Overview of Parathyroidectomy
A parathyroidectomy is a surgical procedure to remove one or more of the four parathyroid glands, small glands in your neck that regulate calcium levels in your body. This surgery is usually required if someone has a condition called hyperparathyroidism, where the glands produce too much parathyroid hormone, leading to high calcium levels in the blood.
The most reliable treatment for this condition is a parathyroidectomy. Usually, people with primary hyperparathyroidism – the most common form of this condition – have a single abnormal gland, called an adenoma. However, in some cases (around 10%), there could be two adenomas, and in rare instances, all four glands might be affected.
The traditional way of performing this surgery involves checking all four glands and removing any that appear abnormal based on their size. In recent times, there have been advancements in surgical techniques. These include the use of ultrasound imaging or a high-resolution endoscope, which can provide a clear view of the glands, thus eliminating the need to explore all four glands. Surgeons can also use a radio-guided method or real-time monitoring of parathyroid hormone levels during surgery to ensure only the abnormal glands are removed.
Despite these new methods, the traditional parathyroidectomy is still commonly performed by many surgeons because of its proven effectiveness. For the purposes of this explanation, we’re focussing on this standard surgery.
Anatomy and Physiology of Parathyroidectomy
The parathyroid glands are a group of four small glands found behind the thyroid in your neck. These glands weigh approximately 30 to 50 milligrams each. They have a key role in controlling the calcium levels in your body by releasing a hormone called parathyroid hormone (PTH).
The top two parathyroid glands are normally situated to the back of the thyroid and are more predictably located than the bottom two. The lower two glands may be found in several areas, including somewhere lower in the neck, inside the thyroid gland or thymus (a small organ in your chest), near the large blood vessels in your neck, or behind your throat. Rarely, there might be extra glands in these areas.
The parathyroid glands get their blood supply from the inferior thyroid artery. In about 20% of cases, the upper glands can also receive blood from other arteries.
When calcium levels in your blood are low, the parathyroid glands produce more PTH. This hormone helps increase calcium levels by acting on your kidneys and bones and promoting the conversion of vitamin D into its active form in your body. The active form of vitamin D helps your gut to absorb more calcium.
Hyperparathyroidism is a condition where the parathyroid glands produce too much PTH. If one or more of the glands are abnormal (for example, due to a non-cancerous tumor or increased number of cells), they may produce too much PTH, causing high calcium levels in your blood. This disorder can lead to muscle and nerve issues, loss of bone density, and kidney stones. Hyperparathyroidism can also occur as a response to low calcium levels, often due to low vitamin D levels or long-term kidney disease. In rare cases, after a kidney transplant, patients with secondary hyperparathyroidism might continue to have high PTH levels.
Why do People Need Parathyroidectomy
If you have a condition called primary hyperparathyroidism, which is when the parathyroid glands in your neck produce too much parathyroid hormone, you might need to have surgery. The symptoms of this condition include excessive thirst and urination, kidney stones, high levels of calcium in the urine, impaired kidney function, weak bones, fractures, pancreatitis, stomach ulcers or acid reflux, and mental and emotional issues.
If you have primary hyperparathyroidism but don’t have any symptoms, you might also need surgery if you’re younger than 50 and your blood calcium levels are high, if your body excretes too much calcium in urine, if your kidney function is lower than expected for your age, if your bone density is very low, if you cannot or do not want to have regular medical check-ups, or if you wish to have the surgery.
Recent studies have shown that having high blood calcium levels and having primary hyperparathyroidism have similar risk factors for heart disease. Surgery could help reduce these risks.
Another condition called secondary hyperparathyroidism is usually managed with medications instead of surgery. This condition is often caused by kidney failure and it can lead to high blood calcium and phosphate levels. However, if the disease doesn’t get better with medication, surgery might be necessary. Around 15% of patients might require surgery after being on dialysis for 5 to 10 years.
In cases of tertiary hyperparathyroidism, which is often seen after a kidney transplant, surgery might be needed, especially if there is high blood calcium level. Surgery is more effective than medication in treating tertiary hyperparathyroidism. The aim of the surgery is to achieve normal calcium levels at least six months after surgery.
In case a patient has parathyroid cancer, a cyst on one of the parathyroids, or a serious condition called hypercalcemic crisis (high calcium levels causing nervous system problems), immediate surgery might be required. This is because these conditions can rapidly cause severe health problems if not treated promptly.
