![Page 1: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/1.jpg)
The 5-hour parathyroidectomy: How is this possible?
David J. Terris, M.D.
Department of Otolaryngology / Head & Neck Surgery
![Page 2: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/2.jpg)
• No dualities of interest
Disclosures
2009 2012 2013 2014 2016
• Royalties from endocrine books
![Page 3: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/3.jpg)
• Inexperienced surgeon (maybe shouldn’t undertake this operation?)
• Experienced surgeon who encounters series of unanticipated findings
2 ways to ponder this:
![Page 4: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/4.jpg)
• 10,000 hours to achieve mastery (baseball, violinist, surgeon)
Volume-outcome relationship
![Page 5: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/5.jpg)
Volume-outcome relationship
• 6100 surgeons – 14,323 operations
Saunders et al, Surgery, 2003
• 80% of operations by surgeons doing ≤3 per year
![Page 6: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/6.jpg)
• Learning curves/inflection points - still improving after 1200 cases
10,000 hours
• Outliers - Gladwell
• Saunders – low-volume PTH surgeons
• An operation more than any other where volume and cumulative experience matter
![Page 7: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/7.jpg)
5 most common pitfalls:
![Page 8: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/8.jpg)
1. Misdiagnosis
• Vitamin D deficiency (elevated PTH)
• FHH (rare); 24-hour calcium may be spuriously low
• Non-pth mediated hypercalcemia
It’s not surgical
• “Normal” PTH It is surgical
![Page 9: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/9.jpg)
• In presence of hypercalcemia, PTH should be zero (or close to it)
1. Misdiagnosis
• If PTH is not low, at least one of the 4 glands is “non-suppressed”
•The “normal” PTH level is not normal relative to the calcium
![Page 10: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/10.jpg)
1. Misdiagnosis
• Vitamin D deficiency (elevated PTH)
• FHH (rare); 24-hour calcium may be spuriously low
• Non-pth mediated hypercalcemia
It’s not surgical
• “Normal” PTH
• True normocalcemic hyperparathyroidism
It is surgical
![Page 11: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/11.jpg)
2. Imaging misinterpretations
15 minutes 2 hours
![Page 12: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/12.jpg)
Rapid washout
15 min 3 hr
Outside sestamibi negative
![Page 13: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/13.jpg)
15 min 2 hr
Sestamibi repeated at AU
![Page 14: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/14.jpg)
Left Inferior Parathyroid Adenoma
Read your own scans
![Page 15: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/15.jpg)
Nagar et al, Surgery, 2014
Read your own scans
![Page 16: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/16.jpg)
Volume-outcome relationship
• 5 = read as positive • 13 = study repeated at AU • All 13 patients (100%) localized
Among 18 outside negative scans
Singer et al, Laryngoscope, 2012
![Page 17: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/17.jpg)
Limitations of Sestamibi
False Positives
![Page 18: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/18.jpg)
Surgeon-performed ultrasound
![Page 19: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/19.jpg)
Ultrasound pearls • Turn the probe to demonstrate orientation of
the adenoma (distinguish from lymph node)
![Page 20: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/20.jpg)
Ultrasound pearls • Turn the probe to demonstrate orientation of
the adenoma (distinguish from lymph node) • Explore for pedicle with Doppler • If adenoma not seen on US, suspect deep
gland
![Page 21: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/21.jpg)
• Turn the probe to demonstrate orientation of the adenoma (distinguish from lymph node)
• Explore for pedicle with Doppler • If adenoma not seen on US, suspect deep
gland • Immediate preop US on the table
Ultrasound pearls
![Page 22: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/22.jpg)
• If the US report says “normal thyroid” except for “posterior hypoechoic thyroid nodule”
Interpreting reports
That’s the parathyroid adenoma
• If the US report says “normal thyroid” except for “posterior hypoechoic thyroid nodule”, and then an FNA is done showing follicular cells, favor follicular neoplasm
That’s STILL the parathyroid adenoma
![Page 23: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/23.jpg)
3. Overly descended superior gland
• Most common cause for needing reoperative surgery
• Etiology – planar imaging reveals “lower pole adenoma”, presumed to be inferior gland
![Page 24: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/24.jpg)
2 hours 15 minutes
3. Overly descended superior gland
![Page 25: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/25.jpg)
Beware of planar imaging
• Overly descended superior adenoma is most common reoperative surgery
• Etiology – planar imaging reveals “lower pole adenoma”, presumed to be inferior gland
• Dissection insufficiently deep; paraesophageal
![Page 26: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/26.jpg)
CT-Mibi
![Page 27: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/27.jpg)
• If inferior gland looks normal do not remove it
Overly-descended superior
Duke et al, Otolaryngol HNS, 2016
• Dissect dorsal to the RLN, expose the esophagus
![Page 28: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/28.jpg)
• Lateral incision (“inhibitory” to bilateral exploration)
• Remote access (eliminates bilateral)
• Insufficient opening (in proper location)
4. Inappropriate (inadequate) access
![Page 29: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/29.jpg)
• Bloodless, magnified dissection (color surgery) • LN (especially Hashimoto’s); thymus; thyroid nodules
(tubercle); muscle • Look for the fat • Low threshold to identify RLN • Monitoring: guard against bilateral paralysis • Use ballotment to reveal adenoma • Low threshold for taking the upper pedicle
(especially if superior gland is elusive) • Avoid removing normal parathyroid glands
5. Other technical issues
![Page 30: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/30.jpg)
• Do the math
What about the high-volume (high-experience) surgeon?
