prof ndr - parathyroid

7/31/2019 Prof NDR - Parathyroid

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PROF.N.DORAIRAJANMS,FRCS(EDIN),FICS,FACS,FICA

PROFESSOR AND HEAD OF THE DEPARTMENTDEPARTMENT OF GENERAL SURGERY

MADRAS MEDICAL COLLEGE &

GOVT GENERAL HOSPITAL

CHENNAI

ENDOCRINE SURGEON APOLLO HOSPITALS, CHENNAI

PRESIDENT (2009-10)INTERNATIONAL COLLEGE OF

SURGEONSINDIAN SECTION

Asian federation secretaryINTERNATIONAL COLLEGE OFSURGEONSINTERNATIONAL SECTION

EDITORIAL BOARD MEMBERINTERNATIONAL SURGERY

CHAIRMANASI - TAMILNADU PONDICHERRY CHAPTER


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GROANS,MOANS


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56/M

C/o general body aches and pain over joints 1 month

H/o heartburns 2 monthsH/o nausea - 2 months

H/o anorexia - 2 months

No h/o hematemesis / melenaNo h/o vomiting

No h/o constipationNo h/o altered bladder habitsNo loss of weight and appetite


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Known diabetic 1 year

Underwent PTCA - 2006

Hypertension - 10 years

ESWL treatment for left renal calculus - 25 years ago.

Pt underwent upper GI endoscopy esophagitis

Pt developed anuria the same day

Admitted in nephrology department ,Apollo


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General examination clinically normal

PR- 82/mtBP 140/70 mmHg

CVS S1S2 +RS NVBS

P/A Soft , no mass felt , no organomegaly

Examination of neck clinically normal.

Examination of cranium / spine / pelvis / long bones clinically normal


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INVESTIGATIONS

Blood sugar 134 mg/dlblood urea 56 mg/dl

Serum creatinine 2.6 mg/dlSerum sodium 142 meq/dl

Serum potassium

4.9meq/dl

Serum calcium 17.8 g/dlSerum phosphrous 2.3 mg/dl

Serum magnesium

1.4 mg/dlUric acid 10.8 g


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Intact paratharmone 2140 pg /ml

Serum alkaline phosphatase 773 IU/dl

Renal doppler normal (left renal cortical cyst)

Serum protein electrophorosis normal


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Hypercalcemia unresponse to forced diuresis

Dialysis against a zero calcium bath.



HYPERCALCEMIA PERSIST

ENDOCRINOLOGIST OPINION


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ENDOCRINOLOGIST OPINION:

Advised :

Skeletal survey

USG neck

MIBI Parathyroid scan

[email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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USG neck

A cystic nodule measuring 1.3cm seen in the leftlobe

Two large nodules are seen close to the lower poleof thyroid on either side measuring about 4 cm onright and 3 cm on left nodules show cystic areas

within.

Impression:

Large nodules with cystic changes close to thelower poles of thyroid glands suggestive of

parathyroid lesions


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99TC MIBI STATIC STUDYOF NECK / MEDIASTINUM

There is persistent tracer concentration noted in the midand the lower poles of both lobes of thyroid

Features suggestive of functioning parathyroid lesion in the

mid and lower poles of both lobes of thyroid


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DIAGNOSIS:

PRIMARY HYPERPARATHYROIDISM

? HYPERPLASIA? ADENOMA

PLAN:

PARATHYROIDECTOMY

STANDARD PARATHYROID SURGERYBILATERAL APPROACH


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PER-OPERATIVE DETAILS:

Right inferior parathyroid found enlarged

Left superior parathyroid also found enlargedLeft inferior parathyroid was enlarged with variable

consistencyLeft thyroid had multiple nodules.

Right superior parathyroid found normalRecurrent laryngeal nerve identified and preserved onboth sides

PROCEDURE :Subtotal parathyroidectomy and left hemithyroidectomy

Right inferior , left superior and inferior Parathyroidectomydone

Left hemithyroidectomy done.


