As a breast and endocrine surgeon, Dr. Ben Green is also a parathyroid surgeon. Brisbane based patients can be referred to Dr. Green for parathyroid surgery at Brisbane’s leading hospitals. Read on to find more about this procedure.
What are the parathyroid glands?
Parathyroid glands are a small glands located in your neck that is responsible for controlling calcium levels. Normally there are 4 glands in your neck. They are closely located adjacent your thyroid gland. Typically there are 2 glands on each side of your neck. They are a small gland, normally about 5-7mm in size and weigh about 30-60mg. They are small and have a yellow tan appearance.
These glands control calcium levels in your body by producing two hormones:
- Parathyroid Hormone (PTH) – increases calcium.
- Calcitonin – reduced calcium.
What is hyperparathyeroidism (HPT)?
Hyperparathyroidism is a condition when one or more of the parathyroid glands become overactive.
There are 3 types of hyperparathyroidism (HPT).
This is the most common form and is due usually to a single gland becoming overactive.
Usually a single gland develops a tumour called an adenoma (benign) that results in an excessive amount of the hormone PTH being produced.
The excess hormone sends a message to the body to increase calcium. Despite the calcium level becoming elevated the gland does not respond to the normal controls and continues to secrete PTH raising the calcium further and resulting in several associated medical problems.
The cause of PTH is due to:
- Single adenoma – 85%.
- Hyperplasia (enlargement) – 10%.
- Multiple adenoma – 5%.
- Cancer <1%.
This form of HPT occurs in patients with renal disease. Patients with renal disease lose excessive amounts of calcium in the urine. To compensate for this the parathyroid glands enlarge (hypertrophy).
In secondary HPT all glands are involved. Renal physicians try to control the calcium loss with medication. Cinacalcet is a medication that controls the excessive PTH production and has dramatically reduced the need for surgical intervention. However, there is a limit to the degree of enlargement that can be controlled and eventually parathyroid surgery is often required in 5% of cases.
Parathyroid surgery requires removal of all glands and reimplanting half of one either in the muscles in your neck or in your arm.
Is rare and is seen in patients who have prolonged untreated secondary HPT. These patients the parathyroid glands enlarge due to the loss of calcium from the kidney but eventually the gland themselves stop responding to the calcium and excrete PTH excessively.
Treatments is initially aimed at controlling the kidney disease, but if surgery is needed 3 ½ glands are removed.
What problems can high calcium cause?
Calcium levels are usually kept within tight limits. Hyperparathyroidism results in an elevated calcium level that can result in several symptoms.
Many people may not realise that their calcium is elevated. However, there are many symptoms related to the elevated PTH and calcium levels that may not be realised and affect many body systems.
The most serious problems with high calcium that would result in a parathyroid surgeon making a recommendation for surgery include:
- Renal calculi (kidney stones).
- Heart arrhythmias – irregular heart beats with very high calcium.
Other causes can be the result of a high PTH and calcium, although may be related to many other factors include:
- Fatigue, memory loss and irritability.
- Excessive thirst.
- Constipation and abdominal pains.
- Excessive urination.
Do I have parathyroid cancer?
Parathyroid cancer is very rare. Less than 1% of hyperparathyroidism is due to a cancer. Most primary hyperparathyroidism is due to a type of tumour called an adenoma. This is a benign tumour that does not have the ability to spread around the body (Compared to a malignant tumour is the dangerous cancer type).
An adenoma results in a gland that can become very large (2-10 times normal size). It only causes problems due to the excessive PTH secretion and resulting high calcium.
What tests do I need before surgery?
Several tests are required if primary hyperparathyroidism is considered. Most patients the diagnosis is suspected due the high calcium and PTH levels that me be found accidentally as part of an investigation for other reasons.
The investigations required can be broken up into two components.
Tests to confirm the diagnosis
- Calcium level.
- PTH level.
- Vitamin D level – a low vitamin D can elevate your PTH level.
- Urine test.
- 24-hour collection of urine to check calcium levels which should be high.
Tests to locate the abnormal gland
- Performed to locate the enlarged parathyroid gland.
- Sestamibi scan -a parathyroid scan where you will be receiving a tiny amount of radioactive labelled injection? This will be taken up by the abnormal parathyroid gland and show up on the scan. This will confirm that the enlarged gland on ultrasound is actually overactive.
- Neck CT - this not often used initially. Allows location of glands in abnormal sites.
What is minimally invasive parathyroidectomy surgery (MIPS) and a bilateral neck exploration (BNE)?
Minimally invasive parathyroidectomy (MIPS)
This is the removal of an enlarged overactive parathyroid via a small (<2cm) incision.
This is a technique that is suitable in approximately 85% of cases. The advantage is a small incision that heals with the best cosmetic outcome. Also, with a focused MIPS there is minimal disruption of the tissue in your neck. This results in a faster recovery and less internal scarring.
A MIPS is possible when the exact location of the abnormal parathyroid gland can be determined preoperatively. In these cases a small incision is used and a tunnel created directly to the gland. This procedure is technically difficult due to the small cut. However, it is now the routine approach for parathyroid removal in glands that are able to be located on preoperative imaging.
