Total Parathyroidectomy and Allotransplantation

During this operative procedure, all parathyroid glands are identified and removed. We also recommend removing the thymus via the cervical incision in these patients because the thymus is a frequent site for supernumerary parathyroid glands. All tissue is confirmed histologically by frozen section examination, and tissue from the more normal-appearing hyperplastic parathyroid gland is placed in iced physiologic saline for autotransplantation and cryopreservation. About 12 to 15 1-mm pieces of this parathyroid tissue are then autotransplanted into separate pockets in the forearm muscle.46'47 One-millimeter pieces of parathyroid tissue ensure better tissue perfusion, and separate pockets are used in case a hematoma develops, which might compromise the viability of the autotransplant. Numerous studies have documented that PTH can be measured in the transplanted arm and that a gradient can be determined by measuring the PTH after 2 weeks in both arms. When the PTH level is twofold or greater on the side of the transplanted tissue, the autotransplanted tissue is working. To determine if the patient's systemic PTH value is normal, serum PTH and calcium levels should be measured in the opposite arm. An advantage of autotransplantation over subtotal parathyroidectomy is that the hyperplastic parathyroid graft can be excised, under local anesthesia, if it overfunctions. To remain viable, the autotransplanted parathyroid tissue must invade into muscle. Removal of all autotransplanted parathyroid tissue from the forearm can, thus, sometimes be difficult.

Late failure of the transplanted tissue also sometimes occurs perhaps because of fibrosis.52,68 Both early and late permanent hypoparathyroidism are more common after total parathyroidectomy with autotransplantation than after subtotal parathyroidectomy (see Table 53-1).

We believe, as mentioned, that parathyroid tissue should be cryopreserved in patients having subtotal or total parathyroidectomy as well as in patients having reoperations as

TABLE 53-4. Incidence of Postoperative Hypocalcemia after Parathyroidectomy for Primary Hyperplasia and Recurrent Hyperparathyroidism

Total Parathyroidectomy and Autotransplantation

Subtotal Parathyroidectomy

Study

NO. OF PATIENTS WITH POSTOPERATIVE HYPOCALCEMIA (%)

WO. OF PATIENTS WITH POSTOPERATIVE HYPOCALCEMIA (%)

Alveryd et al70 Castleman et al63 Ransom et al37 Scholz et al6B Kraimps et al3 Total

8 10

insurance against permanent hypoparathyroidism. We advocate total rather than subtotal parathyroidectomy in the following circumstances:

1. For patients with secondary HPT who are noncompli-ant and will not take their medication to suppress parathyroid stimulation

2. For agonal patients who will not tolerate general anesthesia

3. For technical reasons when it is difficult to preserve viable parathyroid tissue on a vascular pedicle

4. For patients with neonatal HPT27,41

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