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FROZEN SECTION:

Parathyroid adenoma

HPE REPORT:

Parathyroid : Parathyroid hyperplasia of all threeparathyroids

Thyroid : Nodular hyperplasia and focal lymphocyticthyroiditis


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POST OPERATIVE PERIOD:

Serum calcium 17.8 g/dl

Intact paratharmone

2140 pg /ml

Pre operative :

Sr.calcium Sr.Paratharmone

After 6 hrs 14.3 g/dl 422 pg/ml

After 12

hrs12.2 g/dl

After 24hrs 11.4 g/dl

After 48

hrs9.3 g/dl 223 pg/ml


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uneventful

Put on tab.calcium and tab.1,25 dihydroxyvitamin D dailyFrom 1st POD

A successful parathyroidectomy results in a decrease in serum calciumlevel ,which usually reaches its nadir 48 hrs after surgery.

A successful parathyroidectomy results in a decrease in serum PTH

level, > 50% in 5 minutes and > 60 % in 15 minutes


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On 7 th POD:

Blood sugar 134 mg/dlBlood urea 22 mg/dl

Serum creatinine 1.1 mg/dlSerum Na+ - 141 meq/lSerum K+ - 4.5 meq /l

Serum calcium

9.3 g/dlSerum phosphorus 3.3


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BONES

[email protected]
mailto:[email protected]:[email protected]


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FRACTURE NECK OF FEMUR

THIN CORTEX

POOR TRABECULAR PATTERN


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21/ F referred from Royapettah Govt Hospital

H/o accidental fall 3 months back.

Fracture left neck of femur.

H/o muscle and joint pain - 6 months.

H/o weakness on doing manual work - 6 months

No h/o nausea or heartburn.

No h/o loss of weight or appetite.

No h/o polyuria , polydipsia or constipation

Not known DM / HT / PTB

No h/o menstrual disturbances.

No h/o similar complaints in her family.


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General examination -shortening of left lowerlimb (


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INVESTIGATIONS

Biochemical investigations - Normal

LFT WNL

Alk.Phosp 128 IU/L

Serum calcium 13.9 mg/dl

Serum phosphorus 2.1 mg/dl

Serum intact paratharmone 1277 pg/ml

USG abdomen - normal


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USG neck

solitary right inferior parathyroid adenoma


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THIN CORTEX


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CT NECK PLAIN AND CONTRAST

28 X 11 X 11 MM isodense soft tissue lesion showing

intense enhancement with contrast noted in the region of

right paratreacheal ,inferior and posterior to the right

lobe of thyroid

Features suggestive of parathyroid adenoma


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Tc 99m Sestamibi scan study shows an areaof tracer retention corresponding to the

region of right lower pole of thyroid gland

Scan finding concordant with USGfindings of Parathyroid adenoma.


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DIAGNOSIS :


RIGHT LOWER PARATHYROID ADENOMA

PLAN :

RIGHT LOWER PARATHYROIDECTOMY

MINIMAL INVASIVE PARATHYROID SURGERY

UNILATERAL APPROACH


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HEAD

NECK

CHEST

INFERIOR POLE RT THYROID

RT PARATHYROID ADENOMA

RT STERNOCLEDIOMASTOID


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HEAD

NECK

INFERIOR POLE RT THYROID

SPACE AFTER REMOVAL OF PARATHYROID ADENOMA

RT STERNOCLEDIOMASTOID


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SERUMCALCIUM

(g/dl)

Pre

operative

13 .9

Post

operative (6

hrs)

11.3

SERUM

PTH(pg/m

l)

1277 16


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uneventful

Administred with tab.calcium andtab.1,25 dihydroxyvitamin D daily.

