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Surgical Procedures. Parathyroidectomy: Indications, Operative Techniques, Management of Complications, Intraoperative PTH Monitoring, Role of Parathyroid Autofluorescence and ICG

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Endocrine Surgery Comprehensive Board Exam Guide

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Abstract

This chapter provides a comprehensive review of the indications for parathyroidectomy, detailing the operative techniques, management of complications, use of intraoperative parathyroid hormone monitoring, as well as the role of surgical adjuncts including indocyanine green (ICG) and parathyroid autofluorescence (PAF). Indications for the procedure and considerations in the preoperative evaluation of the patient with hyperparathyroidism are reviewed. Use of intraoperative parathyroid hormone (IOPTH) monitoring, including interpretation and IOPTH-guided decision-making, is discussed. Cryopreservation with parathyroid auto-transplantation for subtotal parathyroidectomy are described. Additionally, management of intraoperative and postoperative complications including hematoma, wound infection, postoperative hypocalcemia, hungry bone syndrome, operative failure, and recurrent hyperparathyroidism is discussed. Subject-oriented clinical cases and multiple-choice questions are added at the end of the chapter for the readers practice.

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References

  1. Yeh MW, Ituarte PHG, Zhou HC, Nishimoto S, Liu I-LA, Harari A, et al. Incidence and prevalence of primary hyperparathyroidism in a racially mixed population. J Clin Endocrinol Metab. 2013;98(3):1122–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Siperstein A, Berber E, Barbosa GF, Tsinberg M, Greene AB, Mitchell J, et al. Predicting the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi, and intraoperative parathyroid hormone: analysis of 1158 cases. Ann Surg. 2008;248(3):420–6.

    Article  PubMed  Google Scholar 

  3. Norman J, Lopez J, Politz D. Abandoning unilateral parathyroidectomy: why we reversed our position after 15,000 parathyroid operations. J Am Coll Surg [Internet]. 2012;214(3):260–9. Available from: https://doi.org/10.1016/j.jamcollsurg.2011.12.007

    Article  PubMed  Google Scholar 

  4. Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh QY, et al. The American association of endocrine surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. 2016;151(10):959–68.

    Article  PubMed  Google Scholar 

  5. Bilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marcocci C, et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the fourth international workshop. J Clin Endocrinol Metab. 2014;99(10):3561–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. VanderWalde LH, Liu ILA, Haigh PI. Effect of bone mineral density and parathyroidectomy on fracture risk in primary hyperparathyroidism. World J Surg. 2009;33(3):406–11.

    Article  PubMed  Google Scholar 

  7. Udelsman R, Åkerström G, Biagini C, Duh QY, Miccoli P, Niederle B, et al. The surgical management of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop. J Clin Endocrinol Metab. 2014;99(10):3595–606.

    Article  CAS  PubMed  Google Scholar 

  8. Pasieka JL, Parsons L, Jones J. The long-term benefit of parathyroidectomy in primary hyperparathyroidism: a 10-year prospective surgical outcome study. Surgery [Internet]. 2009;146(6):1006–13. Available from: https://doi.org/10.1016/j.surg.2009.10.021

    Article  Google Scholar 

  9. Burneikis T, Colvin J, Jin J, Berber E, Krishnamurthy VD, Shin J, et al. Validation of a novel patient-reported outcome measure for parathyroid and thyroid disease (PROMPT). Surg (United States) [Internet]. 2019;165(1):232–9. Available from: https://doi.org/10.1016/j.surg.2018.04.091.

  10. Ejlsmark-Svensson H, Sikjaer T, Webb SM, Rejnmark L, Rolighed L. Health-related quality of life improves 1 year after parathyroidectomy in primary hyperparathyroidism: a prospective cohort study. Clin Endocrinol. 2019;90(1):184–91.

    Article  Google Scholar 

  11. Zanocco K, Angelos P, Sturgeon C. Cost-effectiveness analysis of parathyroidectomy for asymptomatic primary hyperparathyroidism. Surgery. 2006;140(6):874–82.

    Article  PubMed  Google Scholar 

  12. Solorzano CC, Carneiro-Pla D. Minimizing cost and maximizing success in the preoperative localization strategy for primary hyperparathyroidism. Surg Clin North Am [Internet]. 2014;94(3):587–605. Available from: https://doi.org/10.1016/j.suc.2014.02.006

    Article  Google Scholar 

  13. Arora S, Balash PR, Yoo J, Smith GS, Prinz RA. Benefits of surgeon-performed ultrasound for primary hyperparathyroidism. Langenbeck’s Arch Surg. 2009;394(5):861–7.

    Article  Google Scholar 

  14. Thier M, Daudi S, Bergenfelz A, Almquist M. Predictors of multiglandular disease in primary hyperparathyroidism. Langenbeck’s Arch Surg. 2018;403(1):103–9.

