Michael M. Krausz, Itamar Ashkenazi, Miri Bidder, and Rikardo Alfici

Division of Surgery, Hillel Yaffe Medical Center and the Technion- Israel Institute of Technology

Surgery of the neck and particularly of the thyroid gland are the most important cause of

hypoparathyroidism and hypocalcemia. Temporary hypocalcemia was described in

5% to 35% following total thyroidectomy Permanent hypocalcemia developed in

0.5% to 4.4% In Re-operative Surgery this incidence

increased to 5% to 10%

Edafe et al. Systematic review and meta-analysis of predictors of post thyroidectomy hypocalcemia.

Brit J Surg 2014; 101: 307-320

Parathyroid Gland

The treatment of permanent hypoparathyroidism is limited because

there is no available hormonal replacement by PTH.

Replacement therapy by Calcium and vitamin D (Alfa D3) does not restore the

autoregulation of blood calcium.

Parathyroid Autotransplantation (PTAT) was first described by F.H. Lahey in 1926.

Immediate Autotransplantation Is usually used to prevent hypocalcemia

when towards the end of the surgical procedure a devascularized parathyroid gland is noted and immediately transplanted in the sternomastoid muscle.

Testini M, et al. The impact of single parathyroid gland autotransplantation during surgery on postoperative hypocalcemia: a multicenter study. Transplant Proc 2007; 39: 225-230.

Delayed Autotransplantation The parathyroid gland is preserved

(cryopreservation) for future transplantation in the arm muscles for treatment of postoperative hypoparathyroidism

Cryopreservationı71% vs 1% viability for tissue cryopreserved 0ver 24 months.(Guerrero et al. World J Surg 2008; 32: 836-839) Cryopresevation of parathyroid tissue should be limited to a maximum of 24 months. Transplantation of extra tissue may result in higher rates of autograft function. Cryopreservation( in RPMI- 1640 and dimethyl sulfoxide) has less success rate than immediate autotransplantation. Immediate transplantation is successful in 85% to 99% Delayed transplantation within 2 years is successful in 71%

Autotransplantation of the parathyroid glandı

hyperparathyroidismı

Indications for PTAT 1. Radical head and neck surgery 2. Bilateral total thyroidectomy 3. Huge nodular goiter 4. Recurrent or persistent hyperparathyroidism 5. Primary parathyroid hyperplasia 6. Secondary hyperparathyroidism 7. Completion thyroidectomy

There is an ongoing argument in the recent literature weather the use of preventive routine PTAT actually reduces the risk of permanent hypoparathyroidism.

Routine use of PTAT increases the risk of temporary hypocalcemia, but does not reduce the risk of permanent hypoparathyroidism. Testini M, et al. The impact of single parathyroid gland autotransplantation during surgery on postoperative hypocalcemia: a multicenter study. Transplant Proc 2007; 39: 225-230. Ahmed N, Aurangzeb M, Muslim M, Zarin M. Routine parathyroid autotransplantation during total thyroidectomy: a procedure with predictable outcome J Pac Med Assoc 2013; 63:190-193

PTAT reduces the risk of permanent hypoparathyroidism. Olson JA, et al. Parathyroid autotransplantation during thyroidectomy. Results of long-term follow-up. Ann Surg 1996; 223: 472-480. Gauer PG, Reeve TS, Wilkinson M, Delbridge LW. Routine parathyroid autotransplantation during total thyroidectomy: the influence of technique. Eur J Surg 2000; 166: 605-609. Abboud B, SleilatyG, Zeineddine S, et al. Is therapy with calcium and vitamin D and parathyroid autotransplantation useful in total thyroidectomy for preventing hypocalcemia? Head and Neck 2008; 30: 1148-1154. Wei T et al. Autotransplantation of inferior parathyroid glands during central neck dissection for papillary thyroid carcinoma: a retrospective cohort study Internat J Surg 2014; 12:1286-1290.

Olson JA, et al. Parathyroid autotransplantation during thyroidectomy-Results of long-term follow-up Ann Surg 1996; 223: 472-480 In 194 patients PTAT was successful in 99% with permanent hypoparathyroidism incidence of 1%. conclusion Routine PTAT at the time of total thyroidectomy virtually eliminates the complication of permanent hypoparathyroidism.

Wei T et al. Autotransplantation of inferior parathyroid glands during central neck dissection for papillary thyroid carcinoma: a retrospective cohort study. Internat J Surg 2014; 12:1286-1290 477 patients (China-Cleveland) Gr.A- 321 patients, Inferior parathyroid gland autotransplantation Gr.B- 156 patients, In –situ preservation Gr. A- 0.9% permanent hypoparathyroidism Gr. B- 3.8% permanent hypoparathyroidism (p=0.028)

Intraoperative parathyroid hormone as an indicator for parathyroid gland preservation in thyroid surgery. Ezzat WF, et al. Swiss Medical Weekly 2011; 141: 1-9 52 patients PTH 15-24 pg/ml –Recovered to normal PTH levels within 4 weeks. (11 patients) PTH >15 pg/ml failed to regain normal PTH levels up to 12 weeks postoperatively. (5 patients) Low intraoperative PTH levels at the termination of total thyroidectomy should guide surgeons to re-examine the removed surgical specimen for inadvertently removed normal parathyroid gland for autotransplantation.

Summary Before termination of a complicated neck exploration (total thyroidectomy, giant goiter, recurrent neck surgery etc.), PTH level should be obtained, and the four parathyroid glands should be thoroughly inspected and a gland which was inadvertently resected or devascularized, should be immediately auto-transplanted in the ipsilateral sternomastoid muscle.

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