In the hands of experts like us, and for the majority of patients, Parathyroid Surgery is generally relatively minor surgery accompanied by minimal pain and is safe, successful, and followed by a quick recovery and improvement in symptoms. There is good evidence that outcomes are better for experienced surgeons- that is: higher success rate, lower complication rate and smoother and quicker surgery and perioperative course.
Parathyroid surgery for Primary Hyperparathyroidism due to Parathyroid adenoma.
At Melbourne Parathyroid Centre, most patients will have a keyhole or minimally invasive operation resulting in removal of a single, benign parathyroid adenoma.
Most patients- in the order of 95%- have only one currently enlarged and overactive gland and will be cured by removing it. State-of-the-art, pre-operative imaging studies, with expert interpretation, will most often, but not always identify the enlarged parathyroid adenoma.
While expert surgeons can usually readily identify all four parathyroid glands, the truth is, in some patients, it can be difficult. There are situations where it may not be straightforward to find all four glands, including patients who have; large thyroid nodules or goitre, Hashimoto’s Thyroiditis, previous neck surgery with scarring, short or very curved neck ( kyphosis) and morbid obesity. Additionally, some patients will have ectopic parathyroid glands, far away from the thyroid gland.
For most patients who have had an adenoma removed by keyhole surgery, we think it may be wiser and better not to look on both side of the neck, for the other, usually normally functioning parathyroid glands. In some, selected patients, the plan will be to go on and check the other three glands are normal.
We believe our approach gives the best balance of successful surgery / cure rates and the lowest surgical risks and least time under anaesthetic, for the highest proportion of patients.
When we carefully examine all four glands in every patient with primary hyperparathyroidism, approximately 15-20% of patients will have some degree of enlargement of more than one gland. However, when imaging shows a single big adenoma, removing it nearly always (aprroximatley 95%) results in normalisation of the bloods tests and symptoms, suggesting that the one large gland is the main problem in most patients. Some surgeons, particularly in the United States, currently recommend all patients should have a 4 gland assessment. Finding and assessing all four glands very slightly improves the cure rate and recurrence rate, but persistent hyperparathyroidism or recurrent hyperparathyroidism can still occur. Re-operation after a 4 gland parathyroid operation is generally more difficult.
We will discuss the options with you and make the best plan for you.
Parathyroid surgery for multiple adenoma or hyperplasia
Those patients with evidence of multi-gland hyperparathyroidism and those with recurrent hyperparathyroidism after previous removal of a single parathyroid adenoma will usually have 4 gland assessment. All abnormally enlarged glands will be removed.
Depending on individual circumstances two or three glands may be removed with preservation of one or two normal glands.
However, and uncommonly, if all four glands are abnormal, then the surgery will be either a subtotal parathyroidectomy or total parathyroidectomy with auto-transplantation.
Subtotal parathyroidectomy means removing the three most abnormal glands and a part of the fourth, leaving in place only an adequate portion of one gland.
Total parathyroidectomy means removing all four abnormal glands. Usually, total parathyroidectomy is accompanied by Auto-transplantation of a small portion of the most normal gland, into the muscle in the neck, where it will function very reliably as a graft, thus preserving parathyroid function. If it overgrows and becomes overactive again, it can be re-operated upon. This is preferable to having no parathyroid function or Hypoparathyroidism.
Familial hyperparathyroidism
Patients who are known or found to have familial hyperparathyroidism, such as Multiple Endocrine Neoplasia and Parathyroid-Jaw Tumour Syndrome will usually have planned 4 Gland assessment and surgery as described above. These conditions can be suspected from the clinical situation and confirmed with genetic testing.
Hyperparathyroidism caused by kidney failure or X-linked Hypophosphataemic rickets (also confusingly known as Secondary and Tertiary Hyperparathyroidism).
Patients with hyperparathyroidism caused by kidney failure will usually have a 4 gland assessment. Because of the extremely high modern success rates of auto-transplantation of parathyroid tissue, most patients will have total parathyroidectomy and autotransplantation, rather than subtotal parathyroidectomy.
Concurrent thyroid surgery
If your thyroid has significant nodules or is very large, it may be wise to plan to remove part or all of it at the same time. We will always assess your thyroid when performing Ultrasound of the Parathyroid glands, and will discuss with you if we think you should have thyroid surgery.
Only 3 parathyroid glands
It is possible that some patients may truly have only three glands, however for the surgeon, it is best to assume that all patients have at least four glands and therefore there is one gland which has not been identified: parathyroid glands can be small, ectopic, intra-thyroid and sometimes similar in appearance to fat.
