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parathyroidectomy

Surgical removal of one or more of the 4 parathyroid glands. Indications: 1) parathyroid adenoma resulting in hyperparathyroidism 2) *end-stage renal disease (ESRD) with a) severe hypercalcemia b) radiologic evidence of renal osteodystrophy c) *refractory uremic pruritus d) calciphylaxis e) *otherwise unexplained symptomatic myopathy 3) 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 Procedures: 1) subtotal parathyroidectomy - removal of all identifiable parathyroid tissue except for 40-60 mg of least hyperplastic gland 2) total parathyroidectomy with autotransplantation a) implantation into brachioradialis or sternocleidomastoid 1] advantage: ease of removal of recurrent hyperplastic parathyroid tissue under local anesthesia 2] disadvantage: implanted tissue may not be culprit in recurrence (50%); unidentified parathyroid tissue may have remained* 3) intraoperoative PTH levels may help localize glands - rapid turnaround (15 minutes) 4) percutaneous techniques may be used [3] * ectopic glands may occur in thorax Complications: 1) hypoparathyroidism resulting from removal of all PTH-secreting tissue 2) hypocalcemia resulting from hungry bone syndrome Management: 1) hypocalcemia usually occurs following parathyroidectomy a) functional hypoparathyroidism b) transient release of calcitonin from thyroid c) hungry bone syndrome may result in prolonged hypocalcemia d) measurement of ionized Ca+2 2-4 time/day for 1st few postoperative days e) oral Ca+2 2-4 g/day as soon as patient able to swallow - administer between meals to avoid phosphate binding f) IV calcium gluconate 1 ampule in 50 mL of D5W infused over 20 minutes for symptomatic hypocalcemia (i.e. (tetany); repeat as necessary g) follow IV calcium gluconate with 6-10 amupules of 10% calcium gluconate 540-720 mg Ca+2 in 1 liter D5W h) vitamin D supplementation: calcitriol up to 4 ug/day 2) correct hypomagnesemia 3) avoid phosphate replacement as this may bind Ca+2 - exception is severe hypophosphatemia (< 1 mg/dL) 4) prognosis a) normal parathyroid tissue regains function within 1 week following long-term suppression b) 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]

General

head & neck surgery surgical resection (excision)

References

  1. Stedman's Medical Dictionary 27th ed, Williams & Wilkins, Baltimore, 1999
  2. UpToDate 11.2 2003 http://www.uptodate.com
  3. 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: 21183844
  4. 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: 31596437 https://jamanetwork.com/journals/jamasurgery/fullarticle/2752279
  5. Seib CD et al. Kidney stone events following parathyroidectomy vs nonoperative management for primary hyperparathyroidism. J Clin Endocrinol Metab 2022 Jul; 107:e2801. PMID: 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: 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: 34126246 https://www.endocrinepractice.org/article/S1530-891X(21)01082-X/fulltext
  6. 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: 36103163 https://jamanetwork.com/journals/jamasurgery/fullarticle/2796289
  7. Wang R et al. Hypercalcemia with a parathyroid hormone level of <= 50 pg/mL: Is this primary hyperparathyroidism? Surgery 2023 Jan; 173:154. PMID: 36202653 https://www.surgjournal.com/article/S0039-6060(22)00673-0/fulltext
  8. 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: 37037034 https://www.acpjournals.org/doi/10.7326/M22-2222