Surgical Excision of Parathyroid Glands: A Comprehensive Insight
Parathyroidectomy is a surgical procedure used to remove one or more of the parathyroid glands, which are four small glands located in the neck. These glands regulate the amount of calcium in the blood.
The most common condition related to the parathyroid glands is hyperparathyroidism, where one or more glands produce too much parathyroid hormone (PTH). This can lead to a variety of symptoms, including fatigue, muscle weakness, joint pain, bone pain, mood changes, loss of appetite, constipation, confusion, memory loss, difficulty concentrating, nausea, vomiting, increased thirst, and urination.
In some cases, a benign tumor may grow in one or more of the parathyroid glands, causing it to become enlarged. This can also lead to hyperparathyroidism.
During the procedure, a person will receive general anesthesia and lay face up with their neck extended and arms by their sides. The main types of parathyroidectomy include total parathyroidectomy (TPTX), total parathyroidectomy with autotransplantation (TPTX+AT), and subtotal parathyroidectomy (SPTX).
In total parathyroidectomy, all four parathyroid glands are removed. In total parathyroidectomy with autotransplantation, all glands are removed but some parathyroid tissue is transplanted (usually into the forearm) to maintain some function. Subtotal parathyroidectomy involves removing most but not all parathyroid tissue, leaving a small portion of one gland intact.
For parathyroid cancer, more extensive surgery such as en bloc resection is performed, removing the affected gland along with surrounding tissues and sometimes part of the thyroid or adjacent structures.
All surgical procedures have associated risks. General surgical risks include bleeding, infection, injury to nearby structures (like the recurrent laryngeal nerve, which can cause voice changes), and hypocalcemia (low calcium due to decreased parathyroid hormone). The risk of permanent hypoparathyroidism is higher in total parathyroidectomy but is lower with subtotal or limited surgery.
Parathyroid cancer surgery has additional risks related to more extensive tissue removal and possible nerve or muscle involvement. Hungry bone syndrome (severe bone uptake of calcium post-surgery causing hypocalciemia) can occur, especially if vitamin D deficiency is present preoperatively; this requires monitoring and supplementation.
Recovery times vary, but most people can get up and walk around within 1-2 days and return to typical activities after around 1 week. Calcium and vitamin D supplementation may be needed temporarily or permanently post-surgery depending on residual parathyroid function.
Parathyroidectomy offers a cure rate of about 96% in primary hyperparathyroidism, especially when performed at experienced centers with good preoperative imaging and intraoperative monitoring. Long term relapse rates are low (<5% over 10 years) for benign disease. Surgery improves bone density and reduces the risk of kidney stones and other complications of hyperparathyroidism.
For parathyroid cancer, the prognosis depends on the extent of disease and completeness of tumor removal, with "clean margins" reducing recurrence risk.
Before the procedure, tests such as a CT scan, neck ultrasound, MRI scan, sestamibi scan, or SPECT scan may be conducted. A person may experience an allergic reaction to anesthesia during the surgery. The recurrent laryngeal nerve injury can lead to temporary hoarseness, vocal weakness, and a tiring voice.
In the rare case of all four parathyroid glands being enlarged (parathyroid hyperplasia), the surgeon may remove three entire glands and half of the remaining gland. Infection is a potential risk after parathyroidectomy, and breathing problems can occur due to significant bleeding from the neck after the surgery.
In summary, the choice of parathyroidectomy type is dictated by disease extent (benign vs malignant) and surgeon expertise. Risks are generally low but include hypocalcemia and nerve injury. Recovery is typically quick, with excellent outcomes in benign disease and more guarded prognosis in cancer requiring extensive surgery. Monitoring and management of calcium levels postoperatively are essential for optimal recovery.
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