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
Tagging of the remnant gland in sub-total parathyroidectomy. The gland chosen to be the remnant has been 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 Hemaclip 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)
Risks, benefits, and indications for sub-total and total parathyroidectomy
  • 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

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #Parathyroidectomy #MSMC #MountSinaiMedicalCenter #HeadandNeckSurgeon #Surgeon #Teacher #EndocrineSurgery

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