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PROF.N.

DORAIRAJAN
MS,FRCS(EDIN),FICS,FACS,FICA
PROFESSOR AND HEAD OF THE DEPARTMENT DEPARTMENT OF GENERAL SURGERY MADRAS MEDICAL COLLEGE & GOVT GENERAL HOSPITAL CHENNAI

ENDOCRINE SURGEON APOLLO HOSPITALS, CHENNAI PRESIDENT (2009-10) INTERNATIONAL COLLEGE OF SURGEONS INDIAN SECTION Asian federation secretary INTERNATIONAL COLLEGE OF SURGEONS INTERNATIONAL SECTION EDITORIAL BOARD MEMBER INTERNATIONAL SURGERY CHAIRMAN ASI - TAMILNADU PONDICHERRY CHAPTER

GROANS,MOANS

56/M C/o general body aches and pain over joints 1 month H/o heartburns 2 months H/o nausea - 2 months H/o anorexia - 2 months No h/o hematemesis / melena No h/o vomiting No h/o constipation No h/o altered bladder habits No loss of weight and appetite

Known diabetic Underwent PTCA Hypertension

1 year - 2006 - 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

General examination clinically normal PR- 82/mt BP 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

INVESTIGATIONS

Blood sugar 134 mg/dl blood urea 56 mg/dl Serum creatinine 2.6 mg/dl Serum sodium 142 meq/dl Serum potassium 4.9meq/dl Serum calcium 17.8 g/dl Serum phosphrous 2.3 mg/dl Serum magnesium 1.4 mg/dl Uric acid 10.8 g

Intact paratharmone 2140 pg /ml Serum alkaline phosphatase 773 IU/dl Renal doppler normal (left renal cortical cyst) Serum protein electrophorosis normal

Hypercalcemia unresponse to forced diuresis

Dialysis against a zero calcium bath.

Dialysis against a zero calcium bath.

Dialysis against a zero calcium bath.

HYPERCALCEMIA PERSIST

ENDOCRINOLOGIST OPINION

ENDOCRINOLOGIST OPINION: Advised : Skeletal survey USG neck MIBI Parathyroid scan

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USG neck

A cystic nodule measuring 1.3cm seen in the left lobe


Two large nodules are seen close to the lower pole of thyroid on either side measuring about 4 cm on right and 3 cm on left nodules show cystic areas within. Impression: Large nodules with cystic changes close to the lower poles of thyroid glands suggestive of parathyroid lesions

99TC MIBI STATIC STUDY OF NECK / MEDIASTINUM

There is persistent tracer concentration noted in the mid and 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

DIAGNOSIS: PRIMARY HYPERPARATHYROIDISM ? HYPERPLASIA ? ADENOMA

PLAN: PARATHYROIDECTOMY STANDARD PARATHYROID SURGERY BILATERAL APPROACH

PER-OPERATIVE DETAILS: Right inferior parathyroid found enlarged Left superior parathyroid also found enlarged Left inferior parathyroid was enlarged with variable consistency Left thyroid had multiple nodules. Right superior parathyroid found normal Recurrent laryngeal nerve identified and preserved on both sides
PROCEDURE : Subtotal parathyroidectomy and left hemithyroidectomy Right inferior , left superior and inferior Parathyroidectomy done Left hemithyroidectomy done.

FROZEN SECTION:
Parathyroid adenoma

HPE REPORT:

Parathyroid : Parathyroid hyperplasia of all three parathyroids


Thyroid : Nodular hyperplasia and focal lymphocytic thyroiditis

POST OPERATIVE PERIOD:


Pre operative :

Serum calcium 17.8 g/dl Intact paratharmone 2140 pg /ml Sr.calcium Sr.Paratharmone

After 6 hrs 14.3 g/dl After 12 hrs After 24 hrs After 48 hrs 12.2 g/dl 11.4 g/dl

422 pg/ml

9.3 g/dl

223 pg/ml

POST OPERATIVE PERIOD:

uneventful

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


A successful parathyroidectomy results in a decrease in serum calcium level ,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

POST OPERATIVE PERIOD:

On 7 th POD: Blood sugar 134 mg/dl Blood urea 22 mg/dl Serum creatinine 1.1 mg/dl Serum Na+ - 141 meq/l Serum K+ - 4.5 meq /l Serum calcium 9.3 g/dl Serum phosphorus 3.3

BONES

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FRACTURE NECK OF FEMUR

THIN CORTEX

POOR TRABECULAR PATTERN

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


No h/o nausea or heartburn. No h/o loss of weight or appetite.

- 6 months

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.

General examination -shortening of left lowerlimb (<3 cm) inability to use the left lower limb Weight 40 kg PR 88 / mt BP 120/80 mmHg CVS S1 S2 +

RS NVBS
P/A Soft , clinically normal

CNS GCS 15/15 EXAMINATION OF NECK AND NECK NODe-CLINICALLY NORMAL

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

USG neck solitary right inferior parathyroid adenoma

THIN CORTEX

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

Tc 99m Sestamibi scan study shows an area of tracer retention corresponding to the region of right lower pole of thyroid gland

Scan finding concordant with USG findings of Parathyroid adenoma.

