Parathyroidectony

1. Surgical Aspects Of Management
Of Hyperparathyroidism
Dr. Osama El-Shahat
Head of Nephrology Department
New Mansoura General Hospital (international)
Egypt
ISN Educational Ambassador

2.  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.

3. 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)

4. RLN and the Parathyroid Glands

5. 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

6. 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

7. Pre-Operative Imaging
in Renal HPT
Only Required
for
Redo Parathyroidectomy

8. 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)

9. 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)

10. Parathyroidectomy
 Only 5-10% will come to
surgery
 Bilateral Neck Exploration
If 4 glands found, minimum 3 ½ glands
removed and thymectomy

11. Found only 3 glands
 Total parathyroidectomy
 Thymectomy
 No auto-transplantation

12. Found 5 or more
 Total parathyroidectomy
 Thymectomy
 No auto-transplantation?

13. 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

14. Histology of the thymus in adults
Fat

15. Total without auto-transplantation,
Subtotal Parathyroidectomy and
Total with auto-transplantation
 No adequately powered RCT
 Recurrence
 Adynamic bone disease (ABD)

16. 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.

17. Descent of the Thymus and The
Inferior Parathyroid Glands

18. Protocol
of parathyroidectomy
for patients with ESRD

20.  Patients with PTH more than 1500 pg.
 Not responding to medical treatment.
 Has no history of surgery in the neck
specially parathyroidectomy.

21.  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.

22.  Insertion of CVP .
 2 amp. Of ca gluconate diluted in 50cc
0.9% Nacl over 1 hour during the surgery
.

23.  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 .

24.  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 .

25.  To present our experience in total
parathyroidectomy with auto-transplantation
of parathyroid gland and thymectomy.

26.  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.

27. 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

28. S. PTH

29. S. Ca

30. S. Po4
0
1
2
3
4
5
6
Pre-op Post-op
5.9
3.4
Pre-op
Post-op

31. Post operative S. Ca

32. 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.

33. 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.

34.  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.

35.  A retrospective review of 70 cases underwent total
parathyroidectomy, 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

40. Parathyroidectomy
No place for a “Cowboy Surgeon”

43. Sheffield
Mansoura – Damanhour – Tanta – Monufiya