Perioperative management - Heterotopic parathyroid autotransplantation in total parathyroidectomy

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

• Presence of adynamic bone disease and renal HPT

• 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)

• 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)

• 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 but not during ION

• Supine, with head reclined (as in thyroidectomy)
• Both arms adducted
• After completion of the procedure at the neck, skin prep and drape the arm to be used for heterotopic parathyroid autotransplantation.

Unilateral findings: Surgeon on contralateral side to be operated on; bilateral findings: After completion of one side, change to other side. First assistant facing the surgeon, second assistant cranial to first assistant, and scrub nurse ipsilateral with surgeon at hip-level of patient.

• Thyroidectomy set
• Titanium clips
• Bipolar electrosurgery system, e.g. LigaSure® dissection forceps
• Neuromonitoring equipment plus vessel loops for the vagus nerve
• Redon drain Ch 8
• recommended: Surgical telescopes for surgeon

Postoperative analgesia: Nonsteroidal anti-inflammatory drugs usually suffice; if necessary, they can be enhanced by opioid analgesics.

Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management).

This link will take you to the International Guideline Library.

Postoperative care: Remove Redon drain on postoperative day 1; serum calcium follow-ups, manage any hypocalcemia, laryngoscopy before discharge.

Deep venous thrombosis prophylaxis: Unless contraindicated, the moderate risk of thromboembolism (surgical operating time > 30 min) calls for prophylactic physical measures and low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation is reached.

Note: Renal function, HIT II (history, platelet check)

This link will take you to the International Guideline Library.

Ambulation: Unrestricted

Physical therapy: None

Diet: Unrestricted

Bowel movement: Laxatives may have to be started on postoperative day 2

Work disability: 2-3 weeks