Parathyroidectomy

Parathyroid glands are four small endocrine system glands situated at the back of the thyroid gland in the neck. They produce the parathyroid hormone (PTH), which regulates the calcium levels in the blood. At times, these glands can become overactive and produce PTH in excess, resulting in excess of calcium levels in the blood. This condition is called hyperparathyroidism. Parathyroidectomy is the surgical procedure to remove one or more of the diseased glands. This surgery is the only way to cure hyperparathyroidism.

However, if your calcium levels are not too high or if the risk of the surgery is high due to existing medical problems, then you may be put on medications. The surgery may be done through a cut in your neck or through the oral route (scarless) and generally takes about an hour.

Your surgeon will decide whether to go for surgery and what type of surgery is best for you based on factors such as your blood and urine calcium levels, your age, and your symptoms.

Your doctor may recommend a parathyroidectomy if you show the following symptoms of hyperparathyroidism:

• Muscle weakness
• Loss of appetite
• Joint pain
• Frequent urination
• Nausea and vomiting
• Kidney stones

The parathyroid glands have benign or rarely malignant growth that can lead to excess or inadequate production of PTH. A diagnosis of parathyroidectomy is reached when an individual has serum calcium level of >10.2 mg/dL along with elevated PTH level (>55 pg/mL). Excessive use of medicines like lithium and thiazide diuretics can cause increased PTH and serum calcium levels, imitating hyperparathyroidism. Therefore, it becomes important to take the use of these medicines into consideration while taking a medical history of an individual and conducting further investigations before moving ahead with the surgery.

For patients who have mild symptoms, the calcium levels are constantly monitored. Such patients are recommended surgery when they show the following:

• Fractures or premature thinning of the bones
• Osteoporosis 
• Reduced kidney function (Glomerular filtration rate [a test used to check kidney function] <60)
• A 24-hour urine calcium value >400 mg
• Calcium levels more than 1 above the upper limit of normal
• Age <50 years

Parathyroidectomy is indicated in people with primary hyperparathyroidism and hereditary hyperparathyroidism.

The surgery is contraindicated in people with familial hypocalciuric hypercalcemia, which is an inherited disorder that causes abnormally high levels of calcium in the blood.

One to two weeks before the surgery, you will have to undergo a physical exam and the surgeon will ask about your medical history. You may also have to undergo the following tests to ensure that you are fit for the surgery 

• Blood tests will be done twice just to confirm the high calcium levels. If the tests indicate high calcium levels, then the doctor will check PTH levels in your blood. Read more: Calcium blood test
• You may also need an electrocardiogram (EKG), chest X-ray or stress test, depending on your medical history, to check the function of your heart and lungs.
• An anesthesiologist will also review your medical history to determine the type of anaesthesia to be given.
• Additionally, you may have to get a few other tests done including an ultrasound, a CT scan, or sestamibi scan to evaluate your parathyroid glands. An ultrasound and a sestamibi scan will help in finding if your parathyroid glands are enlarged. In sestamibi scan, a small amount of sestamibi (radioactive substance) is injected into the body, and pictures are taken after two and four hours to see if sestamibi has collected in any of the parathyroid glands.
• Urinalysis and bone density screening may also be needed.
• Your vocal cords will be examined using a laryngoscope (a small instrument).

Depending on your blood test results, you may be asked to take vitamin D before the procedure.

You will be asked to stop the following medicines before the surgery:

• Cardiac (blood pressure) medicines such as enalapril, ramipril and telmisartan.
• Blood thinners: Stop taking aspirin 7 days before the surgery and warfarin 5 days before the surgery. Heparin must be stopped 12 hours before the surgery. You should ask your surgeon about using antiplatelet agents such as clopidogrel and ticlopidine.
• Diabetes medicines: People using insulin pumps can continue with their basal rate (minimum amount of medicine required to manage daily glucose levels) only. Individuals not using insulin pumps should take their insulin dose based on which insulin they take after consulting their doctor. Oral medicines for diabetes like metformin, glyburide or glipizide should not be taken on the morning of the surgery. 
• Do not use Viagra or similar drugs 24 hours before the surgery.
• Do not consume monoamine oxidase (MAO) inhibitors (antidepressants) or Premarin on the day of the surgery.
• Stop taking non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen 7 days before the surgery. 
• Do not consume iron on the day of the surgery.
• Stop consuming vitamin E–containing multivitamins and herbal supplements 7 days before the surgery.

