View source for Parathyroidectomy

{{short description|Surgical removal of one or more parathyroid glands}}
{{Infobox medical intervention (new)
| name          = Parathyroidectomy
| synonyms      =
| image         = Parathyreoidea Adenom I.jpg
| caption       = Parathyroidectomy for [[parathyroid adenoma]]
| alt           = surgical photo of parathyroid gland removal
| pronounce     =
| specialty     = [[General surgery]], [[Endocrine surgery]]
| uses          =
| complications = [[Hypoparathyroidism|{{shy|Hypo|para|thyroidism}}]]
| approach      = Open
| types         =
| recovery =
| options = [[Calcimimetic]]s
| outcomes      =
| frequency     =
| cost          =
}}
'''Parathyroidectomy''' is the [[surgery|surgical removal]] of one or more of the (usually) four [[parathyroid gland]]s. This procedure is used to remove an [[adenoma]] or [[hyperplasia]] of these glands when they are producing excessive [[parathyroid hormone]]{{nbsp}}(PTH), a condition termed [[hyperparathyroidism|{{shy|hyper|para|thyroidism}}]]. The glands are usually four in number and located adjacent to the [[posterior (anatomy)|posterior]] surface of the [[thyroid gland]], but their exact location is variable. When an elevated {{abbr|PTH|parathyroid hormone}}{{nbsp}}level is found, a [[Sestamibi parathyroid scintigraphy|sestamibi scan]] or an [[medical ultrasonography|ultrasound]] may be performed in order to confirm the presence and location of abnormal parathyroid tissue.

==Indications==
The main indication for parathyroidectomy is [[primary hyperparathyroidism|primary {{shy|hyper|para|thyroidism}}]], a condition in which one or more of the parathyroid glands produce excessive [[parathyroid hormone]]. Not all cases of primary {{shy|hyper|para|thyroidism}} require surgery, but it is recommended if the condition causes significant symptoms or if it affects the kidneys ([[nephrocalcinosis|{{shy|nephro|calcin|osis}}]]) or bone health ([[osteoporosis|{{shy|osteo|por|osis}}]]), and also in people under{{nbsp}}50 even if they do not have symptoms.{{zwj}}<ref name="AAES">{{Cite journal |last=Wilhelm |first=Scott M. |last2=Wang |first2=Tracy S. |last3=Ruan |first3=Daniel T. |last4=Lee |first4=James A. |last5=Asa |first5=Sylvia L. |last6=Duh |first6=Quan-Yang |last7=Doherty |first7=Gerard M. |last8=Herrera |first8=Miguel F. |last9=Pasieka |first9=Janice L. |last10=Perrier |first10=Nancy D. |last11=Silverberg |first11=Shonni J. |last12=Solórzano |first12=Carmen C. |last13=Sturgeon |first13=Cord |last14=Tublin |first14=Mitchell E. |last15=Udelsman |first15=Robert |last16=Carty |first16=Sally E. |date=1 October 2016 |title=The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism |journal=[[JAMA Surgery]] |volume=151 |issue=10 |pages=959–968 |doi=10.1001/jamasurg.2016.2310 |issn=2168-6254 |eissn=2168-6262 |pmid=27532368 |s2cid=4007319 |doi-access=free}}</ref> It is not always possible to anticipate if a parathyroid tumor is [[cancer|malignant]] ([[i.e.]] capable of invading other tissues or [[metastasis|spreading elsewhere]]). Any suspicion of [[parathyroid carcinoma]] is therefore also an indication for surgery.{{zwj}}<ref name="AAES" />

Parathyroidectomy may also be required in [[secondary hyperparathyroidism|secondary {{shy|hyper|para|thyroidism}}]]. This situation arises mainly in people with severe [[chronic kidney disease]]{{nbsp}}(CKD) in which the parathyroid glands are overactive to compensate for the low calcium ([[hypocalcemia|{{shy|hypo|calcemia}}]]) and vitamin D ([[vitamin D deficiency]]) levels often present in{{nbsp}}{{abbr|CKD|chronic kidney disease}}. In many cases, the parathyroid hormone production improves when these abnormalities are treated with medication. A small proportion, however, have persistently raised hormone levels six months after treatment has started, thought to be [[wikt:autonomous|autonomous]] production of hormone by the glands and loss of feedback mechanisms. In this situation surgical {{shy|para|thyroid|ectomy}} may be required, especially if calcium and phosphate levels remain elevated (respectively, [[hypercalcemia|{{shy|hyper|calcemia}}]] and [[hyperphosphatemia|{{shy|hyper|phospha|temia}}]]), there is [[calcium deposition]] in the wall of blood vessels ([[calciphylaxis]] in severe cases) or there is worsening bone disease. In people on [[kidney dialysis]], {{shy|para|thyroid|ectomy}} can improve survival. It does appear that the procedure may be underused.{{zwj}}<ref name="Lau2018">{{Cite journal |last=Lau |first=Wei Ling |last2=Obi |first2=Yoshitsugu |last3=Kalantar-Zadeh |first3=Kamyar |date=7 June 2018 |title=Parathyroidectomy in the Management of Secondary Hyperparathyroidism |journal=[[Clinical Journal of the American Society of Nephrology]] |volume=13 |issue=6 |pages=952–961 |doi=10.2215/CJN.10390917 |issn=1555-9041 |eissn=1555-905X |lccn=2005214803 |oclc=60194474 |pmc=5989682 |pmid=29523679}}</ref>