When a Person Should Avoid Parathyroidectomy
There are certain situations where a parathyroidectomy, or the removal of the parathyroid glands, should not be performed:
Absolute No-go:
People who have familial hypocalciuric hypercalcemia (FHH) should not have a parathyroidectomy. FHH is a condition where the body has high calcium and Parathyroid Hormone (PTH) levels but does not excrete much calcium in the urine. This condition also shows a low ratio of urinary calcium to creatinine clearance – an indicator of kidney function. The important thing to remember is that having a parathyroidectomy will not cure the high calcium levels linked to FHH.
Relative No-go:
Parathyroidectomy might also not be recommended if there’s a risk of injuring the opposite side’s recurrent laryngeal nerve (RLN) or if there’s a vocal cord dysfunction. RLN is a nerve that is important for speaking and swallowing. Damage to it can cause voice changes or difficulty swallowing.
Equipment used for Parathyroidectomy
When a surgeon is preparing to perform a thyroidectomy, which is a surgery to remove your thyroid gland, they need specific equipment on hand. This includes a Bovie or bipolar cautery, a harmonic scalpel, electronic tissue fusion devices, or surgical ties. The choice between these tools will depend on what the surgeon prefers to work with.
They also need to employ what’s called a ‘frozen pathology analysis’. This is a technique where a piece of tissue is rapidly frozen and examined under a microscope by a pathologist during the surgery itself. This is done to make sure the tissue they’re dealing with is parathyroid tissue.
Another crucial piece of equipment is something called ‘intraoperative nerve monitoring’ or IONM. This tool helps to monitor the function of the recurrent laryngeal nerve (RLN) – a nerve that could potentially be injured during the surgery – with the aim to reduce this risk. This is especially necessary if the person undergoing surgery has had parathyroid surgery before.
If the surgery being performed is a ‘focused parathyroidectomy’ (a surgery done to remove parathyroid glands that are overactive), an ultrasound or a gamma probe may be used. These tools can help the surgeon identify the problematic gland during surgery. Additionally, to confirm the removal of the overactive gland, an ‘intraoperative parathyroid hormone’ (IOPTH) test may be performed. This is something that needs to be planned ahead of time with the hospital’s pathology department.
Who is needed to perform Parathyroidectomy?
A group of medical professionals are needed to carry out a thyroidectomy, which is a surgery to remove all or part of the thyroid gland. This team usually includes one or two surgeons, who are doctors specially trained to perform operations. The standard operating room staff helps the surgeons during the procedure. There’s also the anesthesiologist, whose job is to make sure you stay asleep and pain-free during the surgery. If an IOPTH is planned, which is a test to check your parathyroid hormone levels during surgery, a pathologist or clinical chemist should also be involved. Their role is to analyze the test results to ensure your hormone levels are right. Each member of the team plays a crucial part in your surgery and recovery.
Preparing for Parathyroidectomy
Parathyroidectomy is a standard way to treat hyperparathyroidism, a condition that makes an individual’s parathyroid glands produce too much parathyroid hormone (PTH). The purpose of this operation is to take out the glands that are generating too much PTH. Now, you might also ask “What is a parathyroid gland?” Well, it’s a tiny gland in your neck that helps control the amount of calcium in your blood.
More often than not, doctors follow a traditional approach where they explore all the four parathyroid glands during the operation. However, if only one gland is the problem and they know exactly where it is, doctors prefer a less invasive procedure with a smaller cut and less exploration. Both of these methods have similar outcomes, like the chances of the disease returning or the need for another operation. But the less invasive procedure has lower risks of complications and doesn’t take as long.
Now, for some patients with other related problems, doctors might do a complete parathyroidectomy, where they take out all the glands, or a subtotal one, where they leave a tiny bit of the gland. But these methods come with their own risks. For instance, taking out all the glands can lead to chronic low calcium levels and heart issues. On the other hand, leaving a bit of the gland might lead to the disease coming back.
To make the operation as safe and effective as possible, surgeons can use different technologies, such as ultrasound to identify problematic glands, special surgical tools guided by radioactive signals, endoscopic help that comes with a camera, or measuring PTH levels in the middle of the operation.
What’s also required before the operation is localizing, which means figuring out the exact location of the problem gland. Surgeons do it using imaging methods like a special kind of scan called Sestamibi scintigraphy, a type of imaging test called single-photon emission computed tomography (SPECT), neck ultrasound, and others. However, if an individual has a history of neck operations or the imaging results aren’t clear enough, they may also do more advanced techniques.
The preferred method to make a patient comfortable and pain-free during this surgery is called general anesthesia, where the individual is put to sleep. This is the case not only for full parathyroidectomy but also for the minimally invasive procedure. Nowadays, some surgeons use local anesthesia instead which is just numbing the operation area. Recent research says it might be a good option as it cuts down costs and the patient experiences less pain, nausea, and discomfort post-operation.