    Article  Google Scholar 

  15. Wang TS, Cheung K, Farrokhyar F, Roman SA, Sosa JA. Would scan, but which scan? A cost-utility analysis to optimize preoperative imaging for primary hyperparathyroidism. Surgery [Internet]. 2011;150(6):1286–94. Available from: https://doi.org/10.1016/j.surg.2011.09.016

    Article  PubMed  Google Scholar 

  16. Harari A, Mitmaker E, Grogan RH, Lee J, Shen W, Gosnell J, et al. Primary hyperparathyroidism patients with positive preoperative sestamibi scan and negative ultrasound are more likely to have posteriorly located upper gland adenomas (PLUGs). Ann Surg Oncol. 2011;18(6):1717–22.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Lubitz CC, Hunter GJ, Hamberg LM, Parangi S, Ruan D, Gawande A, et al. Accuracy of 4-dimensional computed tomography in poorly localized patients with primary hyperparathyroidism. Surgery [Internet]. 2010;148(6):1129–38. Available from: https://doi.org/10.1016/j.surg.2010.09.002

    Article  PubMed  Google Scholar 

  18. Abbott DE, Cantor SB, Grubbs EG, Santora R, Gomez HF, Evans DB, et al. Outcomes and economic analysis of routine preoperative 4-dimensional ct for surgical intervention in de novo primary hyperparathyroidism: does clinical benefit justify the cost? J Am Coll Surg. 2012;214(4):629–37.

    Article  PubMed  Google Scholar 

  19. Siperstein A, Milas M. Comprehensive Parathyroidectomy for the treatment of PHPT. In: Fischer J, editor. Fischer’s mastery of surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2012. p. 486–96.

    Google Scholar 

  20. Irvin GL, Dembrow VD, Prudhomme DL. Operative monitoring of parathyroid gland hyperfunction. Am J Surg. 1991;162(4):299–302.

    Article  PubMed  Google Scholar 

  21. Irvin G 3rd, Dembrow V, Prudhomme D. Clinical usefulness of an intraoperative “quick parathyroid hormone” assay. Surgery. 1993;114(6):1019–22.

    PubMed  Google Scholar 

  22. Irvin GL, Prudhomme DL, Deriso GT, Sfakianakis G, Chandarlapaty SKC. A new approach to parathyroidectomy. Ann Surg. 1994;219(5):574–81.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Maier GW, Kreis ME, Renn W, Pereira PL, Häring HU, Becker HD. Parathyroid hormone after adenectomy for primary hyperparathyroidism. A study of peptide hormone elimination kinetics in humans. J Clin Endocrinol Metab. 1998;83(11):3852–6.

    Article  CAS  PubMed  Google Scholar 

  24. Lew JI, Irvin GL. Focused parathyroidectomy guided by intra-operative parathormone monitoring does not miss multiglandular disease in patients with sporadic primary hyperparathyroidism: a 10-year outcome. Surgery. 2009 Dec;146(6):1021–7.

    Article  PubMed  Google Scholar 

  25. Irvin GL, Carneiro DM, Solorzano CC, Leight GS, Perrier N, Nelson WR, et al. Progress in the operative management of sporadic primary hyperparathyroidism over 34 years. Ann Surg. 2004;239(5):704–11.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Richards ML, Thompson GB, Farley DR, Grant CS. An optimal algorithm for intraoperative parathyroid hormone monitoring. Arch Surg. 2011;146(3):280–5.

    Article  PubMed  Google Scholar 

  27. Chen H, Mack E, Starling JR, Irvin GL, Clark OH, Prinz RA, et al. A comprehensive evaluation of perioperative adjuncts during minimally invasive parathyroidectomy: which is most reliable? Ann Surg. 2005;242(3):375–83.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Doppman JL, Miller DL. Localization of parathyroid tumors in patients with asymptomatic hyperparathyroidism and no previous surgery. J Bone Min Res. 1991;Suppl 2:S153–8; discussion S159.

    Google Scholar 

  29. Baj J, Sitarz R, Łokaj M, Forma A, Czeczelewski M, Maani A, et al. Preoperative and intraoperative methods of parathyroid gland localization and the diagnosis of parathyroid adenomas. Molecules. 2020;25(7):1–22.

    Article  Google Scholar 

  30. Demarchi MS, Karenovics W, Bédat B, Triponez F. Intraoperative autofluorescence and Indocyanine green angiography for the detection and preservation of parathyroid glands. J Clin Med. 2020;9(3):830.

    Article  CAS  PubMed Central  Google Scholar 

  31. Paras C, Keller M, White L, Phay J, Mahadevan-Jansen A. Near-infrared autofluorescence for the detection of parathyroid glands. J Biomed Opt. 2011;16(6):067012.

