Total parathyroidectomy

Parathyroidectomy is the removal of one or more of the parathyroid glands, and is primarily used to treat a condition known as hyperparathyroidism. When all of the parathyroid glands are removed, the procedure is called a total parathyroidectomy, which would be used to treat severe cases of hyperparathyroidism.

Hyperparathyroidism is a condition in which the parathyroid glands produce too much parathyroid hormone (PTH).

If there is too much PTH, calcium is removed from the bones and goes into the blood, and an increased absorption of calcium from the intestine into the bloodstream. This leads to higher levels of calcium in the blood and an excess of calcium in the urine.

In severe cases, the bone density will diminish and kidney stones can form. Other possible symptoms of hyperparathyroidism include depression, muscle weakness, and tiredness.

There are two main forms of hyperparathyroidism - primary and secondary.

Primary is when one or more of the parathyroid glands is enlarged or overactive, and the abnormality causing it is within the gland itself.

Secondary is when there is nothing obviously wrong with the gland, but an underlying condition exists, such as kidney failure or vitamin D deficiency, that lowers calcium levels. When this happens, the body responds by producing extra parathyroid hormone to prevent from calcium levels from falling to a very low level.

Primary hyperparathyroidism can only be treated through surgery, whilst treatment of secondary hyperparathyroidism depends on the underlying cause and it is unlikely they will require a parathyroidectomy.

Patients will first undergo a blood test to identify the levels of PTH, blood calcium, and phosphorus in their blood, to determine whether they have hyperparathyroidism.

They may then undergo a DEXA scan (a bone density X-ray) to detect bone loss, fractures or bone softening, and X-rays, CT scans or ultrasound scans to show calcium deposits or kidney stones. The scans should help plan management.

Patients will receive an anaesthesia, either local or general, depending on how many or which parathyroid glands require being removed. A small incision will be made in the neck to allow the surgeon to explore all the parathyroid glands, and then the glands with the problems can be removed.

The process usually takes up to three hours. There are two main types of operation, depending on the nature of the problem:

  • a minimally invasive parathyroidectomy (or focused parathyroidectomy) is when the surgeon examines only one area of the neck where the parathyroid tumour is located and removes the affected glands;
  • a total parathyroidectomy is when all of the parathyroid glands are removed, usually accompanied by the implantation of some normal parathyroid tissue, dissected from the patient's own glands into the patient's forearm, which will act as functioning parathyroid tissue.

The minimally invasive option is the preferred approach, but a total removal of the glands may be necessary for the severest of cases.

Patients must not eat or drink anything for roughly six hours prior to the time of the operation. This is because if there is anything in the stomach, it will increase the chances of an anaesthetic complication.

Patients are also strongly advised to stop smoking before and after surgery, as this will improve the healing process and reduce postoperative coughing and bleeding.

Patients should inform their doctor if they take any blood thinning medications and will have to stop taking these medications prior to surgery.

The patient's blood calcium will be checked immediately after the operation. If the blood calcium level is low, the patient may experience hypocalcemia symptoms such as numbness/tingling and muscle cramping.

These symptoms will be relieved by taking calcium supplements and, if needed, vitamin D supplements which may be prescribed to the patient following the operation.

Patients will only spend one night in the hospital or may even be discharged at the end of the surgery day. Patients are advised to arrange for a family member or friend to pick them up once discharged, and the patient should have someone with them at home for the first night.

As the operation concerns the neck this area of the body will be swollen and bruised after surgery, and there will likely be a bandage wrapped around the neck. Bandages can be removed one or two days following surgery.

If patients received a general anaesthetic for surgery, they will be advised to avoid drinking alcohol, operating machinery or signing legal documents for at least 48 hours after the operation.

Patients will usually be able to return to work within one or two weeks.

Patients will be advised to rest for the first week following surgery and avoid excessive talking, smiling, hard chewing, strenuous activities, lifting heavy objects, and bending over. However, walking outside, going up and down stairs, and performing light activities are all encouraged for the recovery process.

A parathyroidectomy is an extremely effective form of treatment and cures around 97% of hyperparathyroidism cases.

Since primary hyperparathyroidism can lead to decreased bone density, a parathyroidectomy will improve bone density and lowers the risk of broken bones. After the operation, patients have been shown to regain as much as 6 to 12% of their bone strength and the risk of fracture returns to that of an average person.

Patients have also reported a significant general improvement in quality of life and noticeable reduction in symptoms, even up to 10 years following the operation. It has also been revealed that if primary hyperparathyroidism is left untreated, 1 of 3 patients will develop kidney stones.

Following a parathyroidectomy, however, 90% of patients do not develop new stones. Therefore, this operation is highly effective and the health benefits are noticeable.

There is the possibility of damage to the patient's vocal cord. This is because the anatomy of the parathyroid glands is complicated by the existence of the recurrent laryngeal nerve, which is a very important nerve that runs very close to or through the thyroid gland next to the parathyroid glands.

This nerve controls movement of the vocal cord on that side of the larynx (voice box), and damage to the nerve can weaken or paralyze the vocal cord. Weakness or paralysis of both vocal cords also can cause difficulty breathing.

In most cases, a breathing tube is used that rests in the larynx between the vocal cords and is designed to allow for the continued monitoring of their function.

There is also the possibility of damage to the thyroid glands, and in rare situations, the parathyroid glands at issue are found within the thyroid gland, and it may also be necessary to remove the thyroid gland.

Unfortunately, primary hyperparathyroidism can only be treated through surgery. All efforts will of course be made to medically treat or control the hyperthyroidism prior to recommending the patient for surgery.

Such measures can include avoiding calcium rich foods, ensuring the patients is always fully hydrated, and medications to avoid bone conditions, such as osteoporosis. None, however, will be as effective as surgery.

If the patient has secondary hyperparathyroidism, treatment will depend on the underlying cause and it is unlikely they will require a parathyroidectomy.

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