Advances in Parathyroid Surgery

Our parathyroid glands are in charge of the metabolism of calcium and related minerals in our body. Typically, each person has four lentil-sized parathyroid glands, two on each side of the neck. Subtle changes in our daily intake of minerals and nutrients can affect the release of the parathyroid hormone. Occasionally, irregularities such as an adenoma or hyperplasia can lead to unregulated elevated levels of parathyroid hormone, which then secondarily causes depletion of calcium from the bones, elevated calcium levels in the blood, and excessive loss of calcium through urine. If this condition is not taken care of, osteoporosis and kidney stones as well as bony fractures can result.

The diagnosis of hyperparathyroidism and hypercalcemia is made by routine blood test. Since there is no other medical treatment for the condition, surgery is the recommended treatment for this condition. In years past, four-gland exploration of every single gland was undertaken to determine which one of the four was the gland that was releasing the extra level of hormone. Visual inspection of the relative size of each gland as well as segmental biopsy of each gland were used to determine which is the abnormal gland. At that point, the abnormal gland was excised.

Several advances have been made that reduce operative time and dissection of the neck during parathyroid surgery. Preoperative localization of the affected gland is typically carried out by a radiographic test called Sestamibi Localization Test . In many cases, this scan is able to provide information to identify the affected gland, and surgery can therefore be confined to the affected side only. Occasionally, a sestamibi scan is not completely able to localize the affected gland, and additional tests including ultrasound, CT scan, or MRI scan would provide supplemental information that could be used for surgical planning. Rarely, the affected gland could not be ascertained pre-operatively, and four-gland exploration might still need to be undertaken.

The most significant recent innovation in parathyroid surgery is Intraoperative Parathyroid Hormone Assay. Once the affected gland is removed during surgery, the patient’s blood level is checked right afterwards to assure a drop in the parathyroid hormone level in the blood. Once this significant drop is documented, surgery can be safely finished and no additional surgery would be necessary.

Another advance that is used by some doctors for parathyroid surgery is the use of Contrast Dye. Methylene blue is typically injected intravenously at the beginning of the surgery. Once enough dissection has been made to the area of concern, the parathyroid glands have a very distinctive bluish coloration to them from preferential absorption of the Methylene blue, and the correct diagnosis and localization is achieved much easier. This can help the surgeon identify the parathyroid more quickly.

The newest advance on the horizon for parathyroid surgery is the use of robotic equipment. This promises additional minimalization of surgical dissection with use of better optics and versatile robotic equipment. The surgery protocol for this kind of surgery is still under investigation and development, and is not under wide use.

Dr. Namdar uses these and other upcoming advances in surgical technique to assure the best possible care for his patients. Make sure you discuss methods with your surgeon.

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