Parathyroid Surgery

Parathyroidectomy @ PACSO

Parathyroidectomy is the surgical removal of one or more of the four parathyroid glands. 

Background

The parathyroid glands are located in neck behind the thyroid gland next to the trachea (windpipe).  They help to regulate the level of calcium in you bloodstream.

The procedure is used to treat a condition where the parathyroid hormone levels are raised (Hyperparathyroidsim).  This could be due to enlargement of one or more of the glands by a benign growth (adenoma), general enlargement of all glands (Hyperplasia) or rarely a cancerous growth. This is called Primary Hyperparathyroidism.  

 Alternatively it might be due to another condition which constantly stimulate that glands to produce more of the parathyroid hormone (PTH), as is commonly seen in chronic renal failure.  This is called Secondary hyperparathyroidism.

NB: The diagnosis of hyperprarathyroidism is made using blood tests, not by doing scans.

Surgery for Primary Hyperparathyroidism

Some patients with primary hyperparathyroidism do not have any clearly related symptoms. However, many people do have symptoms related to their disease. These can vary greatly, and may include:

  • Bone pain
  • Kidney stones
  • Broken bones from bone weakening (Osteoporosis)
  • Chronic fatigue
  • Stomach problems
  • Lack of concentration
  • Depression
  • Memory Problems

In most patients, treatment for primary hyperparathyroidism is parathyroid surgery. Fortunately, parathyroidectomy is generally very successful, safe, and easy to recover from.

 

What tests are needed before surgery?

When an elevated PTH level is found on blood tests and the decision is made to consider surgery, some scans might be done to try and locate the offending abnormal gland.  Three types of examinations are used:

  • A nuclear study where a small dose of a harmless radio-actively marked agent called sestamibi is given intravenously and the distibution of the fluid into the thyroid and parathyroid is evaluated
  • An ultrasound of the neck 
  • Computed Tomography (CT) scan with intravenous contrast. .

Risks

Parathyroidectomy is considered a safe procedure with very low risks, but as with any surgery, a small risk of complications is possible. The best way of reducing this risk is to have your surgery done by an experienced surgeon who performs more than 20 such operations per year.

Potential complications include:

  • Low Calcium levels (hypocalcaemia)  Once the overactive parathyroid is removed, the PTH levels will drop and calcium will be reabsorbed into the bones resulting in low calcium levels. Symptoms of hypocalcaemia can be numbness, tingling or cramping due to low blood-calcium levels. 
  • Bleeding in the wound in the first few hours after the operation. If this occurs, the build-up of blood will need to be drained in the operating theatre.
  • Damage to the nerves running to the vocal cords resulting in a hoarse or weak voice. Although many patients will have some vocal changes in the weeks after the operation due to swelling and irritation of the nerves, this is usually recovers fully. Permanent damage is rare.
  • Infection is exceedingly rare.

How you prepare

Food and medications
If you have low Vitamin D levels and are schedules for a total thyroidectomy, we may give you Vitamin D3 supplementation to use in preparation of the operation.

You may not eat any solid foods within 6 hours of your operation but you may drink water up to 2 hours before your surgery.  If you are on blood thinning agents or blood pressure medication, please inform us and we will advise when you should stop these medications.  

Other precautions
Please ensure that you have authorization from your medical aid well in advance of your scheduled procedure. Be sure to leave jewellery and valuables at home.

The Surgical Procedure

In most cases, a small dose of sestamibi (the same fluid used for the Nuclear scan) will be given 1hour before your operation.

Your surgeon will perform your parathyroidectomy under general anaesthesia, so you won’t be conscious during the procedure. The anaesthetist will visit you before the operation. 

You will be put to sleep by injecting a fast acting mediation through an intravenous line. 
Sometimes you or your anaesthetist might prefer inducing your anaesthetic by breathing a fast acting gas through a mask.

Once asleep, a breathing tube will then be placed in your windpipe to assist your breathing throughout the procedure.

The surgical team places several monitors on your body to help make sure that your heart rate, blood pressure and blood oxygen remain at safe levels throughout the procedure. These monitors include a blood pressure cuff on your arm and heart-monitor leads attached to your chest.