==Procedure==
The [[surgical operation|operation]] requires [[general anesthesia]] (unconscious and pain-free) or [[local anesthesia]] (pain-free). The surgeon makes an incision around {{convert|1|in|cm|abbr=off|disp=flip|frac=2}}{{nbsp}}long in the neck just under the [[larynx]] ("[[Adam's apple]]"), and locates the offending {{nowr|parathyroid glands.}} {{shy|Pre|operative}} testing using [[Sestamibi parathyroid scintigraphy|sestamibi scanning]] can help identify the location of glands. It can also be used to limit the extent of surgical exploration when used in conjunction with {{shy|intra|operative}} [[parathyroid hormone]]{{nbsp}}(PTH) monitoring.{{zwj}}<ref>{{Cite journal |last=Augustine |first=Mathew M. |last2=Bravo |first2=Paco E. |last3=Zeiger |first3=Martha A. |date=Mar–Apr 2011 |title=Surgical treatment of primary hyperparathyroidism |journal=[[Endocrine Practice]] |volume=17 |issue=Suppl 1 |pages=75–82 |doi=10.4158/EP10359.RA |issn=1530-891X |eissn=1934-2403 |oclc=35074613 |pmid=21324817 |id={{CODEN|EPNRAT}}}}</ref> The particular problem or {{nowr|disease process}} will determine how many of the parathyroid glands are removed. Some parathyroid tissue must be left in place to help prevent [[hypoparathyroidism|{{shy|hypo|para|thyroidism}}]].

Recovery after the operation tends to be swift. The {{abbr|PTH|parathyroid hormone}}{{nbsp}}level is back to normal within 10 to 15{{nbsp}}minutes, and can be confirmed by [[intraoperative rapid assessment]] during the operation. However, the remaining {{nowr|parathyroid glands}} may take hours to several weeks to return to their normal functioning levels (as they may have become dormant). [[Calcium supplements]] are therefore often required to prevent symptoms of [[hypocalcemia]] and to restore lost bone mass.{{zwj}}<ref>{{Cite web |last=The American Association of Endocrine Surgeons |author-link=American Association of Endocrine Surgeons |date=10 January 2024<!-- date from page source --> |orig-date=First published 24 October 2023 |title=Parathyroid Surgery |url=https://endocrinediseases.org/parathyroid/parathyroid-surgery/ |url-status=live |archive-url=https://web.archive.org/web/20240615171024/http://endocrinediseases.org/parathyroid/parathyroid-surgery/ |archive-date=15 June 2024 |website=The AAES Endocrine Disease Patient Education Website}}</ref>

The patient is placed in a [[semi-Fowler position]] and the neck is extended. An abbreviated [[Kocher incision]] is made and the [[platysma muscle]] is dissected horizontally. The [[strap muscles]] are released off of the thyroid gland. Then the thyroid gland is mobilized and the parathyroid arterial {{nowr|blood supply}} is {{nowr|suture ligated.}} The entire parathyroid adenoma is identified and dissected out. {{shy|Intra|operative}} {{abbr|PTH|parathyroid hormone}}{{nbsp}}monitoring can begin at this time and will show falling {{abbr|PTH|parathyroid hormone}}{{nbsp}}levels if the entire [[adenoma]] has been resected.{{zwj}}<ref>{{Cite journal |last=Carling |first=Tobias |date=19 April 2022 |title=Minimally invasive parathyroidectomy under local cervical block anesthesia for primary hyperparathyroidism and parathyroid adenoma |journal=J Med Insight |volume=2022 |issue=225 |doi=10.24296/jomi/225 |doi-access=free}}</ref>

==Complications==
{{Redirect|Hungry bone syndrome|low calcium due to other causes|Hypocalcemia}}
{{expand section|date=June 2018}}

While mild [[hypocalcemia]] is common after partial {{shy|para|thyroid|ectomy}}, some people experience persistently prolonged low calcium levels. This is called '''{{vanchor|hungry bone syndrome}}'''. In such a scenario, despite {{shy|re|activation}} of [[Resection (surgery)|unresected]] {{nowr|parathyroid glands}} producing normal-to-elevated levels of [[parathyroid hormone]], serum calcium continues to be low. The balance between calcium influx and efflux within the bone continues to be disrupted, favoring the former. The bone is said to be "hungry" as it consumes minerals without regard to parathyroid hormone levels; calcium, magnesium, and phosphate continue to be deposited into the bones, resulting in ongoing [[hypocalcemia|{{shy|hypo|calcemia}}]], [[hypomagnesemia|{{shy|hypo|magnesemia}}]], and [[hypophosphatemia|{{shy|hypo|phospha|temia}}]]. Prolonged [[calcium supplementation]] may be required. Hungry bone syndrome is particularly common in people who are on long-term [[kidney dialysis]].{{zwj}}<ref name="Lau2018" />{{zwj}}<ref>{{Cite journal |last=Jain |first=Nishank |last2=Reilly |first2=Robert F. |date=July 2017 |title=Hungry bone syndrome |department=Mineral Metabolism |journal=[[Current Opinion in Nephrology and Hypertension]] |publisher=[[Lippincott Williams & Wilkins]] |volume=26 |issue=4 |pages=250–255 |doi=10.1097/MNH.0000000000000327 |issn=1062-4821 |eissn=1473-6543 |pmid=28375869 |s2cid=4630106}}</ref>

== See also ==
* [[Parathyroid disease]]
* [[Parathyroid hormone]]
* [[Thyroidectomy]]
* [[Vocal cord paresis]]{{snd}} potential surgical complication
* [[List of surgeries by type]]

==References==
<references />

==External links==
* {{MedlinePlusEncyclopedia|002931|Parathyroid gland removal}}
* [https://endocrinediseases.org/parathyroid Parathyroid]{{snd}} AAES Endocrine Disease Patient Education Website, [[American Association of Endocrine Surgeons]]

{{Medical resources
| ICD9 = {{ICD9proc|06.8}} }}

{{Endocrine system intervention}}

[[Category:Surgical removal procedures]]
[[Category:Endocrine surgery]]