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PARATHYROIDECTOMY

Why is a Parathyroidectomy performed ?

The four parathyroids are small hormone-producing glands in the neck which control calcium levels in the body. They are usually located on the back of the thyroid. Normal parathyroid glands are each the size of a split pea. Parathyroid enlargement can affect just one gland or all the glands simultaneously. Parathyroidectomy is performed to remove one or more enlarged parathyroid glands from the neck. This enlargement causes an increased level of calcium in the blood (hyperparathyroidism). Many patients with a raised blood-calcium level have mild symptoms of chronic ill health, constipation, lethargy and muscle weakness. In more serious cases of hyperparathyroidism, the excessive production of the parathyroid hormone from the enlarged parathyroid gland or glands causes excess calcium in the urine. This can result in kidney stones (renal calculi). Breakdown of calcium occurs from the bones and may result in thin, brittle bones and even fractures. Too much calcium in the blood may cause inflammation of the pancreas, stomach ulcers, mental confusion and even coma. Parathyroid gland enlargement and overactivity can occur apparently without reason and sometimes is found in patients with long-standing kidney failure.

Preparations needed for a Parathyroidectomy

In patients with mildly raised blood calcium, little preparation is necessary apart from drinking plenty of fluids. In more severe cases, the doctor may wish to reduce the blood calcium to make surgery safe. You would then be given fluids through a drip into a vein to reduce the calcium level in the blood, once you have been admitted for operation. The surgeon may request special scans prior to the operation, to see exactly where the enlarged parathyroid gland is located. However, these scans are not 100% accurate, and it is not uncommon for the scans to fail to identify an enlarged gland. Nevertheless, it may still be found quite easily at the time of operation.

What Happens during a Parathyroidectomy

Under general anaesthesia, a small 4 cm cut is made in the front of the neck. The surgeon looks for the four parathyroid glands. They have a tendency to take up a dye called methylene blue, and some surgeons inject this into the veins before the operation to make the parathyroid glands easier to see. Once all four glands have been found, the surgeon assesses their size and then removes any enlarged ones. This usually means only one gland has to be removed, but the surgeon will also take a small piece of a normal gland so that the pathologist in the operating theatre can confirm immediately that it is normal. The surgeon then has to decide whether to remove all four of your glands or to remove three whole glands but leave a small part of the fourth in the neck. By doing this, there is a chance that the amount left behind will keep the blood-calcium level normal. Some surgeons remove all four glands if they are enlarged. You will later be given vitamin D and calcium supplements by mouth to prevent the calcium level from dropping too low. The straightforward parathyroid operation takes about 40 minutes to perform. However, in difficult cases, and when the glands are hard to find, it can take much longer. At the end of the operation a small drain tube is placed in the neck and fine stitches or metal clips are used to close the wound.

Possible Complications during a Parathyroidectomy

In a very small number of patients, it is impossible to find one or more of the enlarged glands, and as a result, the blood-calcium level remains high. This means that special tests to find the elusive parathyroid gland must be made. One of the nerves which controls the voice box is occasionally damaged, producing temporary, or even permanent hoarseness. However, it is quite common for the blood-calcium level to drop below the normal range 2 to 4 days after the operation. You may have a vitamin D compound prescribed for you before the operation to reduce this risk. A low blood-calcium may cause tingling around the mouth and in the hands, or even spasm of the hands. All these symptoms can be easily reversed by an injection of calcium. If you had severe bone involvement, it may take a while for the blood-calcium level to return to normal. On rare occasions you may need to have a drip for a few days or even longer. The bones will eventually heal and the blood-calcium level will return to normal.

After a Parathyroidectomy

Following the operation, you will be sitting up in bed and eating normally within 24 hours. There will be a drain tube in the neck. Blood transfusion is rarely needed, and within 24 hours patients are usually up and about, with drip and drain removed. After 4 to 5 days the stitches will be removed and the patient discharged. Patients who had only one gland removed will usually need no medication whatsoever. Those patients who have had four glands removed will need to take vitamin D and calcium by mouth on a regular basis. They should have regular checks of their blood-calcium levels to ensure the doses of these supplements are correct. The average patient will be able to return to work after 2 to 3 weeks, feeling fit and well.

If a Parathyroidectomy is not performed

For patients with mild hyperparathyroidism, any delay in surgery would not be dangerous. However, a close eye is always kept on the blood-calcium levels. Patients with severe bone disease, kidney stones or abdominal pain who delay surgery will cause their symptoms to become progressively worse. Patients with severe bone disease who do not have surgery may develop broken bones. If the calcium level is initially quite high, delay in treatment can prove dangerous. A sudden further rise in this level can be brought about by dehydration (for example hot weather or a stomach upset), especially in elderly patients. This rise in blood-calcium causes clouding of consciousness and eventually coma.

Effects on Family of Parathyroidectomy

Friends and relatives may notice quite a striking improvement in alertness following successful surgery.