Surgical Aspects Of Management

Of Hyperparathyroidism

Dr. Osama El-ShahatHead of Nephrology Department

New Mansoura General Hospital (international)

Egypt

ISN Educational Ambassador

Secondary hyperparathyroidism (2HPT) is a common

complication in hemodialysis patients.

The majority of patients with 2HPT can be managed by

medical treatment with vitamin D sterols and

calcimimetics.

In severe cases of 2HPT, medical therapy alone may be

ineffective.

Some patients require surgical treatment in the form of

parathyroidectomy (PTX)

Coulston JE, e tal. Br J Surg. 2010 Nov;97(11):1674-9.

Anatomy

3 glands 3%

4 glands 84%

5 or more 13%

Superior glands are posterior to the nerve (more consistent)

Inferior glands are anterior to the nerve

(less consistent)

RLN and the Parathyroid Glands

Pre-Operative Imaging

High-resolution ultrasound

Sensitivity 65-85% for adenoma; 30-90% for enlarged gland

Results suboptimal in pts with multinodular thyroid disease, pts with short thick neck, ectopic glands (15-20%)

May be useful in detecting Sestamibi scan negative adenomas

CT with contrast/thin section

Sensitivity of 46-87%

Good for ectopic glands in the chest

Pre-Operative Imaging

MRI

Sensitivity of 65-80%

Good for ectopic glands

Sestamibi

85-95% accurate in localizing adenoma in primary HPT

Sestamibi-SPECT

Sensitivity 60% for enlarged gland and 98% for solitary adenomas

Pre-Operative Imaging

in Renal HPT

Only Required

for

Redo Parathyroidectomy

Neck exploration in CKD Patients

Previous dialysis line generates fibrosis (damage)

Vascular calcification (bleeding)

Engorged neck veins (bleeding)

Anticoagulation on dialysis (bleeding)

Anaemia and platelet abnormality (bleeding)

The glands are closely related to RLN (damage)

Inconstancy of the inferior glands (recurrence)

Supernumerary gland(s) (recurrence)

Thymectomy (bleeding into the chest)

Subtotal parathyroidcomy (SPTX)

Resection of 3 ½ parathyroid gland

The most healthy looking parathyroid gland chosen

Leaving a portion of viable parathyroid gland and

marked with clip

Total parathyroidcomy with autotransplantio

( TPTX+AT)

The most healthy looking parathyroid gland chosen

Implantation of a portion of parathyroid gland

Total parathyroidcomy without autotransplantion

( TPTX)

Parathyroidectomy

Only 5-10% will come to

surgery

Bilateral Neck Exploration

If 4 glands found, minimum 3 ½ glands removed and thymectomy

Found only 3 glands

Total parathyroidectomy

Thymectomy

No auto-transplantation

Found 5 or more

Total parathyroidectomy

Thymectomy

No auto-transplantation?

Thymus in the neck

Undescended thymus is associated with

undescended inferior para thyroid gland

The inferior parathyroid glands may be

higher that the superior glands, but stays

anterior to the RLN

Histology of the thymus in adults

Fat

Total without auto-transplantation,

Subtotal Parathyroidectomy and Total with auto-transplantation

No adequately powered RCT

Recurrence

Adynamic bone disease (ABD)

Why Thymectomy

Develops from third pharyngeal pouch

like the inferior parathyroid

Has some parathyroid rests that become

active by persistent stimulation (CKD),

they may develop into a full gland.

Descent of the Thymus and The

Inferior Parathyroid Glands

Protocol

of parathyroidectomy

for patients with ESRD

Patients with PTH more than 1500 pg.

Not responding to medical treatment.

Has no history of surgery in the neck

specially parathyroidectomy.

Labs. including CBC, LFT, KFT, INR, S. k,

S. Na & S. Po4 and S.Ca.

ENT & anesthesia consultation.

Heparin free HD session the day before the

surgery.

Insertion of CVP .

2 amp. Of ca gluconate diluted in 50cc

0.9% Nacl over 1 hour during the surgery

.

Check S.ca & phosphorus on return from theatre then every

6 h. till for 2 days then every 12 h. for 3 days then daily .

IV Ca infusion which , changing the dose according to S.Ca

level .

Send the removed glands for histopathological examination.

Check PTH 1 week after the operation .

Frequency:

Weekly in the 1st month,

every 2 weeks in the 2nd & 3rd months&

then monthly.

Required lab.:

Monthly PTH in first 3 months then every 3

months

Weekly S.Ca & S. phosphorus.

Medications:

Adjust to results .

To present our experience in total

parathyroidectomy with auto-transplantation

of parathyroid gland and thymectomy.

Retrospective review of 82 cases underwent total

parathyroidectomy, thymectomy and auto-transplantation

performed over four years period. Patients were selected

based on symptoms of CKD-MBD with intact PTH level of

1500 pg/ml and above. No preoperative imaging was required

due to lack of acceptable sensitivity in multi-gland disease. 4

glands excision was performed. A part of a relatively

healthy gland (equivalent to size of normal gland) were auto-

transplanted into sternomastoid muscle pouches.

Male Femal Total

Count 50 32 82

Age (yr.) 42.71 42.51 42.63

Duration of HD(yr.) 7.48 6.88 7.26

59.2%

40.7%Male

Femal

S. PTH

S. Ca

S. Po4

0

1

2

3

4

5

6

Pre-op Post-op

5.9

3.4

Pre-op

Post-op

Post operative S. Ca

Results

82patients had curative surgery with the mean postoperative

PTH 108.27pg/ml. Six patients had persistent

hyperparathyroidism where one or 2 glands were not found

in the neck and one patient had recurrence .

5 patients developed symptomatic hypocacemia,3 of them

required hospitalization>

One case developed vocal cord fixation.

Hemothorax related to central venous line one case.

Thrombophlebitis related to Ca infusion 5 cases.

Conclusion:

Our data demonstrates encouraging results in the

treatment of this disabling disease.

Preoperative localization is not essential except in

redo cases where the sensitivity of various imaging

modalities is much better.

28 patients had curative surgery with the mean postoperative

PTH 95.9 pg/ml. Two patients had persistent

hyperparathyroidism where one or 2 glands were not found in

the neck. One patient had recurrence , No surgical

complications were reported.

A retrospective review of 70 cases underwent totalparathyroidectomy, thymectomy and auto-transplantation, performed over three years period.

Six patients had persistent hyperparathyroidism where one or 2

glands were not found in the neck. One patient had recurrence , 5

patients had symptomatic hypocalcaemia. Asingl case of RLN

injury was reported

Parathyroidectomy

No place for a “Cowboy Surgeon”

Sheffield

Mansoura – Damanhour – Tanta – Monufiya