Principles of Surgery Companion Handbook
THYROID AND PARATHYROID
|Solitary or Dominant Thyroid Nodule|
|Surgery of the Thyroid|
|Physiology of Calcium Homeostasis|
|Primary Hyperparathyroidism (PTH)|
|Multiple Endochrine Neoplasia and Hyperparathyroidism|
Normal adult thyroid gland weighs 15–20 g. It consists of two lateral lobes that extend along the sides of trachea to the level of the middle thyroid cartilage and is connected
The thyroid is divided into lobes that contain 20–40 follicles, which are spherical and average 30
m in diameter. Follicles contain a central store of colloid secreted from epithelial cells that are influenced by thyroid-stimulating hormone (TSH). C cells or parafollicular
Recurrent Laryngeal Nerves
These originate in the vagus nerves; on the right, the recurrent nerve
Superior Laryngeal Nerve Most often the nerve is in close proximity to the superior pole vessels; it can be at significant risk if not identified at operation. To avoid injury, the superior pole vessels should be individually ligated and divided low on the thyroid gland and dissected laterally to the cricothyroid muscle.
The median thyroid anlage can fail to develop, resulting in athyreosis, or it may fail to descend, resulting in lingual thyroid, and this occurs more often in females. It can present as a mass in the region of foramen cecum at the base of the tongue; if it enlarges, it can cause dysphagia, dysphonia, or dyspnea. Treatment should be suppression with thyroxine or ablation with radioactive iodine. Surgery is indicated for hemorrhage, degeneration, and necrosis or threatened airway.
Through release of thyroxine (T
) and triiodothyronine (T
), the thyroid gland influences the
Formation of thyroid
Hormone Synthesis Steps in the synthesis are
Storage, Secretion, and Metabolism of Thyroid Hormone
are bound to thyroglobulin and stored in the colloid of the thyroid follicles. Release of active hormones is by endocytosis; hydrolysis results in production of all component
Active thyroid hormones circulate in plasma attached to plasma
Regulation of Thyroid Activity
TRH is produced by the hypothalamus and stimulates anterior
There are two types of thyroid disease: problems relating to function (hyperthyroidism/hypothyroidism) and thyroid masses. Symptoms such as dysphagia, dysphonia, dyspnea, or a
Most masses are visible. Look for retrosternal goiter arising from
Fine-Needle Aspiration Cytology (FNAC) Slides are made from cellular material aspirated from a nodule with a 23-gauge needle. Skilled cytopathologists can accurately diagnose most thyroid diseases. This is less accurate for patients with thyroid nodules, familial nonmedullary thyroid cancer, or exposure to low-dose therapeutic radiation.
Thyroid Function Tests Normal values are
|Serum TSH||0.15–4.2 mIU/L|
|Total T 4||55–150 nmol/L|
|Free T 4||12–28 pmol/L|
|Total T 3||1.5–3.5 nmol/L|
|Free T 3||3–9 pmol/L|
Thyrotoxicosis results when excessive levels of active thyroid hormone are secreted. There are two predominate causes: Graves' disease (diffuse toxic goiter) and toxic solitary or multinodular goiter (Plummer's disease).
This is an autoimmune disease; thyroid-stimulating antibodies are directed at TSH receptors on follicular cells. This stimulates the receptors and results in excess thyroid hormone production.
Macroscopically, the thyroid gland is diffuse and smoothly enlarged with increased vascularity. Microscopically, it is hyperplastic with
Clinical Features Common to All Forms of Thyrotoxicosis
Physical Examination The examination may disclose weight loss, flushing, warm and moist skin, inappropriate sweating, tachycardia, widening of pulse pressure, fine tremor, muscle wasting, and hyperactive tendon reflexes.
The Graves' disease
Autonomous thyroid function is characterized by decreased or undetectable levels of TSH, elevated
Treatment of Graves' Disease
Beta blockers (propranolol) are used to alleviate peripheral adrenergic effects. Main antithyroid drugs are propylthiouracil (PTU) and methimazole (Tapazole), which inhibit organic binding of iodine and the coupling of iodotyrosines. They have no effect on the underlying cause of the disease. T
levels help in assessing response to treatment. It is hoped that natural remission will occur after the patient is rendered euthyroid. The
Surgery is advised when RAI is contraindicated. It is preferred for young patients with severe thyrotoxicosis and large goiters. Toxic adenoma should be excised. Patients should be euthyroid with antithyroid drugs
Advantages of thyroidectomy are immediate cure, decreased long-
TOXIC MULTINODULAR GOITER
Also known as
this is the result of one or more thyroid nodules trapping and organifying more iodine and secreting more thyroid hormone independent of TSH control. Hyperthyroidism is milder than Graves' disease and without extrathyroidal manifestations of ophthalmopathy. Antithyroid antibodies usually are absent.
