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