You will have to reach the hospital at least 2 hours before your surgery time. You cannot eat or drink anything after midnight the night before the operation. If you have to take any medicines, take them with a sip of water. You will be asked to sign a consent form to give permission for the surgery.

Once you are admitted to the hospital, you will be given a hospital gown to change into. General anaesthesia will be given to you so that you won’t feel any pain during the procedure.

The two main methods of parathyroidectomy are as follows:

• Traditional thyroidectomy: The surgeon makes a small cut in the neck and moves aside a thin muscle layer to reach the thyroid and parathyroid glands. Then, parathyroid glands are examined, and those affected are removed. The neck muscles are put back in place, and the skin is closed with glue or stitches (sutures).
• Scarless (transoral) thyroidectomy: It is a new technique in which three small incisions are made in the lower lip, through which a camera and instruments are inserted and the parathyroid glands are removed. This operation leaves no scar as there is no incision on the neck.

In the traditional method, the specific type of operation chosen depends on the location of the abnormal parathyroid glands. The following techniques may be used to remove the parathyroid glands:

• Minimally invasive parathyroidectomy: In this method, you will be given a small amount of radioactive tracer (substance) that helps in highlighting the diseased gland. The surgeon will locate your parathyroid glands with the help of a special probe (surgical instrument). Then, he/she will make a small cut (2.5 to 5 cm) on one side of your neck and remove the diseased gland through it. This entire procedure takes about one hour.
• Video-assisted parathyroidectomy: In this procedure, the surgeon will make two cuts in your neck to insert a tiny camera and other instruments for the surgery. He/she will remove the diseased gland after locating it with the help of the camera.
• Endoscopic parathyroidectomy: Your surgeon will make two or three small cuts in your neck and one cut above your collarbone. He/she will remove the diseased gland with a procedure similar to video-assisted parathyroidectomy. This method reduces pain, visible scarring and recovery time.
• Four glands parathyroid exploration: The surgeon will make a small cut in your lower neck and examine all your parathyroid glands. He/she will remove the diseased glands and close the wound with sutures or Steri-Strips.

When you wake up in the recovery room, you will have an oxygen mask on your face and an intravenous (IV) drip in your arm. The IV drip will be removed once you start drinking enough fluids. A nurse will monitor your vitals until you wake up and can be moved to your room or the ward. You will be asked to drink a small amount of water at first. Once you tolerate it, then you will be given something warm to drink or light to eat.

You will likely be allowed to go home on the same day. However, if multiple parathyroid glands are removed or you have any particular medical condition that needs monitoring, you may have to stay overnight in the hospital.

After coming home, you should rest for two to three days. Mostly, people recover fully and resume normal activities after about two weeks of a parathyroidectomy and it takes about one to three weeks to heal completely.

• Activity: Avoid heavy lifting, strenuous physical activity or exercise until your doctor allows you. Generally, everyone is encouraged to be active as early as possible after this surgery. You should raise the head of your bed to about 30^° to 45^° or sleep in a reclined position to reduce swelling for the first 3 to 4 days after surgery. You may take a shower 24 hours after the surgery; however, do not use the hot tub, bathtub or pool.
• Wound care: Keep the surgical wound dry for 48 hours. You may leave it without dressing or you may cover it with a loose cloth. If you have Steri-Strips, don't remove them for at least seven days. Once the wound healed, your surgeon may suggest you to gently massage it with a lanolin cream to soften the scars.
• Diet: You will be asked to eat soft foods and drink liquids for a day. Although there are no limitations on what to drink or eat, avoid greasy, heavy, or spicy meals for the first few days.
• Medicines: Pain medications, vitamin D, and calcium supplements may be prescribed at the time of discharge.

After parathyroidectomy, you will have routine blood tests to monitor your calcium levels. You may be asked to take calcium supplements for some time depending on your blood test results. 

When to see the doctor?

Call your doctor immediately if you have:

• Fever above 100^oF
• Increased drainage or bleeding at the site of the operation
• Difficulty in swallowing
• Severe pain
• Symptoms of low calcium in blood (muscle cramps, numbness or tingling around the hands, feet, fingertips, and mouth)

The possible risks associated with parathyroidectomy are:

• Failure to find the overactive or enlarged gland
• Persistently low calcium levels in blood
• Changes in the voice like hoarseness
• Bleeding or clotting of blood
• Sore throat
• Injury to the food pipe (oesophagus) or windpipe (trachea)
• Adhesions or scar tissue that requires additional surgery.
• Wound infection
• A blood clot in legs or lungs

You will have the follow-up visit with your surgeon one to two weeks after surgery.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.