www.ncbi.nlm.nih.gov/pubmed/34126246 https://www.endocrinepractice.org/article/S1530-891X(21)01082-X/fulltext - ↑ 6.0 6.1 6.2 Livschitz J, Yen TWF, Evans DB et al Long-term Quality of Life After Parathyroidectomy for Primary Hyperparathyroidism. A Systematic Review. JAMA Surg. 2022;157(11):1051-1058 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36103163 https://jamanetwork.com/journals/jamasurgery/fullarticle/2796289
- ↑ 7.0 7.1 7.2 7.3 Wang R et al. Hypercalcemia with a parathyroid hormone level of <= 50 pg/mL: Is this primary hyperparathyroidism? Surgery 2023 Jan; 173:154. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36202653 https://www.surgjournal.com/article/S0039-6060(22)00673-0/fulltext
- ↑ 8.0 8.1 Seib CD et al. Estimated effect of parathyroidectomy on long-term kidney function in adults with primary hyperparathyroidism. Ann Intern Med 2023 Apr 11; [e-pub] PMID: https://www.ncbi.nlm.nih.gov/pubmed/37037034 https://www.acpjournals.org/doi/10.7326/M22-2222