    Article  PubMed  Google Scholar 

  32. Benmiloud F, Godiris-Petit G, Gras R, Gillot JC, Turrin N, Penaranda G, et al. Association of autofluorescence-based detection of the parathyroid glands during total thyroidectomy with postoperative hypocalcemia risk: results of the PARAFLUO multicenter randomized clinical trial. JAMA Surg. 2020;155(2):106–12.

    Article  PubMed  Google Scholar 

  33. Kahramangil B, Berber E. The use of near-infrared fluorescence imaging in endocrine surgical procedures. J Surg Oncol. 2017;115(7):848–55.

    Article  PubMed  Google Scholar 

  34. Kahramangil B, Berber E. Comparison of indocyanine green fluorescence and parathyroid autofluorescence imaging in the identification of parathyroid glands during thyroidectomy. Gland Surg. 2017;6(6):644–8.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Kose E, Rudin AV, Kahramangil B, Moore E, Aydin H, Donmez M, Krishnamurthy V, Siperstein A, Berber E. Autofluorescence imaging of parathyroid glands: An assessment of potential indications. Surgery. 2020;167(1):173–79. https://doi.org/10.1016/j.surg.2019.04.072. Epub 2019 Sep 13. PMID: 31526579.

  36. Lahey F. The transplantation of parathyroids in partial thyroidectomy. Surg Gynecol Obs. 1926;62:508–9.

    Google Scholar 

  37. Wells S Jr, Christiansen C. The transplanted parathyroid gland: evaluation of cryopreservation and other environmental factors which affect its function. Surgery. 1974;75(1):49–55.

    CAS  PubMed  Google Scholar 

  38. Saxe A, Gibson G. Cryopreservation of parathyroid tissue. In: Clark O, Duh Q, Kebebew E, editors. Textbook of endocrine surgery. Philadelphia: Elsevier Saunders; 2005. p. 530–5.

    Chapter  Google Scholar 

  39. Moffett JM, Suliburk J. Parathyroid autotransplantation. Endocr Pract. 2011;17(Suppl 1):83–9.

    Article  PubMed  Google Scholar 

  40. Sancho J, Sitges-Serra A. Surgical approach to secondary hyperparathyroidism. In: Clark O, Duh Q, Kebebew E, editors. Textbook of endocrine surgery, vol. 1. Philadelphia: Elsevier Saunders; 2005. p. 510–7.

    Chapter  Google Scholar 

  41. Stotler BA, Reich-Slotky R, Schwartz J, Inabnet WB, Lee J, Wu F, et al. Quality monitoring of microbial contamination of cryopreserved parathyroid tissue. Cell Tissue Bank. 2011;12(2):111–6.

    Article  PubMed  Google Scholar 

  42. Moore EC, Siperstein A, Gupta S. Cryopreservation of parathyroid tissue: a white paper on establishing a local service. Endocr Pract. 2019;25:605–11.

    Article  PubMed  Google Scholar 

  43. Agarwal A, Waghray A, Gupta S, Sharma R, Milas M. Cryopreservation of parathyroid tissue: an illustrated technique using the Cleveland clinic protocol. J Am Coll Surg [Internet]. 2013;216(1):e1–9. Available from: https://doi.org/10.1016/j.jamcollsurg.2012.09.021

    Article  Google Scholar 

  44. Guerrero MA, Evans DB, Lee JE, Bao R, Bereket A, Gantela S, et al. Viability of cryopreserved parathyroid tissue: when is continued storage versus disposal indicated? World J Surg. 2008;32(5):836–9.

    Article  PubMed  Google Scholar 

  45. Herrera M, Grant C, van Heerden J, Fitzpatrick L. Parathyroid autotransplantation. Arch Surg. 1992;127(7):825–9.

    Article  CAS  PubMed  Google Scholar 

  46. Shepet K, Alhefdhi A, Usedom R, Sippel R, Chen H. Parathyroid cryopreservation after parathyroidectomy: a worthwhile practice? Ann Surg Oncol. 2013;20(7):2256–60.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Borot S, Lapierre V, Carnaille B, Goudet P, Penfornis A. Results of cryopreserved parathyroid autografts: a retrospective multicenter study. Surgery. 2010;147(4):529–35.

    Article  PubMed  Google Scholar 

  48. Shoback D. Clinical practice. Hypoparathyroidism. N Engl J Med. 2008;359(4):391–403. https://doi.org/10.1056/NEJMcp0803050. PMID: 18650515.

  49. Rothmund M, Wagner PK. Reoperations for persistent and recurrent secondary hyperparathyroidism. Ann Surg. 1988;207(3):310–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Ho LY, Wong PN, Sin HK, Wong YY, Lo KC, Chan SF, et al. Risk factors and clinical course of hungry bone syndrome after total parathyroidectomy in dialysis patients with secondary hyperparathyroidism. BMC Nephrol. 2017;18(1):1–10.

