Surgical Management of Primary Hyperparathyroidism: State of the Art

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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

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