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Ninety-five percent of hyperparathyroid patients can be cured when treated by an experienced endocrine

Table 5-5. POSSIBLE COMPLICATIONS AND TREATMENTS FOLLOWING PARATHYROID SURGERY

Complication

Circumstances

Treatment

Hypocalcemia

Hematoma

Recurrent laryngeal nerve injury

Hungry bone syndrome

Aparathyroid

Hypoparathyroid

More frequent when combined with thyroid operations Unilateral injury Bilateral injury

Acute: 1-2 g Ca carbonate q4h PO or 10% Ca gluconate in

100 cc NS IV or Rocaltrol (vitamin D) 0.25-1.0 |jg q12h PO Chronic: 1-2 g Ca carbonate PO with meals or aluminum hydroxide to bind phosphorus in the gastrointestinal tract

Emergency airway—open wound at bedside or operating room and evacuate blood Weak voice, adequate airway

Normal voice but inadequate airway; may require emergent tracheostomy

Ca = calcium; PO = orally; NS = normal saline; IV = intravenous.

surgeon. BNE remains the standard approach because it is safe and avoids missing a second adenoma or other abnormal glands in patients with asymmetric or adenomatous hyperplasia. It also does not require intraoperative PTH assays and gamma probe localization. A unilateral, focused approach is acceptable when the prevalence of double adenoma and hyperplasia is low, a preoperative imaging study strongly suggests a solitary adenoma, thyroid disease warranting removal is absent, and intraoperative PTH assays are available. Most noninvasive studies are about 80% sensitive for single adenomas and less so for double adenomas or hyper-plasia. However, the addition of IOPTH can improve the success of surgery to 93%.

The most common causes for persistent hyper-parathyroidism are an ectopic parathyroid tumor and multiple abnormal parathyroid glands. Inexperienced surgeons are often unfamiliar with the aberrant location of these glands. The inferior parathyroid glands develop with the thymus from the third brachial pouch and descend to the lower thyroid area (Figure 5-14). The most common position of the inferior glands is anterior-inferior to the junction of the inferior thyroid artery and RLN (Figure 5-15). Ectopic glands are frequently found adjacent to or within the thymus or perithymic fat or in the anterior mediastinum (Figure 5-16).

The superior parathyroid glands develop from the fourth brachial pouch and migrate a short distance, therefore having less variation in position. They are most commonly located superior-posterior to the junction of the inferior thyroid artery and RLN at the level of the cricoid cartilage (see Figure 5-15). Ectopic locations include (1) the tracheoesophageal groove posteriorly, (2) along the esopha gus in the posterior mediastinum, (3) intrathyroidal,

(4) within the carotid sheath, and (5) other locations. Use of IOPTH should help in patients with multiple abnormal parathyroid glands because the PTH level should not fall > 50% at 10 minutes when abnormal parathyroid tissue remains (see Figure 5-13). Reasons for persistent or recurrent hyperparathyroidism after a subtotal parathy-roidectomy include (1) failure to remove a fifth supernumerary or hyperplastic gland, (2) leaving too large a remnant after subtotal resection, (3) regrowth, (4) spilling tumor (parathyroidosis), and

(5) parathyroid cancer. About 15% of patients have more than four parathyroid glands.

Primary hyperparathyroidism causes significant morbidity, including depression, constipation, renal

Figure 5-14. Normal embryologic descent of superior and inferior parathyroid glands from the third and fourth pharyngeal pouches.
Figure 5-15. Normal location of superior and inferior parathyroid glands.

calculi, weight loss, and joint pain. Patients often seek care from multiple medical providers and acquire extensive treatment regimens. Thus, the cost savings of surgery are significant. Surgery has striking benefits on quality of life in patients with primary hyperparathyroidism, even with mild disease. A survey with the 28-item version of the General Health Organization revealed a clinically and statistically significant reduction in psychological distress at 3 months after surgery.60

The NIH 1990 consensus statement recognized the need for a randomized clinical trial to address the role of surgery in asymptomatic patients with PHPT with minimal hypercalcemia.14 In one trial, 53 patients with asymptomatic hyperparathy-roidism underwent parathyroidectomy or observation, completing the Short-Form SF-36 Health Survey to assess wellness every 6 months for 2 years.61

The scores on two of nine domains, social functioning and emotional role functioning, were significantly different, favoring the intervention group. This trial supports intervention by an experienced endocrine surgeon for mild PHPT at the time of diagnosis as many patients have reversible nonclas-sic symptoms of disease. The best outcomes are achieved by initially referring patients to an experienced endocrine surgeon because repeated surgery, even by experienced surgeons, may result in compromised outcome.9

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