    Article  Google Scholar 

  51. Shin JJ, Milas M, Mitchell J, Berber E, Ross L, Siperstein A. Impact of localization studies and clinical scenario in patients with hyperparathyroidism being evaluated for reoperative neck surgery. Arch Surg. 2011;146(12):1397–403.

    Article  PubMed  Google Scholar 

  52. Udelsman R. Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg. 2002;235(5):665–72.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Westerdahl J, Bergenfelz A. Unilateral versus bilateral neck exploration for primary hyperparathyroidism: five-year follow-up of a randomized controlled trial. Ann Surg. 2007;246(6):976–80.

    Article  PubMed  Google Scholar 

  54. Powell AC, Alexander HR, Chang R, Marx SJ, Skarulis M, Pingpank JF, et al. Reoperation for parathyroid adenoma: a contemporary experience. Surgery [Internet]. 2009;146(6):1144–55. Available from: https://doi.org/10.1016/j.surg.2009.09.015.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Weber C, Sewell C, McGarity W. Persistent and recurrent sporadic primary hyperparathyroidism: histopathology, complications, and results of reoperation. Surgery. 1994;116(6):991–8.

    CAS  PubMed  Google Scholar 

  56. Silverberg SJ, Clarke BL, Peacock M, Bandeira F, Boutroy S, Cusano NE, et al. Current issues in the presentation of asymptomatic primary hyperparathyroidism: proceedings of the fourth international workshop. J Clin Endocrinol Metab. 2014;99(10):3580–94.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. Lee D, Walker MD, Chen HY, Chabot JA, Lee JA, Kuo JH. Bone mineral density changes after parathyroidectomy are dependent on biochemical profile. Surg (United States) [Internet]. 2019;165(1):107–13. Available from: https://doi.org/10.1016/j.surg.2018.04.065.

  58. Cusano NE, Rubin MR, Silva BC, Tay YKD, Williams JM, Agarwal S, et al. Skeletal microstructure and estimated bone strength improve following parathyroidectomy in primary hyperparathyroidism. J Clin Endocrinol Metab. 2018;103(1):196–205.

    Article  PubMed  Google Scholar 

  59. Walker MD, Silverberg SJ. Primary hyperparathyroidism. Nat Rev Endocrinol [Internet]. 2018;14(2):115–25. Available from: https://doi.org/10.1038/nrendo.2017.104

    Article  CAS  Google Scholar 

  60. Khan AA, Hanley DA, Rizzoli R, Bollerslev J, Young JEM, Rejnmark L, et al. Primary hyperparathyroidism: review and recommendations on evaluation, diagnosis, and management. A Canadian and international consensus. Osteoporos Int [Internet]. 2017;28(1):1–19. Available from: https://doi.org/10.1007/s00198-016-3716-2.

  61. Pepe J, Cipriani C, Sonato C, Raimo O, Biamonte F, Minisola S. Cardiovascular manifestations of primary hyperparathyroidism: a narrative review. Eur J Endocrinol. 2017;177(6):R297–308.

    Article  CAS  PubMed  Google Scholar 

  62. Vázquez-Díaz O, Castillo-Martínez L, Orea-Tejeda A, Orozco-Gutiérrez JJ, Asensio-Lafuente E, Reza-Albarrán A, et al. Reversible changes of electrocardiographic abnormalities after parathyroidectomy in patients with primary hyperparathyroidism. Cardiol J. 2009;16(3):241–5.

    Google Scholar 

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Authors and Affiliations

  1. Case Western Reserve University, School of Medicine and Lerner College of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA

    Talia Burneikis

  2. Case Western Reserve University, School of Medicine and Lerner College of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA

    Allan E. Siperstein

Authors
  1. Talia Burneikis
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  2. Allan E. Siperstein
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Correspondence to Allan E. Siperstein .

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Editors and Affiliations

  1. Department of Surgery, Jersey Shore University Medical Center, Neptune, NJ, USA

    Alexander L. Shifrin

  2. Division of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy

    Marco Raffaelli

  3. The Claire and John Bertucci Endowed Chair in Thyroid Surgical Oncology, Harvard Medical School, Boston, MA, USA

    Gregory W. Randolph

  4. Department of Surgery, Linköping University, Linköping, Sweden

    Oliver Gimm

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Burneikis, T., Siperstein, A.E. (2021). Surgical Procedures. Parathyroidectomy: Indications, Operative Techniques, Management of Complications, Intraoperative PTH Monitoring, Role of Parathyroid Autofluorescence and ICG. In: Shifrin, A.L., Raffaelli, M., Randolph, G.W., Gimm, O. (eds) Endocrine Surgery Comprehensive Board Exam Guide. Springer, Cham. https://doi.org/10.1007/978-3-030-84737-1_16

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  • DOI: https://doi.org/10.1007/978-3-030-84737-1_16

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