Introduction:
Excessive parathyroid hormone (PTH) secretion from one or more parathyroid glands causes primary hyperparathyroidism (PHPT), which raises serum calcium levels and causes various systemic symptoms. The only effective treatment for symptomatic PHPT is surgery, which aims to remove the hyperfunctioning parathyroid gland or glands and restore calcium balance. Surgical methods for parathyroid gland transplantation have changed considerably over time, owing to developments in medical imaging, surgical methods, and anatomy knowledge.
This article reviews the surgical techniques frequently used to treat PHPT, emphasizing their benefits, indications, and results. For a long time, the best surgical alternatives for parathyroidectomy were traditional procedures like bilateral neck exploration (BNE). However, a paradigm shift towards less invasive operations has occurred with the introduction of minimally invasive parathyroidectomy (MIP) techniques, which offer shorter operating durations, smaller incisions, and quicker recovery.
Moreover, technological advancements such as intraoperative parathyroid hormone monitoring (IOPTH) have transformed the intraoperative evaluation of surgical success, allowing surgeons to verify the sufficiency of parathyroid gland excision in real time. Clinicians who treat patients with PHPT must be aware of the subtle differences between various surgical techniques to customize treatment plans that maximize results while reducing surgical morbidity.
What Is Primary Hyperparathyroidism?
Excessive parathyroid hormone (PTH) release from one or more parathyroid glands is the hallmark of primary hyperparathyroidism (PHPT). These tiny endocrine glands, usually four in number, are found in the neck behind the thyroid gland.
PTH is essential for controlling blood calcium levels. Hypercalcemia, a condition marked by high blood calcium levels, is caused by the overproduction of PTH in PHPT. This happens due to increased calcium release from bones, improved intestinal absorption of calcium, and reduced renal excretion.
The most frequent cause of PHPT is the formation of a benign tumor within one of the parathyroid glands, known as a parathyroid adenoma. PHPT is less commonly caused by parathyroid carcinoma (cancer) or hyperplasia (enlargement) of numerous parathyroid glands.
Numerous symptoms, such as weakness, exhaustion, kidney stones, bone pain, gastrointestinal issues, and mental abnormalities, can result from PHPT. Some PHPT sufferers, however, may not exhibit any symptoms, and their condition may only be discovered by chance when regular blood testing reveals high calcium levels.
The main treatment for symptomatic PHPT is surgical excision of the hyperfunctioning parathyroid gland(s) to restore normal calcium levels and avoid consequences like kidney stones, osteoporosis, and other organ damage.
What Are the Surgical Approaches to Manage Primary Hyperparathyroidism?
The removal of the hyperfunctioning parathyroid gland(s) that cause an excessive amount of parathyroid hormone (PTH) to be secreted is the surgical management of primary hyperparathyroidism (PHPT). Various surgical techniques are used, each with specific indications, benefits, and possible downsides. These methods consist of:
Bilateral Neck Exploration (BNE):
Bilateral neck exploration (BNE) is the conventional method of performing a parathyroidectomy. Its purpose is to locate and remove any aberrant parathyroid gland(s) by exploring both sides of the neck.
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Indications: BNE is usually advised when multiglandular disease is suspected or when preoperative imaging investigations cannot identify the hyperfunctioning gland(s).
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Benefits: BNE makes it possible to thoroughly examine each parathyroid gland, guaranteeing that all diseased tissue is removed.
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Cons: Compared to minimally invasive procedures, this method may require a wider incision and longer operating periods.
Minimally Invasive Parathyroidectomy (MIP):
MIP entails the precise extraction of the hyperfunctioning parathyroid gland or glands with a smaller incision and minimally invasive methods.
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Indications: Patients with a single, localized adenoma found on preoperative imaging examinations can benefit from MIP.
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Benefits: Compared to BNE, MIP offers quicker recovery times, fewer incisions, less pain following surgery, and shorter operating times.
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Cons: If other abnormal glands are found, there is a chance that they won't be found, which could result in chronic or recurrent hyperparathyroidism.
Radioguided Parathyroidectomy (RGP):
RGP locates and guides the removal of hyperfunctioning parathyroid glands using radiotracer-guided localization techniques, such as technetium-99m sestamibi scintigraphy.
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Indications: Patients with suspected ectopic or deeply placed parathyroid adenomas, as well as those with negative or inconclusive preoperative imaging examinations, benefit from RGP.
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Benefits: RGP improves surgical results by increasing the accuracy of parathyroid gland localization, especially in cases of ectopic glands.
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Cons: Interpreting radiotracer imaging has a learning curve, and false-positive or false-negative results can happen.
Video-Assisted Parathyroidectomy (VAP):
VAP allows for a tiny incision parathyroidectomy by combining minimally invasive procedures with endoscopic vision.
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Indications: Patients with isolated parathyroid adenomas who respond well to minimally invasive surgery should consider VAP.
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Benefits: VAP reduces tissue damage and improves operative field visibility, enabling accurate dissection of the parathyroid glands.
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Cons: Only some institutions may have access to this method, and it requires certain training and equipment.
Robotic-Assisted Parathyroidectomy (RAP):
RAP performs precise, minimally invasive parathyroidectomies with enhanced visualization and dexterity thanks to robotic technology.
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Indications: RAP is recommended for patients who are candidates for minimally invasive surgery and have one or more parathyroid adenomas.
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Benefits: Compared to traditional laparoscopic procedures, RAP provides better three-dimensional visibility, enhanced instrument dexterity, and less surgeon fatigue.
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Cons: Compared to other minimally invasive procedures, RAP is more expensive, needs specialized equipment, and requires longer operating durations.
Conclusion:
In summary, achieving the best possible outcomes for individuals with primary hyperparathyroidism (PHPT) requires a sophisticated understanding of surgical techniques. This article emphasizes how advances in surgical procedures, such as minimally invasive parathyroidectomy (MIP) from standard bilateral neck exploration (BNE), demonstrate a dedication to enhancing patient care via accuracy and innovation.
Although BNE is still an option in some circumstances, MIP is a desirable alternative for patients who are a good fit because of its unique benefits, which include shorter recovery times, smaller incisions, and shorter operating times. The inclusion of intraoperative parathyroid hormone monitoring (IOPTH) further improves surgical success rates, offering real-time feedback to guarantee the completeness of parathyroid gland excision.
The future of PHPT management will surely be shaped by ongoing research into innovative surgical procedures, developments in imaging modalities, and the improvement of intraoperative techniques. Clinicians can further improve outcomes and the quality of life for individuals affected by this endocrine condition by keeping up with these discoveries and customizing treatment techniques to meet the needs of individual patients. Delivering complete care for patients with PHPT requires a multidisciplinary strategy that includes coordination between endocrinologists, surgeons, radiologists, and allied healthcare providers.