[email protected]


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BONE MINERAL DENSITY

TOTAL BODY BONE MINERAL DENSITY OF 0.635 G /CM3 ,

CORRESPONDING TO A T - SCORE OF 4.4

AP SPINE L1 L4 MEAN DENSITY OF 0.425 G /CM3 ,

CORRESPONDING TO A T - SCORE OF

6.2RIGHT FEMUR MEAN DENSITY OF 0.257 G /CM3 ,

CORRESPONDING TO A T - SCORE OF 6.2

LEFT ORTHO FEMUR MEAN DENSITY OF 0.295 G /CM3

SUGGESTIVE OF OSTEOPOROSIS , FRACTURE RISK HIGH


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STONES


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28 / F referred from Urology department

C/o pain left loin 3 months

No h/o hematuria

H/o muscle and joint pain - 6 months.

H/o weakness on doing manual work - 4 months.

No h/o nausea or heartburn.

No h/o loss of weight or appetite.

No h/o polyuria , polydipsia or constipation





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Past history of passing calculus during micturation

5yrs agoESWL treatment for left renal calculus - 4 years ago





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General examination clinically normal

PR- 82/mtBP 120/70 mmHg

CVS S1S2 +RS NVBS

P/A Soft , no mass felt , no organomegaly

Examination of neck clinically normal.

Examination of cranium / spine / pelvis / long bones clinically normal


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INVESTIGATIONS

Biochemical profile - NormalX-Ray KUB multiple renal calculus both left and right side


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USG ABDOMEN : multiple left renal calculus

calculus measuring 6 x 5mm in right

pelvic ureteric junction

bladder normal

Serum Calcium 14.2 g/dlSerum Phosphorus 2 g/dl

Intact paratharmone - 945 pg/ml

Sketetal survery - normal

PARATHYROID SCAN


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There is persistent tracer concentration noted in the

lower poles of right lobe of thyroid

Features suggestive of parathyroid lesion in the

lower poles of right lobe of thyroid


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DIAGNOSIS:


ADENOMA

PLAN :

RIGHT LOWER PARATHYROIDECTOMY

MINIMAL INVASIVE PARATHYROID SURGERYUNILATERAL APPROACH


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video

docndr@gmai


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POST OPERATIVE PERIOD


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Per operative serum calcium 14.2 g/dl

Peropaerative serum Paratharmone 945 pg/mlSr. Calcium Sr .Paratharmone

After 6 hrs 11.5 g/dl 180 pg/ml

After 24

hrs10.6 g/dl

After 48hrs 9.3 g/dl 70 pg/ml

[email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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uneventful

Administred with tab.calcium andtab.1,25 dihydroxyvitamin D daily.

[email protected]


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HYPERPLASIA HYPERPLASIA ADENOMA

RENAL CALCULUS

RENAL FAILURE PATHOLOGICAL

FRACTURES

HOW HYPERPARATHYROIDISM PRESENTS ?


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Tired all the time.

Feel old. Depression. Osteoporosis and Osteopenia.fractures Gastric acid reflux; heartburn; GERD. Decrease in sex drive. Thinning hair (predominately in older females).

Kidney Stones. High Blood Pressure Recurrent Headaches (usually patients under the age of 40). Heart Palpitations (arrhythmias). Typically atrial arrhythmias.

Most people with hyperparathyroidism will have 4 - 6 of these symptoms

In general, the longer you have hyperparathyroidism, the more symptoms youwill develop.

HOW HY E HY O D SM ESEN S ?

Copyright 1996-2008 Norman Endocrine Surgery Clinic
http://parathyroid.com/about-Parathyroid.htmhttp://parathyroid.com/about-Parathyroid.htm


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People with calcium levels of 10 or 11 have just as many symptoms as people with

calcium levels of 12 or 13.

People with higher calcium levels do NOT have more symptoms.

Norman Parathyroid clinic


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In patients who have Serum Calcium levelsthat are only slightly elevated, or they areelevated and the PTH levels are borderlinehigh, THEN, the measurement of Ionized

Calcium becomes important.

Remember

It is NEVER normal to have a high calcium level.

