Mitch Medical Healthcare

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.