I uptake is localized to autonomous toxic nodules, and the remaining thyroid
This is life-
This occurs because of a deficiency in the circulating levels of thyroid hormone. It is cretinism in neonates and is characterized by neurologic
Hypothyroidism secondary to autoimmune thyroiditis is more common in females (80 percent). In adults, symptoms are nonspecific: tiredness, weight gain, cold intolerance, constipation, and menorrhagia. Severe hypothyroidism (
) is characterized by facial and periorbital puffiness, rough, dry, yellow-tinged skin, hair loss with the remainder dry and brittle, and slowed speech. Other
Laboratory Findings Low circulating T 4 and T 3 levels with raised TSH levels are evidenced in primary failure, in secondary (pituitary) failure, TSH levels are low. Thyroid autoantibodies may be present. Other findings are anemia and flattened T waves.
Treatment Thyroxine is given in doses of 50–200 m g/day. The dosage is titrated against TSH levels. For severe disease in the elderly, the dose is started lower and increased slowly. Myxedema coma requires emergency treatment with large doses of intravenous thyroxine.
This is an autoimmune disease; it is more common at ages 30–60
The gland is firm, granular, and mildly enlarged, and the
Clinical Manifestations Twenty percent present with hypothyroidism, and a few present with hyperthyroidism. Most are euthyroid. Common symptom is tightness in the throat with painless, nontender enlargement of the thyroid gland.
Diagnostic Findings Tests are biphasic with early signs of hyperfunction, later hypofunction, and then normalization. Diagnosis is confirmed by circulating antithyroid antibodies. FNAC may confirm the diagnosis or document cancer.
SUBACUTE THYROIDITIS (DEQUERVAIN'S THYROIDITIS)
This is granulomatous or giant cell thyroiditis, an uncommon acute inflammatory disease that might be precipitated by viral infection. Patients present with fever, malaise, and unilateral or bilateral thyroid pain; they may have a recent history of upper respiratory
Treatment Nonsteroidal anti-inflammatory drugs (NSAIDS) are used for pain relief, and beta blockers are used for thyrotoxicosis. In more severe cases it may be necessary to prescribe steroids for short periods. The disease usually lasts 1–6 weeks and resolves spontaneously. Some patients can alternate between bouts of exacerbation and remission.
This is a rare disease characterized by dense, invasive fibrosis that may extend beyond the thyroid
Treatment Treatment is with tamoxifen or steroids. Isthmectomy to relieve compressive symptoms or establish diagnosis may be necessary.
ACUTE SUPPURATIVE THYROIDITIS
This is a rare disease of childhood or
Goiter is an enlargement of the thyroid gland in a euthyroid patient.
Familial goiter is caused by an inherited
This is defined as thyroid enlargement
Sporadic Goiter This is goiter for which no definitive causes can be established.
Pathology The thyroid gland may be diffusely enlarged and smooth or grossly nodular. Early hyperplasia is reversible. Nodules are filled with gelatinous, colloid-rich substance interspersed with normal tissue.
Clinical Manifestations Most patients are asymptomatic, but patients may present with pressure in the neck and a mass. Dysphagia or tracheal compression occurs with respiratory distress, particularly with substernal extension. Sudden pain with rapid expansion is caused by hemorrhage. The gland may feel soft and diffusely enlarged or may evidence multiple nodules of varying size and firmness. FNAC accurately defines a colloid nodule.
Treatment Diffuse goiter and familial goiter respond to thyroxine. Surgical indications include cosmesis, compressive symptoms, substernal goiter, or malignancy on FNAC.
Four percent of population have palpable thyroid nodules; 40 per million will be malignant. There are two high-risk groups for cancer. The first group consists of those with a family history of thyroid cancer. Medullary cancer is autosomal dominant (RET point mutation); 6 percent of papillary cancers have family history. The second
Clinical Manifestations History Forty percent of nodules with a history of irradiation are malignant. Important criteria are the time of onset (recent or growing), age and gender (nodule in a child or adolescent or new nodule in male over 40 or a female over 50 is likely to be malignant), rapid enlargement, husky voice (recurrent nerve involvement), and dyspnea or dysphagia (indicating compression).