During the procedure:
Once you’re unconscious, the surgeon makes a cut (incision) low in the centre of your neck. 

The length of the incision depend on the extent of your operation and your build, but is generally 3-4cm in length.

It can often be placed in a skin crease where it will be difficult to see after the incision heals. 

If a targeted parathyroidectomy is done where the site of the abnormal parathyroid is known, the thyroid lobe on that side of the neck will be elevated to look for the abnormal parathyroid.  A special probe is used to pick up the radio-activity in the glandular tissue caused by the sestamibi injection. This may guide your surgeon to find the abnormal parathyroid more easily.  Usually, no part of the thyroid gland is removed. During the operation, care it taken to control any blood vessels and avoid bleeding, identify and protect the nerves going to the vocal cords and preserve the normal parathyroid glands.

Once the abnormal parathyroid gland is found and removed, the radio-activity levels will be confirmed outside the body and a pathologist will look at the tissue under a microscope to confirm that this is an abnormal parathyroid gland.  

If a conventional parathyroidectomy is performed where (where the position of the abnormal gland could not be confidently identified before the operation) the other side of the thyroid will also be elevated and the two parathyroid on that side of the neck will be explored to confirm that they are normal. If any of the other parathyroids are enlarged or has increased levels of radio-activity, they will be removed.  Up to 20% op people may have more than one abnormal parathyroid.

Parathyroidectomy usually takes one hour in theatre. It may take more or less time, depending on the extent of the surgery needed.

Occasionally some people may need to have a drain placed through the incision in the neck. This drain is usually removed the morning after surgery.

There are other possible approaches to parathyroidectomy, including endoscopic or transoral routes, but these are not offered by our team.

We also do not make use of blood tests during the operation. 

After the procedure

After surgery, you’re moved to a recovery room where the health care team monitors your recovery from the surgery and anaesthesia. Once you’re fully conscious, you’ll be moved to a hospital room.

You will receive pain medication, Calcium tablets to use and medication to prevent nausea.

A few people may experience neck pain and a hoarse or weak voice. This doesn’t necessarily mean there’s permanent damage to the nerve that controls the vocal cords. These symptoms are often short-term and may be due to irritation from the breathing tube that’s inserted into the windpipe during surgery, or be a result of nerve irritation caused by the surgery.

You’ll be able to eat and drink as usual after surgery. Depending on the type of surgery you had, you may be able to go home the day of your procedure or your doctor may recommend that you stay overnight in the hospital.

Your Calcium and PTH level will be tested the following morning by a blood test.

On discharge you will be given a prescription to take calcium tablets two or three times per day as well as Vitamin D once or twice per week. It is important to use this as directed. Pain medication may be used as needed.

You will also receive request forms to have calcium levels drawn from your nearest pathology laboratory. Do this early in the morning on the date advised and call our office to confirm this and follow-up on the results.  Your calcium dose will be adjusted according to these results.

When you go home, you can usually return to your regular activities. Wait at least 10 days to two weeks before doing anything vigorous, such as heavy lifting or strenuous sports.

It takes up to a year for the scar from surgery to fade. Your doctor may recommend using sunscreen to help minimize the scar from being noticeable.

Results

After successful parathyroidectomy, symptoms should start improving within hours.  Bone pain often disappear within hours. The effects on your brain such as poor memory, tiredness or just feeling unwell, should improve over two to 4 weeks.

Most patients will report significant improvement in their wellbeing after surgery.  

Calcium levels may take two to 3 weeks to stabalize and during this time your dose of calcium will be reduced down to once  a day. We ususally advise that you continue with a daily calcium supplement and weekly Vitamin D for at least 6 months after your operation.

Surgery for Secondary Hyperparathyroidism

(For Primary  Hyperparathyroidism, click here)

Secondary hyperparathyroidism is a condition in which a disease outside of the parathyroid glands causes all of the parathyroid glands to become enlarged and hyperactive. The most common causes of secondary hyperparathyroidism are kidney failure and vitamin D deficiency. 

