Surgical Management of Primary Hyperparathyroidism: State of the Art
Section snippets
History of parathyroid surgery
…It seems hardly credible that the loss of bodies so tiny as the parathyroids should be followed by a result so disastrous.
—William S. Halsted, 19071
Surgical anatomy, embryology, and pathology of the parathyroid glands
Normal parathyroid glands present in varied shapes and sizes. When subscapular at the upper thyroid pole, parathyroid glands may appear flattened. At the cricothyroid junction or thymic tongue, such glands may resemble oval, spherical, or teardrop shapes. Most parathyroid glands are yellow-tan or reddish in color depending on fat content, number of oxyphilic cells, and degree of vascularity. The average parathyroid gland measures 5 mm at greatest dimension with an average weight ranging from 30
Clinical presentation and evaluation
Primary hyperparathyroidism results from PTH overproduction by one or more hyperfunctioning parathyroid glands that usually cause hypercalcemia. The widespread use of serum channel autoanalyzers since the 1970s has allowed for earlier diagnosis of primary hyperparathyroidism in patients before the manifestation of clinical symptoms.29 This development along with the aging population in the United States has led to the reported increased incidence of primary hyperparathyroidism.30, 31 The most
Indications for parathyroidectomy
Although symptomatic primary hyperparathyroidism remains a clear indication for surgical treatment, there remains some controversy among clinicians regarding the indications for performing parathyroidectomy in asymptomatic patients. The efficacy of parathyroidectomy in asymptomatic patients has been questioned due to the indolent nature and less understood natural history of primary hyperparathyroidism. To address this issue, the National Institutes of Health (NIH) convened a consensus
Preoperative parathyroid localization
The only localization that a patient needs who has primary hyperparathyroidism is the localization of an experienced surgeon!
—John L. Doppmann, 199145
An important advancement in the surgical treatment of primary hyperparathyroidism has been the improved preoperative localization of hyperfunctioning parathyroid glands using a variety of imaging techniques including sestamibi-technetium 99m scintigraphy (sestamibi), ultrasonography (US), and 4-dimensional computed tomography(4D-CT). Sestamibi,
Intraoperative parathyroid hormone monitoring
When surgeons have the ability to measure endocrine gland function intraoperatively, our dedication to chasing hormones will become a lot easier and much more fun.
—George L. Irvin, 1999 21
A significant innovation in the surgical treatment of primary hyperparathyroidism, IPM, serves as a surgical adjunct to quantitatively determine the excision of all hyperfunctioning parathyroid tissue. Refined and first implemented routinely by George Irvin at the University of Miami, IPM allows for more
Focused parathyroidectomy
With the advent of improved preoperative localization techniques, increased availability of IPM, and the predominance of single gland disease in 85% to 96% of patients with primary hyperparathyroidism, limited or focused parathyroidectomy has replaced traditional BNE as the standard approach at many specialized centers worldwide.75, 76, 77, 78, 79 Attractive advantages of focused parathyroidectomy include improved cosmetic results with smaller incisions, decreased pain, shorter operative time,
Bilateral neck exploration
The traditional standard approach in the surgical treatment of primary hyperparathyroidism, BNE requires the identification and careful examination of usually 4 parathyroid glands. When performed by experienced surgeons, the operative cure rate for BNE is more than 95% with a complication rate ranging from 1% to 4%.87, 88 There are certain clinical conditions in which BNE is preferred over focused parathyroidectomy. BNE is indicated for cases of MEN and non-MEN FIHPT wherein there is a higher
Radioguided parathyroidectomy
Radioguided parathyroidectomy is another more recent surgical approach used in the treatment of primary hyperparathyroidism. Patients are injected with Tc-99m sestamibi isotope about 2 hours before surgery, and then taken to the operating room where a gamma probe is used to direct the incision site and localize the abnormal parathyroid glands for excision. After the suspected adenoma is removed, the gamma probe is used to measure the radioactivity of the excised tissue, which is compared with
Endoscopic and video-assisted parathyroidectomy
Recent interest has revolved around the development of minimal access surgical techniques that include endoscopic and video-assisted parathyroidectomy performed with clear preoperative localization, and IPM used to verify the adequacy of abnormal parathyroid gland resection. For the endoscopic approach as described by Gagner, a 5-mm trocar for a 30° laparoscope is first placed at the cervical midline superior to the sternal notch, and carbon dioxide is insufflated to create the work space.93
Reoperative parathyroidectomy
Reoperative neck exploration for persistent or recurrent disease can be very difficult to perform due to loss of normal tissue planes and replacement by scar tissue. Such operations are associated with higher rates of injury to the recurrent laryngeal nerves as well as permanent hypoparathyroidism.100 It is therefore paramount that the surgeon review all operative and pathology reports from previous neck operations to determine which parathyroid glands have been removed and remain. Biochemical
Summary
With the advent of improved preoperative parathyroid localization studies, increased availability of IPM, and the predominance of single-gland disease in most patients with primary hyperparathyroidism, focused parathyroidectomy has become the alternative to conventional BNE. The focused approach has durable cure rates of more than 95%, comparable to BNE, and it can be performed in an ambulatory setting with minimal morbidity. The additional advantages of focused parathyroidectomy include
References (103)
Extraction of a parathyroid hormone which will prevent or control parathyroid tetany and which regulates the levels of blood calcium
J Biol Chem
(1925)Presidental address: chasin' hormones
Surgery
(1999)- et al.
Normocalcemic hyperparathyroidism in patients with osteoporosis
Surgery
(2004) - et al.