DIAGNOSIS : PRIMARY HYPERPARATHYROIDISM

RIGHT LOWER PARATHYROID ADENOMA

PLAN :

RIGHT LOWER PARATHYROIDECTOMY


MINIMAL INVASIVE PARATHYROID SURGERY UNILATERAL APPROACH

HEAD
INFERIOR POLE RT THYROID RT STERNOCLEDIOMASTOID

NECK RT PARATHYROID ADENOMA

CHEST

HEAD
INFERIOR POLE RT THYROID RT STERNOCLEDIOMASTOID

NECK

SPACE AFTER REMOVAL OF PARATHYROID ADENOMA

POST OPERATIVE PERIOD:

SERUM CALCIUM (g/dl)


SERUM PTH(pg/m l)

Pre Post operative operative (6 hrs) 13 .9 11.3

1277

16

POST OPERATIVE PERIOD:

uneventful

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

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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 6.2 RIGHT 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

STONES

28 / F referred from Urology department C/o pain left loin 3 months No h/o hematuria

H/o muscle and joint pain


H/o weakness on doing manual work No h/o nausea or heartburn.

- 6 months.
- 4 months.

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.

Past history of passing calculus during micturation 5yrs ago ESWL treatment for left renal calculus - 4 years ago

Not known DM / HT / PTB No h/o menstrual disturbances. No h/o similar complaints in her family.

General examination clinically normal PR- 82/mt BP 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

INVESTIGATIONS

Biochemical profile - Normal


X-Ray KUB multiple renal calculus both left and right side

USG ABDOMEN :

multiple left renal calculus

calculus measuring 6 x 5mm in right

pelvic ureteric junction


bladder normal

Serum Calcium 14.2 g/dl Serum Phosphorus 2 g/dl

Intact paratharmone - 945 pg/ml


Sketetal survery - normal

PARATHYROID SCAN

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

DIAGNOSIS:
PRIMARY HYPERPARATHYROIDISM

ADENOMA PLAN :
RIGHT LOWER PARATHYROIDECTOMY MINIMAL INVASIVE PARATHYROID SURGERY

UNILATERAL APPROACH

video

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POST OPERATIVE PERIOD:


Per operative serum calcium 14.2 g/dl
Peropaerative serum Paratharmone 945 pg/ml Sr. Calcium Sr .Paratharmone

After 6 hrs 11.5 g/dl After 24 hrs After 48 hrs 10.6 g/dl

180 pg/ml

9.3 g/dl

70 pg/ml

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POST OPERATIVE PERIOD:

uneventful

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

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PRIMARY HYPERPARATHYROIDISM

HYPERPLASIA HYPERPLASIA

ADENOMA

RENAL CALCULUS

RENAL FAILURE

PATHOLOGICAL FRACTURES

HOW HYPERPARATHYROIDISM PRESENTS ?


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 you will develop.

Copyright 1996-2008 Norman Endocrine Surgery Clinic

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

In patients who have Serum Calcium levels that are only slightly elevated, or they are elevated and the PTH levels are borderline high, THEN, the measurement of Ionized Calcium becomes important.
Remember It is NEVER normal to have a high calcium level.

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Diagnosis of PHPT is made by metabolic testing

Elevated serum calcium Elevated ionised calcium Elevated intact PTH Low or normal blood phosphorus Increased chloride phosphorus ratio ( > 33 ) Increased uric acid Elevated alkaline phosphatase Parathyroid 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
Ultrasound Endoscopic Ultrasound CT Scan

Sensitivity
71-80% 71% 46-80%

Specificity
80%

88-98%

MRI Scan Thallium-Technetium


Technetium-Sestamibi Scan

64-78%
75% 90.7% 80-94% 91-95% 70-80%

88-95%
73-82% 98.8%

Scan

PET Scan
Angiography & Venous Sampling
Venous SamplingAlone

96-98%

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

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 are inconclusive 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
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 th difficulty of surgical resection, often requiring microdissection technique to 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

PRIMARY HYPERPARARTHYROIDISM

SURGICAL MANAGEMENT

WHY ???
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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
Renal stones Osteitis fibrosa Hypertension Malaise , fatigue Abdominal pains Vague pains in extremities depression

LONG TERM IMPROVEMENT(%)


90 100 3 78 63 51 65

INDICATIONS FOR SURGERY IN PATIENTS WITH ASYMPTOMATIC PRIMARY HYPERPARATHYROIDISM

CONDITION
AGE
Young old

SURGERY
Always If additional indications

SERUM CALCIUM
>3.0 mmol 2.85 3.0 <2.85 Always Usually If additional indications

CALCIUM EXCRETION
> 10 mmol/24 h Usually

RENAL FUNCTION
impaired Usually

General principles for surgical exploration in Primary hyperparathyroidism Keep the surgical field bloodless , so as to prevent discoloring of Parathyroid glands.

Parathyroid Fat Lymphnodes

Light brown Yellow Grey

Cryopreserve parathyroid tissue for subtotal Parathyroidectomy 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


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 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 the


tracheoesophageal groove posteriorly and may descend along the esophagus into the posterior mediastinum

TROUBLE SHOOTING FOR MISSING 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

TROUBLE SHOOTING FOR MISSING PARATHYROID GLANDS

Right upper parathyroid gland cannot be localized.: Space dorsal to the thyroid gland and the esophagotracheal groove should be explored. Space between the esophagus and the vertebrae should be opened.

TROUBLE SHOOTING FOR MISSING 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.

TROUBLE SHOOTING FOR MISSING

PARATHYROID GLANDS

Left lower parathyroid gland is missing: At the level of the superior thyroid artery and 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

OPEN

ENDOSCOPIC

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Identify which patients have only one abnormal parathyroid BEFORE the operation, not during it!

Know with a very high degree of accuracy WHERE the tumor is located
BEFORE the operation so you don't have to dissect all of the neck structures trying to find it.

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.

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.

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.

1. Symptoms of parathyroid disease do NOT correlate with the level of calcium in the blood. 2. Fluctuating levels of calcium are typical of parathyroid disease. 3. All patients with hyperparathyroidism will develop osteoporosis. 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 cured with a minimal

operation.

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

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