Editing Parathyroidectomy

{{short description|Surgical removal of one or more of the parathyroid glands}}
{{Infobox medical intervention (new)
| name          = Parathyroidectomy
| synonyms      =
| image         = Parathyreoidea Adenom I.jpg
| caption       = Parathyroidectomy for parathyroid adenoma
| alt           =
| pronounce     =
| specialty     = [[General surgery]], [[Endocrine surgery]]
| uses          =
| complications = [[Hypoparathyroidism]]
| 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]] (PTH): [[hyperparathyroidism]]. The glands are usually four in number and located adjacent to the posterior surface of the [[thyroid gland]], but their exact location is variable. When an elevated PTH 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, a condition in which one or more of the parathyroid glands produce excessive parathyroid hormone. Not all cases of primary hyperparathyroidism require surgery, but it is recommended if the condition causes significant symptoms or if it affects the kidneys ([[nephrocalcinosis]]) or bone health ([[osteoporosis]]), and also in people under 50 even if they do not have symptoms.<ref name=AAES>{{cite journal |last1=Wilhelm |first1=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. |title=The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism |journal=JAMA Surgery |date=1 October 2016 |volume=151 |issue=10 |pages=959–968 |doi=10.1001/jamasurg.2016.2310 |pmid=27532368|s2cid=4007319 }}</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.<ref name=AAES/>

Parathyroidectomy may also be required in secondary hyperparathyroidism. This situation arises mainly in people with severe [[chronic kidney disease]] in which the parathyroid glands are overactive to compensate for the low calcium and vitamin D levels often present in CKD. 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 autonomous production of hormone by the glands and loss of feedback mechanisms. In this situation surgical parathyroidectomy may be required, especially if calcium and phosphate levels remain elevated, 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|dialysis]], parathyroidectomy can improve their survival. It does appear that the procedure may be underused.<ref name=Lau2018>{{cite journal |last1=Lau |first1=WL |last2=Obi |first2=Y |last3=Kalantar-Zadeh |first3=K |title=Parathyroidectomy in the Management of Secondary Hyperparathyroidism |journal=Clinical Journal of the American Society of Nephrology |date=7 June 2018 |volume=13 |issue=6 |pages=952–961 |doi=10.2215/CJN.10390917 |pmid=29523679|pmc=5989682 }}</ref>

==Procedure==
The [[Surgery|operation]] requires a [[general anesthetic]] (unconscious and pain free) or a [[local anesthetic]] (pain free). The surgeon makes an incision around an inch long in the neck just under the [[larynx]] ([[Adam's apple]]), and locates the offending parathyroid glands. Preoperative 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 intraoperative PTH hormone monitoring.<ref>{{cite journal|last=Augustine|first=MM |author2=Bravo, PE |author3=Zeiger, MA|title=Surgical treatment of primary hyperparathyroidism|journal=Endocrine Practice|date=Mar–Apr 2011|volume=17|issue=Suppl 1 |pages=75–82|pmid=21324817|doi=10.4158/EP10359.RA}}</ref>  The particular problem or disease process will determine how many of the parathyroid glands are removed. Some parathyroid tissue must be left in place to help prevent [[hypoparathyroidism]].

Recovery after the operation tends to be swift. The [[Parathyroid hormone|PTH]] level is back to normal within 10–15 minutes, and can be confirmed by intraoperative rapid assessment during the operation.  However, the remaining 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.<ref>[http://endocrinediseases.org/parathyroid/surgery_recovery.shtml ''Parathyroid surgery: Recovery''], [https://www.endocrinesurgery.org/ The American Association of Endocrine Surgeons].</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 blood supply is suture ligated. The entire parathyroid adenoma is identified and dissected out. Intraoperative PTH monitoring can begin at this time and will show falling PTH levels if the entire adenoma has been resected.<ref>[https://jomi.com/article/225/minimally-invasive-parathyroidectomy-under-local-cervical-block], Carling T. Minimally Invasive Parathyroidectomy under Local Cervical Block. J Med Ins. 2018;2018(225) doi:https://jomi.com/article/225</ref>

==Complications==
{{expand section|date=June 2018}}

While mild hypocalcemia is common after partial parathyroidectomy, some people experience persistently prolonged low calcium levels. This is called '''hungry bone syndrome'''. Despite the reactivation of unresected parathyroid glands producing normal to elevated levels of PTH, 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 PTH; calcium, magnesium, and phosphate continue to be deposited into the bones, resulting in hypocalcemia, hypomagnesemia, and hypophosphatemia. Prolonged calcium supplementation may be required. Hungry bone syndrome is particularly common in people who are on long-term regular dialysis.<ref name=Lau2018/><ref>{{cite journal |last1=Jain |first1=Nishank |last2=Reilly |first2=Robert F. |title=Hungry bone syndrome |journal=Current Opinion in Nephrology and Hypertension |date=July 2017 |volume=26 |issue=4 |pages=250–255 |doi=10.1097/MNH.0000000000000327 |pmid=28375869|s2cid=4630106 }}</ref>

== See also ==
* [[List of surgeries by type]]

==References==
<references />

==External links==
* {{cite web |title=How is parathyroid surgery performed? |url=http://endocrinediseases.org/parathyroid/surgery_overview.shtml |publisher=American Association of Endocrine Surgeons |access-date=11 May 2019}}
* {{cite web | url = https://www.nlm.nih.gov/medlineplus/ency/article/002931.htm | title = Parathyroid gland removal | publisher = Medline Plus | website = Medical Encyclopedia | date = 3 December 2018 | access-date = 8 December 2018}}

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

{{Endocrine system intervention}}

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