Turbo PTH
• Lab-based “rapid” iopth assay = 35 minutes
Future Diagnostics
; POC = 8 minutes
![Page 31: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/31.jpg)
• 15 minutes to find and remove
What about the high-volume (high-experience) surgeon?
Surgery start
Surgery termination
Excision
Pre-incision
level
Level I
5-min level
10-min level
15-min level
Level II
Level III
Level IV
Augusta Algorithm
![Page 32: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/32.jpg)
• 15 minutes to find and remove
• Won’t even know double adenoma for 38 minutes (1 hour 5 minutes)
What about the high-volume (high-experience) surgeon?
• An additional 38 (or 65) minutes for each additional abnormal gland (assuming 15 minutes to find each one
• What about 4-gland hyperplasia
![Page 33: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/33.jpg)
• Imaging co-localized to left superior; explored and 1.1 gm left superior adenoma removed
Case 1: 59 y.o. primary HPT
![Page 34: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/34.jpg)
59 y.o. primary HPT
![Page 35: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/35.jpg)
59 y.o. primary HPT
![Page 36: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/36.jpg)
• Straightforward double adenoma
Case 1:
• With POC pth, still took 1½ hours . . . (with the Turbo pth – 2½ hours)
![Page 37: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/37.jpg)
• C.N. – 66 y.o. male with calcium 11.4, pth 147; kidney stones
Case 2:
• Imaging: solitary parathyroid adenoma inferior lateral to the inferior margin lower pole left thyroid lobe in the same coronal plane
![Page 38: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/38.jpg)
• Intraoperatively: 4 normal eutopic glands identified
Case 2:
Now what??
![Page 39: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/39.jpg)
Physiologic adjuncts
• Bilateral jugular venous PTH levels exploring for differential to lateralize
Carneiro-Pla, AAES 2009 Preoperatively (10% difference)
“poor man’s” selective venous sampling
Ito F and Chen H, Ann Surg 2007 Intraoperatively – Chen (5% difference)
![Page 40: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/40.jpg)
• Bilateral IJ: right = 160.1; left = 174.9
Case 2:
• Further exploration on left; thyroid lobe removed, thymus removed, esophagus skeletonized, submandibular triangle explored
![Page 41: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/41.jpg)
• Just prior to raising the white flag, carotid sheath opened (further):
Case 2:
C V IJ
![Page 42: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/42.jpg)
Case 2:
• 2 hours, 50 minutes (with Turbo pth, >5 hours)
![Page 43: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/43.jpg)
• Doing an operation fast does not necessarily correlate with success (as a well-known colleague discovered)
A need for speed
![Page 44: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/44.jpg)
• 6% recurrence rate • Now 4-gland exploration (and biopsy) in 97% • Still call it a MIRP
MIRP is “retired”
Norman et al, JACS, 2012
![Page 45: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/45.jpg)
Reason for 6% recurrence rate
• Reliance on flawed logic of a“20% rule” • Stubborn arrogance in refusing to to
utilize intraoperative assay (at least in the OR)
• Obsession with doing operation fast • Puts both nerves and all 4 glands at risk
resulting in unnecessary disasters
![Page 46: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/46.jpg)
MI Parathyroidectomy
• Local anesthesia • Endoscopic • Mini-incision • Remote access • Radioguided
Many definitions have been proposed:
![Page 47: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/47.jpg)
• ***Single-gland surgery*** • Image-guided • Confirmation of cure (PTH) • Outpatient • ½ to ¾ inch incision • Endoscopically-assisted
Critical elements MI Parathyroidectomy
![Page 48: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/48.jpg)
• In up to 40% of patients who undergo curative parathyroidectomy, PTH remains elevated for up to 12 months after surgery
• Vitamin D deficiency; renal dysfunction; normal glands finding new “set-point”
Persistent Eucalcemic HPT
![Page 49: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/49.jpg)
Persistently elevated pth • 314 parathyroidectomies, 187 pHPT and
single gland disease, 119 met criteria
• 25.2% with eucalcemic HPT
Duke, Terris et al, Laryngoscope, 20126
![Page 50: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/50.jpg)
• “for the missing superior gland look inferior to the inferior gland; for the missing inferior gland, look superior to the superior gland”
Jon van Heerden
![Page 51: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/51.jpg)
• Find the fat • Pass nothing off • Let the ioPTH tell its story • Biopsy as needed (and
especially if failing) • Mediastinal usually thymic
Final surgical thoughts
a
b
c
d e
• Know the common hiding places
![Page 52: The 5-hour parathyroidectomy: How is this possible?€¦ · 2013 . 2014 . 2016 •Royalties from ... FHH (rare); 24-hour calcium may be spuriously low • Non-pth mediated hypercalcemia](https://reader036.vdocuments.us/reader036/viewer/2022081402/6050bab4b92ae533263fefeb/html5/thumbnails/52.jpg)
Conclusions
• Normal pth glands preserved • Recurrent laryngeal nerves are preserved • And especially if the adenoma was removed • It happens rarely
5-hour parathyroidectomy ok, as long as . . .