Parathyroid Surgery

The goal of parathyroid surgery is to return the patient’s blood calcium level to the normal range.  In patients with a single abnormal gland that is well localized on preoperative localization studies, this typically is achieved using a “focused parathyroidectomy.”  In this approach, the surgeon identifies the single diseased gland and removes it.  To ensure that there are no other diseased parathyroid glands in the neck that were not identified on imaging, the blood levels of parathyroid hormone are measured in the operating room.  If the PTH falls by more than 50% of the preoperative value and into the normal range 10 minutes after the gland is removed, then the procedure is complete and the surgeon does not need to visualize the other three glands to ensure a cure.  In patients who do not have a well localized gland on imaging, those with multi-gland disease, and in situations where the intraoperative PTH does not decline, the surgeon will need to perform a bilateral neck exploration.  In this procedure, which is still done through the same small incision used for the focused approach, the surgeon identifies all four parathyroid glands and removes the abnormal ones.

The traditional incision for parathyroid surgery (called a collar incision) was low in the neck and very long.  Today, this type of incision can generally be avoided.  Rather, the incision is placed high in the neck in a natural skin crease which dramatically reduced the length of the incision needed to perform the surgery.  The scar itself is composed of two things.  First is the normal healing process which is necessary and unavoidable.  The second is reaction to foreign material.  Because sutures are foreign material, they are avoided for this reason.  Instead, your incision will be glued together.  The glue is a clear plastic with a purple tint.  It is ok to take a shower the day after surgery, just do not let the water run right onto the glue.  If the glue gets wet, it may get sticky.  In this case simply fan it dry.  It takes about 7 to 10 days for the glue to curl up and fall off.  After that, everything should be healed up underneath.  Many patients ask about a myriad of skin care products marketed to reduce scarring.  To our knowledge none of these over the counter preparations are harmful and you should feel free to use them if you wish once the glue has come off.  Finally, the scars do tend to darken when they are exposed to sunlight.  So it is a good practice to keep sunblock on the incision when going out into the sun.

Bleeding and infection can happen with any operation.  The risk of needing to return to the operating room for bleeding is about 1 in 300.  In our experience all of these patients were identified within the 4 hour observation period prior to potential discharge.  Infection rates in skin incisions in the head and neck are very low, but are more common in immunocompromised patients.

Injury to the nerve to the voice box, the recurrent laryngeal nerve, occurs in about 1 percent of patients.  If this happens, you will not lose your voice, but our voice will become hoarse.  The hoarseness will last for a period of time ranging anywhere from 6 weeks up to 9 months.  During that period of time, the paralyzed vocal cord will shorten and stiffen and the other vocal cord will learn to accommodate.  So after a period of time, the voice will be quite normal in pitch and tone, but it will always be weaker than it had been in the past.  These patients have difficulty projecting their voice.

In patients with PHP, the function of the normal glands can be suppressed by the over function of the diseased gland or glands.  When the disease is removed, it can take a period of time for the remaining suppressed normal glands to recover function.  During this period of time the patient may not make enough parathyroid hormone to achieve normal blood calcium levels.  Symptoms of low calcium are numbness and tingling in the finger tips and around the lips.  Some patients will also describe cramping in the hands.  The treatment for this is to take calcium supplements by mouth.  If symptoms occur (in about 5% of patients), they typically start about 24 hours after the surgery and last for about one week.  All patients discharged after parathyroid surgery are sent home with instructions to take supplemental calcium for the first week.  If you experience tingling, you should take more calcium and call your surgeon.  In most patients the tingling will resolve, however, in 1 out of 200 patients, the parathyroid dysfunction will be permanent and these patients will need to take lifelong calcium supplementation.  Patients at increased risk for parathyroid dysfunction include patients who undergo concomitant thyroid surgery and patients with four gland hyperplasia.

In general, patients do not need to be admitted to the hospital following parathyroid surgery.  After the operation is completed, the patient is taken to the recovery room for a 4 hour observation period and then discharged home.  Patients who may require admission to the hospital include those on blood thinners and those with large thyroids that extend into the chest who undergo concomitant thyroid surgery.  Most patients are back to their usual activities within a week of the surgery.  It will hurt to swallow after the surgery much like a sore throat from a cold.  Patients are able to swallow anything after the surgery, but the hardest thing to swallow is water because you have to elevate your soft palate the highest to swallow thin liquids.  The easiest thing to swallow is ice cream. Most patients take pain medicine for two or three days following the surgery.  About half get by with Tylenol of Motrin while the rest will take a mild narcotic for which you will receive a prescription prior to leaving the hospital.

Patients should resume their preoperative medications following the surgery.  Patients should consult with their surgeon about resuming blood thinners.  Patients will be given a prescription for narcotics, but should start with Tylenol or Motrin first.  Finally, patients need to take high doses of calcium (1000 mg four times a day) for the first week to treat any potential temporary dysfunction of the remaining parathyroid glands.
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Reoperative Parathryoid Surgery

The cure rate following parathyroid surgery is greater than 95% in experienced hands.  However, even in the most experienced centers, some patients will not be cured by the initial operation (persistent disease) while others will develop hypercalcemia again at some point in the future (recurrent disease).  In many of these patients further surgery is necessary to cure the hyperparathyroidism.  In this small percentage of patients, often multiple preoperative imaging studies are ordered to pinpoint the abnormal gland.  At re-exploration, often these glands are found in ectopic locations.  The complication rate is increased in the setting of reoperative surgery because of the scar tissue that develops from the initial operation underscoring the need for precise preoperative localization and a focused surgical approach.

 

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