Perioperative management - Heterotopic parathyroid autotransplantation in total parathyroidectomy

  1. Indications

    Secondary (renal) hyperthyroidism

    • In non-drug related hypercalcemia after all medicinal treatment options (phosphate binders, calcimimetics, active vitamin D3 analogs) have been exhausted
    • In severe renal osteopathy (confirmed by radiology and/or histology)
    • In atherosclerosis and other soft tissue calcifications, severe hyperphosphatemia, calciphylaxis (calcific uremic arteriolopathy), and pruritus after all medicinal treatment options have been exhausted while parathyroid hormone levels are elevated (>800 pg/mL)

    Tertiary hyperparathyroidism in autonomous hypercalcemic (>3.0 mmol/L) renal HPT after kidney transplant

    Multi-glandular disease in MEN-1 and MEN-2 (familial syndrome with formation of active endocrine tumors) → disorder of the entire organ system, i.e., of all parathyroids

    MEN-1 → subtotal parathyroidectomy (3 1/2) parathyroids with thymectomy or total parathyroidectomy with thymectomy and autotransplantation, in resection of individual tumors high probability of persistence/recurrence, prophylaxis of thymic neuroendocrine tumors (carcinoid)

    MEN-2 → resection of just the enlarged parathyroids

  2. Contraindications

    • Presence of adynamic bone disease and renal HPT
  3. Preoperative diagnostic work-up

    • Lab study of parathyroid hormone
    • Additional lab studies (serum calcium, phosphate, alkaline phosphatase (possibly bone specific), creatinine, urea, albumin/total protein; optionally T3, T4, TSH
    • Ruling out neoplasia (thyroid neoplasia and multiple endocrine neoplasia)
    • Bone histology (optional)
    • Laryngoscopy (vocal cord function)
    • Location work-up
    • Ultrasonography, MIBI-SPECT, (CT, MRI, PTH selective venous sampling)
  4. Special preparation

    • Intraoperative peripheral venous PTH study (IOPTH) →PTH level as “pre-incision” baseline.
    • Pre- and postoperative laryngoscopy
    • Neuromonitoring with vagus stimulation pre- and post-resection
    • Standardized intraoperative neuromonitoring (ION)
    • Verifiable documentation of the stimulated EMG of the ipsilateral vagus nerve before and after resection (for medicolegal reasons)
  5. Informed consent

    • Usual risk in surgical procedures (bleeding, infection, secondary wound healing, revision surgery)
    • Undetectable adenoma(s) and revision surgery
    • In case of signal loss resection of contralateral postponed to some later time
    • Persistent hyperparathyroidism
    • Postoperative hyperparathyroidism
    • Recurrent laryngeal nerve paralysis, if bilateral possibly tracheotomy
    • Parathyroid autotransplantation into muscles of the neck or forearm
    • Exploration of the thyroid, with possible excision in case of abnormalities
    • Pneumothorax
    • Possibly postoperative calcium supplementation
    • Recurrence

General anesthesia Administration of short-acting muscle relaxants only during anesthesia induction

Activate now and continue learning straight away.

Single Access

Activation of this course for 3 days.

€4.99 inclusive VAT

Most popular offer

webop - Savings Flex

Combine our learning modules flexibly and save up to 50%.

from €3.29 / module

€39.50 / yearly payment

price overview

general and visceral surgery

Unlock all courses in this module.

€9.08 / month

€109.00 / yearly payment