Operative Technique

A Kocher incision is used. All the parathyroid glands are identified. If all the glands are abnormal, the parathyroid gland closest in size to normal and the farthest from the recurrent nerve should undergo biopsy or subtotal resection first before the other hyperplastic glands are removed. The parathyroid remnant should be about 50 mg, which is the size of a normal parathyroid gland.

TABLE 53-1. Incidence of Postoperative Hypocalcemia after Parathyroidectomy for Secondary Hyperparathyroidism

Total Parathyroidectomy and

Autotransplantation Subtotal Parathyroidectomy

NO. OF PATIENTS WITH POSTOPERATIVE NO. OF PATIENTS WITH POSTOPERATIVE

Total Parathyroidectomy and

Autotransplantation Subtotal Parathyroidectomy

NO. OF PATIENTS WITH POSTOPERATIVE NO. OF PATIENTS WITH POSTOPERATIVE

Study

N

HYPOCALCEMIA (%)

N

HYPOCALCEMIA

Lundgren et alM

15

11 (73)

7

4(57)

Cordell et al7'

8

4(50)

36

11(31)

Dubost et al72

9

0(0)

10

2(20)

Mozes et al68

16

4(25)

0

Rothmund et al18

45

1(2)

0

Malmaeus et al73

16

5(31)

27

7(26)

Albertson et al71

10

2(20)

22

1 (45)

Delmonico et al75

0

32

1(3)

Zodon et al57

14

2(14)

Sitges-Serra et al76

3

1(33)

15

1(7)

Welk et al77

23

0(0)

0

Hellman et al7B

46

22 (48)

37

8 (22)

Demeure et a]57

37

0(0)

Rothmund et al63

20

1(5)

20

1(5)

Total

211

51 (24)

257

38 (15)

The selected parathyroid gland undergoes biopsy or subtotal resection initially to ensure that the remaining parathyroid remnant from which a biopsy has been taken has an adequate blood supply. When the remnant tissue is of questionable viability, it should be removed and another parathyroid gland should undergo biopsy or subtotal resection. In all patients with parathyroid hyperplasia, we recommend thymectomy because a fifth parathyroid gland is found in the thymus in 13.7% to 25% of patients.1060 When a biopsy specimen is taken from the parathyroid remnant, the site is marked with a silver clip or stitch. As previously mentioned, using this technique, we have had no patients with persistent hypoparathyroidism.

Patients treated with subtotal parathyroidectomy have few complications, and permanent hypoparathyroidism and recurrent HPT vary considerably (Tables 53-1 to 53-4). Some of the reported differences perhaps are due to "bone hunger" resulting from osteitis fibrosa cystica. These patients may experience profound postoperative hypocalcemia, but PTH levels are increased or normal. Most of these patients eventually become normocalcemic. As mentioned, we recommend cryopreserving parathyroid tissue in all patients undergoing subtotal or total parathyroidectomy with autotransplantation as insurance against possible permanent hypoparathyroidism. Some centers report a high incidence of permanent hypoparathyroidism (see Table 53-1),61,62 which we believe is unacceptable after initial operations for patients with primary or secondary HPT. The incidence of permanent hypoparathyroidism should be less than 1%. For the small number of patients in whom recurrent HPT

TABLE 53-2. Incidence of Persistent or Recurrent Hyperparathyroidism (HPT) after Parathyroidectomy in Renal Patients

Total Parathyroidectomy and

Autotransplantation Subtotal Parathyroidectomy

TABLE 53-2. Incidence of Persistent or Recurrent Hyperparathyroidism (HPT) after Parathyroidectomy in Renal Patients

Total Parathyroidectomy and

Autotransplantation Subtotal Parathyroidectomy

NO. OF PATIENTS

NO, OF PATIENTS

NO. OF PATIENTS

NO. OF PATIENTS

WITH PERSISTENT

WITH RECURRENT

WITH PERSISTENT

WITH RECURRENT

Study

N

HPT(%)

HPT (%)

N

HPT (%)

HPT (%)

Cordell et al71

8

2(25)

2 (25)

36

0(0)

3(8)

Dubost et al72

9

0(0)

1 (11)

10

0(0)

4 (40)

Mozes et al68

16

2(13)

1(6)

Malmaeus et al73

17

1(6)

1(6)

30

0(0)

3 (10)

Albertson et al74

10

1 (10)

1(10)

22

0(0)

0(0)

Delmonico et al75

32

0(0)

2 (62)

Zodon et al67

14

0(0)

0 (0)

Sitges-Serra et al76

3

0(0)

0(0)

15

0(0)

1(7)

Welk et al77

21

1(5)

4(19)

Takagi et al79

17

7(6)

19

0(0)

3 (16)

Hellman et al78

46

4(9)

3(7)

37

4(11)

4(11)

Demeure et al67

37

2(5)

1(3)

Total

130

11(8)

20(15)

252

6(2)

21 (8)

TABLE 53-3. Incidence of Symptomatic Improvement after Parathyroidectomy for Secondary

Hyperparathyroidism

Total Parathyroidectomy and

Autotransplantation

Subtotal Parathyroidectomy

NO. OF PATIENTS WITH

NO. OF PATIENTS WITH

POSTOPERATIVE SYMPTOMATIC

POSTOPERATIVE SYMPTOMATIC

Study

N

IMPROVEMENT (%)

N

IMPROVEMENT (%)

Sicard et al80

6

6(100)

8

8 (100)

Mozes et al6S

16

15(94)

Albertson et al74

10

8 (80)

22

21 (95)

De Francisco et alB8

62

55 (89)

Fujimoto et al81

23

22 (96)

9

3(33)

Welk et al77

21

14(67)

Demeure et al57

37

34(92)

Rothmund et al63

20

17(85)*

20

8 (40)*

Cordell et al71

8

6(75)

32

26 (81)

Total

104

88 (85)

190

155 (82)

•Values represent mean; range, 14-20 (69-100%).

'Values represent mean; range, 5-12 (25-60%).

develops after subtotal parathyroidectomy (see Table 53-2), the remnant parathyroid tissue can usually be relatively easily and safely removed because its position was marked at the initial operation and its relationship to the recurrent laryngeal nerve was also clearly described in the operative note. Numerous studies63 67 suggest that subtotal parathyroidectomy is the procedure of choice for most patients with parathyroid hyperplasia.

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