Most nodules are
Fine-Needle Aspiration for Cytology
This is the procedure of choice for evaluating thyroid nodules. Nodules can be categorized as benign (65 percent), suspicious (15 percent), malignant (5 percent), and nondiagnostic (15 percent). Incidence of false-positive results is 1 percent and false-negative is 5 percent.
Thyroid function tests usually are not useful. Thyroglobulin levels are used to follow post-total thyroidectomy patients for cancer. Serum calcitonin levels are measured in
Colloid nodule is operated on for cosmesis or symptoms. Lesions are measured with ultrasound. A baseline thyroglobulin level is determined, and a repeat FNAC is performed in 6 months if the lesion enlarges. Thyroid lobectomy is indicated for nodules enlarging on suppressive doses of thyroxine, cysts recurrent after three aspirations or complex on ultrasound, or symptoms. Patients who have had previous irradiation should be
Tyroid cancer occurs in about 40 per million persons per year; 90–95 percent are differentiated (papillary, follicular, or Hrthle cell), 6 percent are medullary, and of those, 30 percent are familial.
Molecular Basis of Thyroid Tumors Oncogenes contribute directly to tumor genesis. Several oncogenes are involved in thyroid tumor genesis.
Papillary carcinoma is the most common of thyroid cancers (80 percent). There is a 2:1 female-to-male ratio, and the mean age at presentation is 35 years.
Tumors are hard and whitish. Macroscopic calcification, necrosis, or cystic change may be apparent. Histologically, papillary carcinomas may be pure follicular with intranuclear inclusions or a mixed pattern. Cells are cuboidal with abundant cytoplasm, crowded nuclei and intranuclear cytoplasmic inclusions (Orphan Annie cells), and calcium deposits (psammoma bodies). Bewteen 30 and 87.5 percent are multifocal. Commonly, there is lymphatic spread within the gland and to local nodes, but the tumor may invade adjacent structures (e.g., trachea,
Clinical Manifestations Most patients are euthyroid and present with a slowly growing, painless mass in neck. Ipsilateral lymphadenopathy may be present and is most common in children, as are lung metastases.
For patients with minimal disease, lobectomy with isthmectomy usually is sufficient. In all others, total or near-total thyroidectomy is preferred, which will manage multifocal disease (4.2–26 percent), decrease the incidence of local
This represents 10 percent of thyroid cancers; it occurs more often in females at a ratio of 3:1, and the mean age at presentation is 50 years.
It is usually solitary, and 90 percent are encapsulated. Vascular invasion and hematogenous spread to bone, lung, and liver are more common than lymphatic spread. Histologically, follicles are present; colloid may be absent. Categories include
Surgical Treatment and Prognosis
Follicular neoplasm diagnosed on FNAC should undergo lobectomy, including the isthmus and pyramidal lobe. Intraoperative frozen sections should be performed when there is evidence of capsular or vascular invasion. Total thyroidectomy is indicated for carcinoma, except in patients with minimally invasive follicular cancers. Total thyroidectomy enables
I detection and ablation of metastatic disease. Mortality is 15 percent at 10 years and 30 percent at 20 years, but the long-term prognosis is
HRTHLE CELL CARCINOMA
These represent 3 percent of thyroid cancers and are considered by the World Health Organization (WHO) to be a variant of follicular neoplasm. Tumors contain sheets of eosinophilic cells. Tumors possess TSH receptors and produce thyroglobulin. Only 10 percent trap RAI. They often are multifocal and bilateral and are more likely to metastasize to local nodes (25 percent). Hrthle cell neoplasm is diagnosed by FNAC; 20 percent are malignant. Treatment is similar to that of follicular cancer. When malignancy is confirmed on frozen or permanent section, total thyroidectomy with central node dissection is appropriate. With palpable nodes, modified radical neck dissection should be performed and the patient treated with T 4 postoperatively.
These represent 5 percent of thyroid malignancies and arise from C cells or parafollicular cells, which secrete calcitonin. These cells are neuroectodermal and originate from the ultimobranchial bodies and then join the thyroid gland proper and are concentrated
Tumors are located in the middle to upper poles of the thyroid and are 75 percent unilateral. Familial cases are more likely multicentric with premalignant C-cell hyperplasia; 90 percent are bilateral. Microscopically, sheets of cells are separated by areas of collagen and amyloid; cells may be polyhedral and resemble carcinoid or spindle cells. The tumor
Clinical Manifestations Patients usually present with a neck mass; 15–20 percent have palpable nodes. Local pain is more common, and local invasion may produce symptoms of dysphagia, dyspnea, or dysphonia. The female-to-male ratio is 1.5:1. Age at presentation is 50–60 years, except in familial cases, which present at a younger age. Tumors may secrete a variety of peptides. Debilitating diarrhea is a late symptom.