In kidney failure, the kidney is no longer able to make enough vitamin D or remove all of the phosphorus that is made by the body, which leads to low calcium levels. These low calcium levels stimulate the parathyroid glands to make more PTH. Over time, this constant stimulation causes the parathyroid glands to become larger and produce higher levels of PTH. Patients with kidney failure and secondary hyperparathyroidism can often have PTH levels in the hundreds and even thousands. A potential complication of untreated secondary hyperparathyroidism is a condition called calciphylaxis where calcium deposits form in the skin and muscles causing painful skin lesions that over time can cause necrosis (i.e. tissue death) and ulcers.

The best treatment for secondary hyperparathyroidism is typically aimed at fixing the cause of the parathyroid problem. For example, patients with secondary hyperparathyroidism from vitamin D deficiency are best treated by raising the vitamin D levels to the normal range. For patients with secondary hyperparathyroidism from kidney failure, the only treatment is to have a kidney transplant. If the underlying problem cannot be fixed, the best treatment is medical therapy and surgery is only done for patients in whom optimal medical therapy is not working. For patients with kidney failure, the main treatments include phosphate binders (to bind the extra phosphate), vitamin D supplements (i.e. calcitriol), and calcimimetics. Calcimimetics are drugs that “trick” parathyroid cells into making less PTH. Calcimimetics like Sensipar lower the PTH levels by about 50% on average. The main side effects of calcimimetics include nausea and vomiting.

Some patients with secondary hyperparathyroidism do not have any clearly related symptoms. However, many people do have symptoms related to their disease. These can vary greatly, and may include:

  • Bone pain
  • Broken bones from bone weakening (Osteoporosis)
  • Chronic fatigue
  • Lack of concentration
  • Depression
  • Memory Problems
  • Uncontrolled itching
  • Calciphylaxis

Unfortunately, medical therapy does not work in up to 25% of patients and surgery is sometimes necessary. The main reasons for an operation worsening symptoms or a PTH level which continues to climb despite medication, usually to levels above 70pmol/l (800 pg/ml), and inability to control calcium and phosphorus levels in the blood by dialysis. 

The aim of surgery for secondary hyperparathyroidism is to reduce the PTH levels without removal all the parathyroid tissue.  The most common operation is called a subtotal parathyroidectomy (i.e. removal of 3 and ½ of the parathyroids) Sometimes all  4 glands may be removed and a small piece of parathyroid tissue may be implanted into a muscle (autotransplantation)  Since none of these operations fix the underlying cause of the secondary hyperparathyroidism, patients are at risk for recurrence (i.e. disease that comes back).

What tests are needed before surgery?

Imaging has a limited role to play in the surgical planning of secondary hyperparathyroidism but some tests are occasionally used:

  • A nuclear study where a small dose of a harmless radio-actively marked agent called sestamibi is given intravenously and the distibution of the fluid into the thyroid and parathyroid is evaluated
  • An ultrasound of the neck 
  • Computed Tomography (CT) scan with intravenous contrast.

Risks

Parathyroidectomy is considered a safe procedure with very low risks, but as with any surgery, a small risk of complications is possible. The best way of reducing this risk is to have your surgery done by an experienced surgeon who performs more than 20 such operations per year.

Potential complications include:

  • Low Calcium levels (hypocalcaemia)  Once the PTH levels come down after surgery calcium levels will also drop resulting in low calcium levels. Symptoms of hypocalcaemia can be numbness, tingling or cramping due to low blood-calcium levels. 
  • Bleeding in the wound in the first few hours after the operation. If this occurs, the build-up of blood will need to be drained in the operating theatre.
  • Damage to the nerves running to the vocal cords resulting in a hoarse or weak voice. Although many patients will have some vocal changes in the weeks after the operation due to swelling and irritation of the nerves, this is usually recovers fully. Permanent damage is rare.
  • Infection is exceedingly rare.

How you prepare

Food and medications
If you are on dialysis, it is important to continue with your schedule prior to your operation. 

You may not eat any solid foods within 6 hours of your operation but you may drink water up to 2 hours before your surgery.  If you are on blood thinning agents or blood pressure medication, please inform us and we will advise when you should stop these medications.  

Other precautions
Please ensure that you have authorization from your medical aid well in advance of your scheduled procedure. Be sure to leave jewellery and valuables at home.