[email protected]

Diagnosis of PHPT is made by metabolic testing


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Diagnosis of PHPT is made by metabolic testing

Elevated serum calcium

Elevated ionised calcium

Elevated intact PTHLow or normal blood phosphorus

Increased chloridephosphorus ratio ( > 33 )

Increased uric acid

Elevated alkaline phosphataseParathyroid harmone related peptide (PTHrP) - Most common

peptide secreted by Nonparathyroid cancers.

The intact PTH assays do not cross react with Parathyroid harmone

related peptide (PTHrP)

Documentation of serum creatinine,blood urea nitrogen and

serum protein electrophoresis - To rule out Multiple myeloma

Study Type Sensitivity Specificity


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Study Type Sensitivity Specificity

Ultrasound 71-80% 80%

EndoscopicUltrasound 71%

CT Scan 46-80% 88-98%

MRI Scan 64-78% 88-95%

Thallium-TechnetiumScan

75% 73-82%

Technetium-SestamibiScan

90.7% 98.8%

PET Scan 80-94%

Angiography & Venous

Sampling91-95% 96-98%

Venous SamplingAlone 70-80%

Parathyroid localisation - current practice

B. DIJKSTRA, C. HEALY, L.M. KELLY, E.W. MCDERMOTT, A.D.K. HILL and N.OHIGGINS

Department of Surgery, St Vincents University Hospital, Elm Park, Dublin 4, Ireland

L li i f id if h i b d k h


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Localization tests often identify the tumor site but do not make the

diagnosis because both false positive and false negative localization

tests occur.

SPECT (Single Proton Emission Computerized Tomography)

SPECT scanning is a variant of Sestamibi Scanning for parathyroid glands.

increase the accuracy of routine Sestamibi scanning by about 2 to 3 percent.The most important use for SPECT scanning is when ordinary Sestamibi scans areinconclusive or when a more detailed anatomic localization is necessary such as when

patients are being re-operated on.

MRI Scans

Are valuable very rarely (almost never) because MRI scans don't show

parathyroid tumors.

At best, an MRI will find less than 8% of parathyroid tumors

ROLE OF FNAC


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ROLE OF FNAC

Diagnostic aspiration of parathyroid adenomas causes

severe fibrosis complicating surgery and final histologic diagnosis.Norman J, Politz D, Browarsky I.Norman Endocrine Surgery Clinic, Tampa, Florida 33613, USA.

FNA of parathyroid adenomas can cause a severe fibrotic process that

typically involves adjacent tissues. This reaction dramatically increases t

difficulty of surgical resection, often requiring microdissection techniquto preserve nerves and assure complete removal.

The fibrosis can cause confusing histology mimicking malignancy.

FNA of parathyroid adenomas should be avoided unless absolutely

necessary.

Thyroid. 2007 Dec;17(12):1251-5


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PRIMARY HYPERPARARTHYROIDISM

SURGICAL MANAGEMENT

WHY ???

[email protected]

EFFECT OF SURGICAL TREATMENT


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EFFECT OF SURGICAL TREATMENT

Normocalcemia is achieved by surgery in 95% and maintained for

years.

Risk of complication is small and mortality is rare

Response of symptoms to Parathyroid surgery

SYMPTOMS

LONG TERM

IMPROVEMENT(%)

Renal stones 90

Osteitis fibrosa 100

Hypertension 3

Malaise , fatigue 78

Abdominal pains 63

Vague pains in extremities 51

depression 65

INDICATIONS FOR SURGERY IN PATIENTS WITH


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ASYMPTOMATIC


CONDITION SURGERY

AGEYoung

old

Always

If additional indications

SERUM CALCIUM>3.0 mmol

2.85 3.0

10 mmol/24 h Usually

RENAL FUNCTIONimpaired Usually

General principles for surgical exploration inP i h h idi


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Primary hyperparathyroidism

Keep the surgical field bloodless , so as to prevent discoloring of

Parathyroid glands.

Parathyroid Light brown

Fat Yellow

Lymphnodes Grey

Cryopreserve parathyroid tissue for subtotalParathyroidectomy and for all reoperations.

