Parathyroid surgery
Parathyroidectomy – surgery to remove a parathyroid gland - is currently the only available definitive cure for primary hyperparathyroidism. It is known to improve the bone, abdominal and urological effects associated with primary hyperparathyroidism. It frequently also improves the more subtle symptoms that often co-exist including fatigue, memory loss and reduced concentration. As a consequence surgery is usually recommended in all patients with primary hyperparathyroidism that have symptoms.
International guidelines recommend that a parathyroidectomy should also be considered in young (under 50 years) asymptomatic patients. Increasing evidence demonstrates that patients with long term untreated hypercalcaemia are susceptible to adverse consequences including being more prone to heart disease as well as possibly malignancy. Parathyroidiectomy is associated with a quantifiable improvement in health related quality of life and may also normalise the long term risk of premature death especially in younger patients.
However, each patient requires assessment of their specific biochemical and clinical disease characteristics prior to contemplating surgery.
Minimally invasive parathyroidectomy
The traditional operation for primary hyperparathyroidism is called a bilateral neck exploration. This operation involves a neck collar type incision and aims to identify and preserve the normal parathyroid glands, which are typically the size of a grain of rice or smaller, and at the same time to identify and remove the diseased parathyroid gland or glands. Given the frequent variation in the position and appearance of diseased parathyroid glands the experience of the surgeon plays a major role in determining the outcome of this surgery.
The arrival of reliable preoperative localisation studies has permitted the identification of the diseased gland in the majority of cases, therefore making most patients candidates for a minimally invasive parathyroidectomy. Many techniques of this minimal access parathyroidectomy exist including endoscopic parathyroidectomy, video-assisted parathyroidectomy, and mini incision parathyroidectomy under general or local anaesthesia. The principal advantage of the minimally invasive parathyroidectomy is that when performed appropriately it allows the parathyroid adenoma to be dissected and removed through a small incision, leaving the other neck tissues undisturbed. In the hands of specialist surgeons this technique offers results equivalent to the best traditional operation but with the added advantages of (i) a smaller incision, (ii) a shorter operation, (iii) shorter hospital stay and (iv) the possibility of a local rather than general anaesthetic. Intra-operatively it is now possible to measure the patient’s PTH level in addition when necessary to assess the parathyroid gland with the use of a microscope. These aids may add to the success rate of surgery.