The Surgical Procedure

Your surgeon will perform your parathyroidectomy under general anaesthesia, so you won’t be conscious during the procedure. The anaesthetist will visit you before the operation. 

You will be put to sleep by injecting a fast acting mediation through an intravenous line. 
Sometimes you or your anaesthetist might prefer inducing your anaesthetic by breathing a fast acting gas through a mask.

Once asleep, a breathing tube will then be placed in your windpipe to assist your breathing throughout the procedure.

The surgical team places several monitors on your body to help make sure that your heart rate, blood pressure and blood oxygen remain at safe levels throughout the procedure. These monitors include a blood pressure cuff on your arm and heart-monitor leads attached to your chest.

During the procedure:
Once you’re unconscious, the surgeon makes a cut (incision) low in the centre of your neck. 

The length of the incision depend on the extent of your operation and your build, but is generally 4-5cm in length.

It can often be placed in a skin crease where it will be difficult to see after the incision heals. 

The thyroid lobe on one side of the neck will be elevated to look for the enlarged parathyroid glands. Usually, no part of the thyroid gland is removed unless it is abnormal. During the operation, care it taken to control any blood vessels and avoid bleeding, identify and protect the nerves going to the vocal cords and preserve the normal parathyroid glands.

Once the abnormal parathyroid gland is found , the other side of the thyroid is elevated and the exploration is continued.

Once all 4 of the glands are identified, your surgeon will remove 3 of the largest glands. The fourth gland will be trimmed down to about 5 mm in size while ensuring that the blood vessels to the gland are not damaged.

The glands which are removed, will be examined by a pathologist who will look at the tissue under a microscope to confirm that this is parathyroid gland.  

Some people may have additional parathyroid tissue in the lower part of the neck (in the thymus tissue) the therefore the tissue below the thyroid over the windpipe will also be removed.

Parathyroidectomy usually takes 60-90 minutes in theatre. It may take more or less time, depending on the extent of the surgery needed.

Occasionally some people may need to have a drain placed through the incision in the neck. This drain is usually removed the morning after surgery.

There are other possible approaches to parathyroidectomy, including endoscopic or transoral routes, but these are not offered by our team.

We also do not make use of blood tests during the operation. 

After the procedure

After surgery, you’re moved to a recovery room where the health care team monitors your recovery from the surgery and anaesthesia. Once you’re fully conscious, you’ll be moved to a hospital room.

You will receive pain medication, Calcium tablets to use and medication to prevent nausea.

A few people may experience neck pain and a hoarse or weak voice. This doesn’t necessarily mean there’s permanent damage to the nerve that controls the vocal cords. These symptoms are often short-term and may be due to irritation from the breathing tube that’s inserted into the windpipe during surgery, or be a result of nerve irritation caused by the surgery.

You’ll be able to eat and drink as usual after surgery. Depending on the type of surgery you had, you may be able to go home the day of your procedure or your doctor may recommend that you stay overnight in the hospital.

Your Calcium and PTH level will be tested the following morning by a blood test. Your medication will e adapted based on the calcium levels.

On discharge you will be given a prescription to take calcium tablets two or three times per day as well as activated Vitamin D (One-Alpha) 1-3ug per day. It is important to use this as directed. Pain medication may be used as needed.

You will also receive request forms to have calcium levels drawn from your nearest pathology laboratory or before dialysis. Do this early in the morning on the dates advised and call our office to confirm this and follow-up on the results.  Your calcium dose will be adjusted according to these results.

When you go home, you can usually return to your regular activities. Wait at least 10 days to two weeks before doing anything vigorous, such as heavy lifting or strenuous sports.

It takes up to a year for the scar from surgery to fade. Your doctor may recommend using sunscreen to help minimize the scar from being noticeable.

Results

After successful parathyroidectomy, symptoms should start improving within hours.  Bone pain often disappear within hours. The effects on your brain such as poor memory, tiredness or just feeling unwell, should improve over two to 4 weeks.

Most patients will report significant improvement in their wellbeing after surgery.  

Calcium levels may take several weeks to stabilize and during this time your dose of calcium will be determined by your doctor.