Diagnosis is established by history, mass on examination, raised serum calcitonin or CEA level, and FNAC. New patients should be screened for RET point
Medullary thyroid carcinoma (MTC) is sporadic (70 percent) or familial (30 percent), which occurs as MEN IIA and MEN IIB syndrome. MEN IIA consists of MTC, pheochromocytoma or medullary hyperplasia, and hyperparathyroidism. C-cell hyperplasia is present in all. Bilateral pheochromocytomas are detectable in 50 percent. Patients may have Hirshsprung's disease and cutaneous amyloidosis.
MEN IIB patients are found with MTC, bilateral pheochromocytomas, and mucosal ganglioneuromas. Patients display a thickened tongue and lips. Marfanoid features, slipped epiphyses, and pectus excavatum also may occur.
Total thyroidectomy is the treatment of choice because of the high incidence of multicentricity and more aggressive course. More than 60 percent have positive nodes. Neck dissection is necessary if nodes are involved or for tumors larger than 2 cm. Debulking ameliorates APUD effects. Pheochromocytomas should be operated on before thyroidectomy; laparoscopic removal is favored. Abnormal parathyroids are removed; normal parathyroid should be preserved. When a normal parathyroid cannot be
Postoperative Follow-Up and Prognosis
Patients should have periodic examinations with levels of serum calcitonin and CEA
This is the most aggressive of thyroid cancers. Few survive 6 months after diagnosis. Most anaplastic carcinomas arise from differentiated cancers during the seventh and
Growth is extremely rapid. Tumors are unencapsulated with invasion of surrounding tissues. Sheets of cells are seen with
Clinical Manifestations Long-term masses enlarge rapidly and become painful. Dysphonia, dysphagia, and dyspnea are common. The mass is hard and fixed. Diagnosis is by FNAC.
Treatment All forms of treatment are disappointing. A combination of radiation therapy with doxorubicin and debulking may have some effect.
One percent of thyroid malignancies are lymphomas. Diagnosis is by FNAC with biopsy for definitive diagnosis, if necessary. Patients usually respond rapidly to chemotherapy; a combined treatment with radiation therapy and chemotherapy often is recommended. Thyroidectomy and nodal resection are used to alleviate symptoms of airway obstruction in those who do not respond quickly to initial treatment.
Between 2 and 4 percent of patients dying of malignant disease have metastases in the thyroid. Kidney, lung,
Intrathoracic goiter usually represents an extension of cervical thyroid tissue into the chest, which usually can be removed through a cervical incision. Occasionally, transsternal resection is necessary.
Complications Mortality is very low; serious morbidity occurs in less than 2 percent.
Recurrent Laryngeal Nerve Injury This is relatively uncommon (1 percent of thyroid operations). It is more likely with large, invasive, or recurrent tumors. It may be temporary (6–12 months) or permanent. With abductor laryngeal palsy, the vocal cord assumes a medial position. The voice is husky and hoarse. Bilateral vocal cord paralysis can compromise the airway. It is wise to evaluate vocal cord function preoperatively.
Hypoparathyroidism This occurs 0.5–2 percent of patients. The incidence varies with size and invasion of the tumor, pathology, extent of the procedure, and experience of the surgeon. It rarely results from removal of all glands. Hypoparathyroidism results from parathyroid ischemia as a consequence of disruption of the blood supply. Risk can be minimized by dissection along the thyroid capsule and gently teasing the parathyroid gland on a broad plane of tissue away from the thyroid gland in a posterolateral direction. Devascularized gland may be minced and implanted in pockets in the sternomastoid or the arm.
Hypoparathyroidism is manifest within days of operation with signs of circumoral numbness, tingling of fingertips, and anxiety. Chvostek sign occurs early, followed by Trousseau's sign and carpopedal spasm. This may lead to tetany. The serum calcium level is reduced, and the phosphorus level is increased. Symptoms may be transient and resolve in a few days or be permanent.
Treatment is with 1 g calcium by mouth every 4 h. If calcium remains low, intravenous calcium (1–10 ampules of calcium gluconate) is given over several hours. For permanent hypoparathyroidism, vitamin D (Rocaltrol 0.25–1.0 m g/d) is given in addition to calcium.
