Perioperative management - Heterotopic parathyroid autotransplantation in total parathyroidectomy - general and visceral surgery
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Indications
Secondary (renal) hyperthyroidism
- In non-drug related hypercalcemia after all medicinal treatment options (phosphate binders, calcimimetics, active vitamin D3 analogs) have been exhausted
- In severe renal osteopathy (confirmed by radiology and/or histology)
- In atherosclerosis and other soft tissue calcifications, severe hyperphosphatemia, calciphylaxis (calcific uremic arteriolopathy), and pruritus after all medicinal treatment options have been exhausted while parathyroid hormone levels are elevated (>800 pg/mL)
Tertiary hyperparathyroidism in autonomous hypercalcemic (>3.0 mmol/L) renal HPT after kidney transplant
Multi-glandular disease in MEN-1 and MEN-2 (familial syndrome with formation of active endocrine tumors) → disorder of the entire organ system, i.e., of all parathyroids
MEN-1 → subtotal parathyroidectomy (3 1/2) parathyroids with thymectomy or total parathyroidectomy with thymectomy and autotransplantation, in resection of individual tumors high probability of persistence/recurrence, prophylaxis of thymic neuroendocrine tumors (carcinoid)
MEN-2 → resection of just the enlarged parathyroids
Contraindications
- Presence of adynamic bone disease and renal HPT
Preoperative diagnostic work-up
- Lab study of parathyroid hormone
- Additional lab studies (serum calcium, phosphate, alkaline phosphatase (possibly bone specific), creatinine, urea, albumin/total protein; optionally T3, T4, TSH
- Ruling out neoplasia (thyroid neoplasia and multiple endocrine neoplasia)
- Bone histology (optional)
- Laryngoscopy (vocal cord function)
- Location work-up
- Ultrasonography, MIBI-SPECT, (CT, MRI, PTH selective venous sampling)
Special preparation
- Intraoperative peripheral venous PTH study (IOPTH) →PTH level as “pre-incision” baseline.
- Pre- and postoperative laryngoscopy
- Neuromonitoring with vagus stimulation pre- and post-resection
- Standardized intraoperative neuromonitoring (ION)
- Verifiable documentation of the stimulated EMG of the ipsilateral vagus nerve before and after resection (for medicolegal reasons)
Informed consent
- Usual risk in surgical procedures (bleeding, infection, secondary wound healing, revision surgery)
- Undetectable adenoma(s) and revision surgery
- In case of signal loss resection of contralateral postponed to some later time
- Persistent hyperparathyroidism
- Postoperative hyperparathyroidism
- Recurrent laryngeal nerve paralysis, if bilateral possibly tracheotomy
- Parathyroid autotransplantation into muscles of the neck or forearm
- Exploration of the thyroid, with possible excision in case of abnormalities
- Pneumothorax
- Possibly postoperative calcium supplementation
- Recurrence
Anesthesia
Positioning
Operating room setup
Special instruments and fixation systems
Postoperative management
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