For the operation, the individual’s placed on the operation table with the neck stretched out and arms by the sides. A roll might be set under the shoulders to give a clear view of the neck area. The table would be in a little tilt. If the person has any neck bone conditions, doctors need to look at the angle of neck stretching to not cause any harm.
How is Parathyroidectomy performed
Here’s what your procedure will look like if you need to have a surgery to explore the area around your collar bone:
1. The surgeon will make a cut just above the collar bone and separate the skin from the muscle underneath, using either electrically heated equipment or a traditional surgical suture to control any bleeding.
2. The surgeon will continue making careful cuts to lift up the area of tissue known as the platysma muscle, which is found in the neck. This is done to create a clear path all the way from the bony notch at the top of your breastbone to the bottom of the notch.
3. The surgeon then cuts deeper into the neck, right down the middle, spreading the muscles apart. This is done to clear a pathway to your thyroid gland.
These steps allow the surgeon to create clear access to the thyroid gland and the nearby muscles. They will then carefully move the thyroid and muscles aside to get to the paratrhit gland. The goal here is to isolate and remove an enlarged parathyroid gland. It’s very important that the gland isn’t ruptured during removal to prevent problems down the road. The tissue that’s removed during the operation will be sent to a lab to make sure it’s the parathyroid gland.
If you have testing done before your surgery that finds the parathyroid gland problem early, the surgeon can perform a more focused surgery. This procedure only needs a smaller incision and less dissection, and the operation will take less time overall.
Some decisions will need to be made during your operation, based on what the surgeon finds. For example, they may need to carefully move the thyroid gland around to look for a parathyroid gland that might be in an unusual location. If they can’t find the gland, they might need to check areas like the bottom of the thyroid or check inside the thymus gland, another gland found in the neck.
If it turns out you have a condition called multiple endocrine neoplasia (MEN), which affects your parathyroid glands, the surgeon will print a plan based on the specifics of your case. MEN 1 usually involves removing most of the parathyroid glands, but not all. MEN 2A might involve removing only the enlarged glands. If you have parathyroid cancer, the surgeon will aim to remove the cancerous gland and any tissue it might have spread to.
Possible Complications of Parathyroidectomy
Several complications can occur after parathyroidectomy, the surgery to remove the parathyroid glands:
Postoperative Bleeding and Hematoma: This is when blood collects near the surgical site, causing a lump after the operation. Though it’s a very rare complication, it is a serious one that can cause complications for the airway, such as difficulty breathing. In such cases, immediate medical action is needed to remove the hematoma and maintain a clear airway.
Recurrent Laryngeal Nerve Injury: This nerve, if injured during surgery, can lead to voice changes like hoarseness or even difficulty with breathing. This is one of the most feared complications of parathyroid surgery as it can also increase the risk of inhalation of food particles into the lungs, which can lead to serious lung infections. Usually, the injury to the nerve heals by itself over time, within half a year post-surgery. During the operation, the doctors take additional steps like the use of nerve monitoring devices to reduce the possibility of injuring this nerve.
Hypoparathyroidism and Hypocalcemia: After the surgery, there is a drop in the production of parathyroid hormone leading to low calcium levels in the body, which can cause symptoms like numbness around the mouth, tingling in the fingertips, muscle cramps, irregular heartbeat, and even seizures. This condition is usually temporary, but its severe form is reported in very few cases. The treatment involves intake of supplements of calcium and, if necessary, calcitriol (a form of Vitamin D) to help increase the body’s calcium levels.
Persistent or Recurrent Hyperparathyroidism: In some cases, patients can continue to have high levels of parathyroid hormones causing high blood levels of calcium even after the surgery. This can occur due to various reasons such as the presence of extra parathyroid glands which were not noticed or removed during the first operation, or due to surgeries performed by less practiced surgeons. In such cases, it is often recommended to consider a second surgery; though the chances of success may be lower and risks may be higher, so the decision must be taken carefully after re-evaluating all aspects.
What Else Should I Know About Parathyroidectomy?
Primary hyperparathyroidism, a condition where the parathyroid glands produce too much hormone, is best treated with a surgery called parathyroidectomy. This surgery may also be needed for secondary or tertiary hyperparathyroidism, which are more advanced stages of the disease. The standard procedure is called a bilateral neck exploration, and it’s especially helpful for patients with multigland disease, meaning more than one gland is affected, or when medical imaging can’t locate the disease.
However, as medical techniques have improved, there’s now a less invasive option called minimally invasive parathyroidectomy. This surgery involves a smaller cut and less damage to surrounding tissues. It’s often used when a single gland is affected and its location is known before surgery. Even if all four glands need to be examined, it’s possible to do this in a minimally invasive way. This means patients have a quicker recovery and less discomfort.