Bilateral neck exploration (BNE)
Patients where the abnormal gland is not able to be located on the pre-operative imaging will need to have both sides of the neck explored. It is often necessary for all 4 glands to be located to determine which of the glands is abnormal. This operation is referred to as a bilateral neck exploration (BNE).
A BNE requires a 3-5cm incision and a more extensive dissection. This does results in more scarring inside your neck and a little more post-operative discomfort.
Both a MIPS and BNE have similar recovery times and similar risks.
Can everyone have a minimally invasive parathyroidectomy (MIPS)?
Not every person can have a parathyroidectomy performed via a small (<2cm) incision. 85% of cases the abnormal gland can be located with the pre-operative images. In the remainder of cases when the location of the gland is unknown and a larger incision is required so as both sides of the neck can be explored. In these cases potentially all 4 parathyroid glands need to be found to determine which of the glands is abnormal. This requires a much more extensive dissection and thus a MIPS is not suitable.
As your parathyroid surgeon, Dr. Green will be able to advise you before your surgery if a MIPS is planned or if all areas of the neck need to be explored.
What is involved in the operation?
Parathyroid surgery, performed as either a minimally invasive approach (MIPS) or as a bilateral neck exploration (BNE) requires a general anaesthetic and an overnight stay in hospital.
The operation can take between 30 minutes to 2 hours depending on how difficult it is to locate the abnormal gland.
On admission to hospital you will meet the anaesthetist and a drip will be placed in your hand. This will be used to put you off to sleep.
Both procedures will result in a small incision in your neck so as the abnormal gland can be located. Once the parathyroid gland is located it will be removed and confirmed as abnormal by a pathologist whilst you are asleep. This is known as a frozen section.
Once the operation is completed your wound will be closed with dissolving stitches and covered with a plastic strip.
For specific post-operative instructions see the post-operative advice section.
After parathyroid surgery you will return to the ward where you will be able to eat and drink as you wish. You will have a sore throat that should be able to be managed with some simple tablet pain relief medication.
The success of the operation will be confirmed with a blood test the following morning.
When will I know the operation has been successful?
Immediately after your operation Dr Green will be able to advise you as to the likely successfulness of the operation. Whilst you are asleep a pathologist will attend the operating room. Once Dr Green finds a parathyroid that appears abnormal it will be removed and checked under the microscope to confirm that it is a parathyroid gland and also abnormal. This is a very good guide. Over the next day or two the gland will be more thoroughly assessed to confirm it is an abnormal gland.
A few hours after your operation a blood test will be performed. This will be to check your parathyroid hormone (PTH) and calcium levels. If the operation has been successful these should return to normal very quickly.
Is surgery always successful?
There is a very good success rate for patients undergoing a parathyroidectomy in a single operation (over 85-90%).
The vast majority of patients with hyperparathyroidism can have a successful operation where the abnormal parathyroid gland is removed with a single operation. Unfortunately there are a small number of patients where the abnormal parathyroid gland cannot be located at the first operation and further tests and surgery are required. The likelihood of a successful operation is influenced.
In cases where the abnormal parathyroid gland can be located with the imaging prior to surgery a successful operation occurs for around 95% of people.
When the parathyroid location is not a able to be located prior to surgery there is a greater chance that the abnormal gland will not be able to be located in a single operation. However, in these cases there is still over an 85% success rate of a successful operation the first time.
What happens if the abnormal gland is not found?
In a small number of patients the parathyroid surgeon may not be able to find the abnormal gland at the first operation. The location of the parathyroid is usually quite predictable. They are often symmetrical on each side of the neck.
The superior parathyroid glands are usually quite predictable in their location. 80% of the time they are located where expected. This is in contrast to the inferior glands where the position can be quite variable. Only 50% of the time the parathyroid is located in a predictable position behind the lower part of the thyroid. The inferior gland can also be very variable in its location and can descend down into the neck and chest or may not have descended during your development and still be located up near your skull. In these instances the abnormal gland may not be detectable at the first operation.
If the first operation is not successful the original imaging studies will be repeated. Additional tests may also be requested including a 4D CT. This is a CT scan specifically looking for the parathyroid. This test is useful for glands that are in abnormal positions away from the neck.
In a very small number of cases where none of the images have helped an invasive test called ‘selective venous sampling’ may be performed. A catheter is placed into the veins of the neck via your arm. Serial blood tests are taken to find what veins have a high PTH level. This will guide the parathyroid surgeon as to where to loom for the gland.
What are the potential complications?
Anyone having a mastectomy will be given information about breast reconstruction. There are many options including having an immediate reconstruction (at the same time as your mastectomy) or delayed.
There are various types of reconstruction that can be offered. It is important to note that some patients are not suitable for an immediate reconstruction or some forms of reconstruction, especially if you are going to need radiotherapy after. Dr. Green will provide you with information about this at the time of your consultation.
What are some of the possible complications?
Parathyroidectomy is a common operation performed by Dr. Green for which he has been well trained. The vast majority of patients will follow the “usual” path of recovery and will be discharged from hospital feeling well the day after your surgery.
Despite this things may not always go according to plan and a small number of patients may experience a significant complication. If you would like more information after your consultation and reading this page please feel free to discuss any issues with Dr Green.
Uncommon (up to 5% of cases)
Rare but important (up to 1% of cases)