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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