About Parathyroid

About Parathyroid Glands

PARATHYROIDS

Anatomy

Parathyroids are small endocrine glands located in the neck. Although they are very close to the thyroid gland, their functions are completely different. There are normally four parathyroid glands though some people could have fewer or more than that number. Parathyroids are the size of the grain of rice each and are usually situated behind the thyroid at the base of the neck. Sometimes they could be located in unusual places, such inside the chest, and they are called ectopic glands.

Physiology

Parathyroid glands produce and secrete parathyroid hormone (PTH), which controls the level of calcium in the blood by releasing calcium from the bones and increasing its absorption from guts

The control of blood calcium levels is important for the proper functioning of the brain, muscles, nervous tissue and the maintenance of healthy bones. 

In patients with parathyroid disease this mechanism is altered and too much or too little PTH is secreted. Too much PTH leads to high concentration of calcium in the blood, depletion of calcium from the bones and kidney stones. Too little or no PTH at all will cause low calcium in the blood

Intraoperative PTH Monitoring

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In some patients with kidney disease a complex sequence of events can cause the parathyroid glands to become overactive and produce too much hormone.  This leads to an excess of calcium in the blood, most of which is drawn from the bones which are thereby damaged.  Some of this excess calcium may be deposited in other structures such as blood vessel walls where it may cause damage.  This sequence of events is known as renal or tertiary hyperparathyroidism (RHPT).  RHPT may persist even when the original damage to the kidney has been corrected by dialysis or by transplantation.

Hyperparathyroidism is an insidious disease which can exist for many years before it is diagnosed. In fact, many patients have this condition diagnosed on routine blood tests during which high calcium levels are found before they develop any specific symptoms.

Untreated hyperparathyroidism will over time weaken the bones by depriving them of calcium and cause osteoporosis. In extreme cases long bones or vertebra might even fracture. High levels of calcium in the blood can also cause kidney stones.

The symptoms however can be also very non specific such as abdominal pain, constipation, tiredness, lack of energy, depression or pains in the muscles, bones and joints. There is also some evidence that patients with hyperparathyroidism have an increased risk of heart disease and possibly cancer.

In the past hyperparathyroidism was considered a rare condition as it was diagnosed only in patients with devastating complications such as kidney stones or severe osteoporosis resulting in bone fractures.

Nowadays we know it is a surprisingly common condition which affects 1% of general population and 3% of postmenopausal women. It is extremely rare in children. Women are 3 to 4 times more likely to develop this problem than men. In USA 100.000 patients are diagnosed with hyperparathyroidism each year.

Diagnosis of hyperparathyroidism is based on blood test which show high calcium and inappropriately elevated parathormone (PTH) levels. It is often necessary to check renal function tests and vitamin D3 levels in blood or measure calcium in the urine

Rarely but quite importantly genetic test is needed to detect mutations predisposing to hyperparathyroidism and some other endocrine problems

It is important to know before surgery how many of the parathyroid glands are enlarged and what is their exact position in the neck. Abnormal and enlarged parathyroid gland can be identified before operation with a neck ultrasound which can give us this information in about 70 – 80% of patients. Often it is necessary to perform a nuclear scan called Sestamibi which is positive in about 70% of patients. If these two investigations agree as to the location of abnormal gland, minimally invasive or keyhole surgery should be considered. If both of these scans are negative other investigations such as angiography, CT or MRI scan are necessary, mostly in rare and complex situations such as re-operation.

Negative scans are not the reason to abandon surgery if it is indicated. In this scenario keyhole surgery cannot be performed and neck exploration through slightly larger incision with visual identification of all parathyroid glands is necessary.

In the past, surgeons rarely knew before surgery, which one of the four glands was abnormal and exploration of all parathyroid glands through a long neck incision was a standard treatment. Recent improvements in the quality of pre-operative imaging (ultrasound, Sestamibi) allows us to know before operation, which gland is enlarged and should be removed.

With this knowledge, current parathyroid operations are performed through much smaller incisions which are known as minimally invasive or ‘keyhole’ procedures. During the operation the surgeon finds and removes the abnormal parathyroid glands without disturbing normal glands. Most of the time only one gland is removed but sometimes two, three and occasionally all four glands need to be removed to cure hyperparathyroidism.

Biological half-life of circulating parathormone (PTH) is only 5 minutes and this allows surgeon to measure its changing concentrations very quickly. Patients with hyperparathyroidism have high levels of PTH at the beginning of operation and removal of abnormal parathyroid will cause 50% reduction of PTH concentration within 5 minutes indicating biochemical cure. If PTH concentration remains high, there is a need to perform neck exploration and look for another abnormal parathyroid gland. This technique is called Intraoperative PTH Monitoring (IOPTH)

We have introduced this stunning technology to our practice 15 years ago and since operated on over a thousand patients with hyperparathyroidism. We have cured 98% of them with first operation, a truly “world class” result.

Minimally invasive parathyroidectomy (MIP) produces better scars, less pain and quicker recovery, but only 70 – 80% of patients with hyperparathyroidism can have their surgery done that way.

Bests candidates for MIP are patients with single solitary abnormal gland detected by both ultrasound and Sestamibi nuclear scan.

In 10- 30% of patients’ scans are not helpful in localising the abnormal gland or they might have a disease which involve all four glands. These patients should have all glands looked at the operation with abnormal ones removed. During this procedure surgeon identifies, inspects and possibly takes samples from all parathyroid glands. This could be difficult as sometimes abnormal glands may not be found at the time of the first operation because the gland may be very small, hidden inside thyroid or in abnormal location (ie chest) This happens very rarely but if that is the case you may need more test followed by an operation at another time to remove it. 

Parathyroidectomy for hyperparathyroidism is a very successful operation and we have operated on more than 1000 patients achieving cure in 98% of them! Normal levels of calcium and parathormone levels in the blood after the operation indicate that cure has been achieved. Blood tests need to be performed after surgery. Sometime parathormone levels after surgery remain marginally elevated despite normal calcium, a situation known as “smouldering PTH”. This is often only temporary and can be caused by low vitamin D levels. In this situation vitamin D supplementation is needed.

Most patients who had only one or two parathyroid glands removed do not need any medication apart from pain killers. Patients who had all four glands removed will need to take oral calcium and highly active form of Vitamin D (alfacalcidol) for the rest of their life.

Sometimes patients with very high calcium before operation or patients who had three glands removed can develop low calcium after successful parathyroidectomy. This is because remaining glands have become lazy or underactive. They usually will recover their normal function within days but you may require calcium and vitamin D tablets temporarily after the operation to boost the level of calcium in the body. 

There is good clinical evidence that curing hyperparathyroidism by performing parathyroidectomy improves neuropsychiatric symptoms, increases bone density mass and prevents recurrence of kidney stones. It is likely that it can also improve cardiovascular health and reduce mortality but good clinical evidence to support this are not yet available.

Ultrafast Hormones LTD 

Endocrine Surgery with Global Reach

Ultra Fast Hormones Ltd.

Company registered in England No 08395526

Phone:  +44 (0)20 7486 1164

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