The risk of post operative hypoparathyroidism is increased if all

normal Parathyroid glands are biopsied routinely,so routine biopsy

of all normal Parathyroid glands should be discouraged.

WHERE TO FIND THE


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WHERE TO FIND THE

INFERIOR PARATHYROID GLANDS ?

The inferior parathyroid glands and thymus develops from

the third branchial pouch.

The most common position of the inferior parathyroid gland

is anteroinferior to the junction of the Inferior thyroid

artery and the recurrent laryngeal nerve

WHERE TO FIND THE


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WHERE TO FIND THE

SUPERIOR PARATHYROID GLANDS ?

The superior parathyroid glands develops from the fourth

branchial pouch.

Most common location of the superior gland is just superoposterior

to the junction of the inferior thyroid artery and the recurrent

laryngeal nerve at the level of cricoid cartilage.

The superior parathyroid is frequently found in thetracheoesophageal groove posteriorly and may descend along

the esophagus into the posterior mediastinum

TROUBLE SHOOTING FOR MISSING


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PARATHYROID GLANDS

Right lower parathyroid gland cannot be localized:

The thymus on the side should be

exposed.

The retrosternal part of the thymus is

mobilised

Consider possibility of intrathyroidal parathyroid



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PARATHYROID GLANDS

Right upper parathyroid gland cannot be localized.:

Space dorsal to the thyroid gland and theesophagotracheal groove should be

explored.

Space between the esophagus and thevertebrae should be opened.



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PARATHYROID GLANDS

Four normal parathyroids have been visualised.

Increased levels of parathyroid harmone:

Rule out another cause of hypercalcemia.Can be due to tumor orginating from a

supernumerary parathyroid gland located

in the thymus.

Resection of the left and right thymus

is indicated.

R BLE H NG F R NG


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PARATHYROID GLANDS

Left lower parathyroid gland is missing:

At the level of the superior thyroid arteryand anterior to the carotid bulb,an enlarged

parathyroid gland with a thymic remnant is

encountered.

A maldescended fourth pharyngeal pouch

is likely,resulting in a cranial position of the

upper Parathyroid gland.

SURGERIES FOR PARATHYROID


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SURGERIES FOR PARATHYROID

OPEN ENDOSCOPIC

[email protected]


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Identify which patients have only one abnormalparathyroid BEFORE the

operation, not during it!

Know with a very high degree of accuracy WHEREthe tumor is located

BEFORE the operation so you don't have to dissectall of the neck structures

trying to find it.

UN L TER L VER U B L TER L PPRO CH


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UNILATERAL VERSUS BILATERAL APPROACH

UNILATERAL APPROACH:

Post operative hypocalcemia will be reduced.

Early ambulation can be achieved - reducing the total cost

for the surgery.

Non explored side the parathyroid glands are ready to start

functioning immeditely after the removal of the adenoma

The mere exploration of the contralateral side without

removing any parathyroid tissue will increase post operative

hypocalcemia.


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Carries low risk of nerve complication

Reduced time of surgery

For patients with severe respiratory or cardiovascular

disease and an increased surgical risk,Unilateral exploration

under local anasthesia is a useful method of treatment.

DISADVANTAGES:

Missing of Supernumerary glands and Double adenomas.

ll


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Follow up:

In patients with parathyroid hyperplasia

annual serum calcium determination

In patients with adenoma

every 5th year serum calcium determination

Measurement of other biochemical parameters -unnecessary if Preoperative renal function

is normal.


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1. Symptoms of parathyroid disease do NOT correlate with thelevel of calcium in the blood.

2. Fluctuating levels of calcium are typical of parathyroiddisease.

3. All patients with hyperparathyroidism will developosteoporosis.

4. As a rule Parathyroid disease will worse with passage of time

5. There is only one treatment for parathyroid disease(hyperparathyroidism): Surgery

6. Nearly all parathyroid patients can be curedwith aminimaloperation.

7. The success rate and complication rate for parathyroidsurgery is VERY dependent upon the surgeons experience.


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THANK YOU

prof ndr - parathyroid

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