What Surgery to Perform if Four Gland Hyperplasia is Found as the Cause of Primary Hyperparathyroidism (PHPT)

• Four-Gland Hyperplasia (Four Abnormal Glands):
  • Hyperplasia of all four glands may be seen as:
    • Primary hyperparathyroidism (HPT)
    • Progressive secondary HPT
    • Tertiary HPT
• If multi-gland disease (MGD) in primary HPT is known preoperatively:
  • Genetic testing should be considered prior to operation:
    • As this may further change the operative approach
• There are two distinct operative approaches in MGD:
  • Total parathyroidectomy with auto-transplantation (TP)
  • Sub-total parathyroidectomy (STP):
    • In a sub-total parathyroidectomy, the most normal appearing gland is chosen to be the remnant (ideally an inferior gland):
      • Which is then cut back to approximately the size of a normal gland
    • The gland is subsequently tagged with a Prolene suture:
      • Cut 1 to 2 cm long with a Hemoclip on the ends:
        • Which will aid in identification should re-exploration be required
    • Care should be taken not to compromise the vascular supply of the gland with this suture

• Each approach carries different risks, benefits, and indications, as shown in the Table:
  • Which should always be considered with regard to the patient and his or her underlying pathology (e.g., genetic syndrome, tertiary HPT)

• Other important considerations when dealing with MGD include:
  • Cervical thymectomy:
    • Due to the increased risk of ectopic supernumerary glands in MGD
  • Cryo-preservation of resected tissue:
    • Should be performed to protect against the rare, though devastating, complication of permanent hypoparathyroidism due to graft or remnant failure
  • If available, iPTH can be used to help guide the extent of resection in sub-total:
    • Aiming for a greater than 90% reduction at the completion of the operation
  • Close observation postoperatively for hypoparathyroidism and hungry bone syndrome regardless of approach

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