Characterization of normocalcemic primary hyperparathyroidism
Am J Med
(2004) - et al.
Indications for operative intervention in patients with asymptomatic primary hyperparathyroidism: practice patterns of endocrine surgery
Surgery
(2006) - et al.
Surgeon performed ultrasound as the initial and only localizing study in sporadic primary hyperparathyroidism
J Am Coll Surg
(2006) - et al.
Detection of parathyroid adenoma in patients with primary hyperparathyroidism: the use of office-based ultrasound in preoperative localization
Am J Surg
(2006) - et al.
Can localization studies be used to direct focused parathyroid operations?
Surgery
(2001) - et al.
What is the link between nonlocalizing sestamibi scans, multigland disease and persistent hypercalcemia? A study of 401 consecutive patients undergoing parathyroidectomy
Surgery
(2006) - et al.
Prospective comparison of technetium-99m-sestamibi/iodine-123 radionuclide scan versus high-resolution ultrasonography for the preoperative localization of abnormal parathyroid glands in patients with previously unoperated primary hyperparathyroidism
Am J Surg
(1993)
Efficacy of preoperative diagnostic imaging localization of technetium 99m-sestamibi scintigraphy in hyperparathyroidism
Surgery
A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003
Otolaryngol Head Neck Surg
Role of intraoperative parathormone monitoring during parathyroidectomy in patients with discordant localization studies
Surgery
Long term outcome of patients with intraoperative parathyroid hormone level remaining above the normal range during parathyroidectomy
Surgery
The evolution of parathyroid failures
Surgery
Intraoperative parathyroid hormone testing improves cure rates in patients undergoing minimally invasive parathyroidectomy
Surgery
Parathyroid histopathology: is it of any value today?
J Am Coll Surg
Does histopathology predict parathyroid hypersecretion and influence correctly the extent of parathyroidectomy in patients with sporadic primary hyperparathyroidism?
Surgery
Video-assisted versus conventional parathyroidectomy in primary hyperparathyroidism: a prospective randomized study
Surgery
Presidential Address: minimally invasive endocrine surgery—standard of treatment or hype?
Surgery
Hypoparathyreosis, status parathyreoprivus, and transplantation of the parathyroid glands
Am J Med Sci
On the anatomy of the Indian rhinoceros (Rh. unicornis, L)
Tran Zool Soc Lon
On new gland in man and several mammals
Bull Hist Med
Ueber Tetanie. Samml Klin Vortr, 189
Inn Med
Sur les fonctions du corps thyroide
C R Seances Soc Biol Fil
Tetania parathyreopriva
Mitt Grenzgeb Med Chir
On the relation of the parathyroid to calcium metabolism and the nature of tetany
Bull Johns Hopkins Hosp
Ueber ostitis deformans ohne osteides Gewebe
Arb Pathol Inst Tubingen (Leipzig)
Zwei falle von parathyreoideatumoren
Wien Kiln Wochenschr
Therapeutischer versuch bein einem falls von otitis fibrosa generalisata mittles. Exstirpation eines epithelkorperchentumors
Wien Klin Wochenschr Zentral
Tumors of the parathyroid glands
Surg Gynecol Obstet
The story of hyperparathyroidism at the Massachusetts General Hospital
N Engl J Med
Hyperparathyroidism
JAMA
An elementary chemical study of the parathyroid glands of cattle
Mil Surgeon
Immunoassay of bovine and human parathyroid hormone
Proc Natl Acad Sci U S A
A radioimmunoassay for parathyroid hormone in man
Proc Soc Exp Biol Med
Highly sensitive two-site immunoradiometric assay of parathyrin, and its clinical utility in evaluating patients with hypercalcemia
Clin Chem
Circulating intact parathyroid hormone measured by a two-site immunochemiluminometric assay
J Clin Endocrinol Metab
Studies in patients with hyperparathyroidism using a new two-site immunochemiluminometric assay for circulating intact (1–84) parathyroid hormone
Surgery
A new approach to parathyroidectomy
Ann Surg
Ambulatory parathyroidectomy for primary hyperparathyroidism
Arch Surg
The weight of the parathyroid glands
J Pathol Bacteriol
The normal histology of the parathyroid glands
J Pathol Bacteriol
Surgical anatomy of human parathyroid glands
Surgery
The embryology of the parathyroid glands, the thymus and certain associated rudiments
J Pathol Bacteriol
The anatomy of the primary hyperparathyroidism
Surgery
Incidence of primary hyperparathyroidism in Rochester, Minnesota, 1993–2001: an update on the changing epidemiology of the disease
J Bone Miner Res
Primary hyperparathyroidism: incidence, morbidity and potential economic impact on the community
N Engl J Med
Parathyroidectomy in the elderly: do the benefits outweigh the risks?
World J Surg
Primary hyperparathyroidism in younger and older patients: symptoms and outcome of surgery
World J Surg
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Double adenoma as a cause of primary hyperparathyroidism: Asymmetric hyperplasia or a distinct pathologic entity?
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2020, American Journal of SurgeryCitation Excerpt :A systematic review comparing focused PTx and PTx performed with bilateral neck exploration found a mean difference of 40 min between the two operations.14 Furthermore, for PTx carried out during bilateral neck exploration, the incision is longer, the postoperative pain is greater, the hospital stay is lengthier, and the incidence of symptomatic postoperative hypocalcemia is higher.1,2,5,6,15 The success of focused PTx is highly dependent upon the accuracy of preoperative PT localization studies.
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