Postoperative Management of Differentiated Thyroid Cancer Postoperatively, patients should be placed on thyroxine as replacement hormone and to suppress TSH. Thyroglobulin levels in patients who have undergone total thyroidectomy should be below 2 ng/dL when the patient is taking thyroxine and below 3 ng/mL when the patients is not taking thyroxine. A thyroglobulin level above 3 ng/mL is highly suggestive of metastatic disease.
Metastatic differentiated thyroid cancer can be
External-beam radiotherapy occasionally is required to control unresectable disease. Taxol has been
The superior parathyroid glands arise from the fourth branchial pouch with ultimobranchial bodies so as to
Primary hyperparathyroidism is due to parathyroid adenomas (90 percent), hyperplasia, or rarely, carcinoma. Double adenomas occur in 2 percent. Hyperplasia occurs in 8 percent with sporadic disease and is almost universal in familial disease. Hyperplasia is seldom symmetric. Normal glands primarily contain chief cells with
Parathyroid Hormone (PTH)
PTH is a single-chain polypeptide. The
-terminal portion is biologically active with a half-life 2 min. The hormone increases osteoclast and osteoblast activity. It increases the rate of production of the active form of vitamin D, which increases
Calcium is the principal
Vitamin D is
Hypercalcemia is a result of overproduction of PTH by one or more parathyroid glands. It occurs in 1 in 700 persons (the female-to-male ratio is 3:1) and 1 in 200 postmenopausal women.
Etiology The exact cause is unknown. Typically, it is caused by benign enlargement of one (90 percent) or two (2 percent) parathyroid glands; the condition is referred to as benign adenoma(s). Multigland enlargement accounts for 8 percent. Parathyroid carcinoma is a rare cause (<1 percent).
Clinical Manifestations Before serum calcium levels were measured routinely, patients typically presented with renal stones (64 percent), bone disease (20 percent), peptic ulcer (12 percent), and hypertension (4 percent). After successful surgical management, nearly all patients realize that they had been symptomatic.
Diagnosis is commonly one of exclusion. Differential diagnosis includes a history of the use of thiazide diuretics, lithium, excessive vitamin A or D, extraordinary amounts of milk or antacids (milk-alkali syndrome), granulomatous disease (sarcoidosis, tuberculosis, histoplasmosis, etc.), malignancy (renal cell carcinoma, multiple myeloma, squamous or small cell lung cancer that can produce a parathyroid hormone-like polypeptide), and metastatic malignancy (commonly prostate or breast). A family history of MEN or benign familial hypocalciuric hypercalcemia (low urinary calcium excretion) may be an indication. Physical examination rarely is helpful (neck mass, voice abnormality, or hoarseness could indicate parathyroid cancer). Adenomas, regardless of size, rarely are palpable. A single serum calcium determination is
Radiologic studies are unnecessary unless previous neck operations have been undertaken. With reoperation, in those in whom dissection is more hazardous, ultrasound of the neck with FNAC of any suspicious cervical mass is useful. If
The indication for surgical intervention is the diagnosis of primary hyperparathyroidism. Expected success rate is 98 percent, and there is negligible mortality and minimal morbidity. For recurrent or persistent hyperparathyroidism, repeat exploration is indicated if the offending gland is localized in imaging studies. Expected success rate is 90 percent. For a solitary adenoma, excision without biopsy of the other glands is sufficient. Double adenomas should both be removed. For multigland hyperplasia, three and one-half gland parathyroidectomy or total parathyroidectomy with reimplantation of 50 mg in the neck or forearm is an option. Normocalcemia within 24–72 h can be expected. Transient hypocalcemia is common; the cause is bone hunger (low serum phosphate and normal PTH levels) or hypoparathyroidism (elevated phosphate and abnormally low PTH levels). Hospitalization is overnight while calcium levels are checked and stabilized before
Technique A 10-cm collar incision 2 fingerbreadths above the sternal notch is made. The operative technique should be gentle and unhurried with a bloodless field. The strap muscles are retracted or divided, and the thyroid is elevated anteriorly, superiorly, and then medially. Superior parathyroids usually are found close to the posterolateral aspect of the upper pole. Takedown of the upper pole seldom is necessary. Inferior glands are intimately involved with the lower pole and the thyrothymic tongue of fat that extends inferiorly toward the mediastinum. They are often subscapular. Glands may be found as high as the angle of the mandible or as low as in thymus, in the anterior mediastinum, or in the aortopulmonary window in the posterior mediastinum. If the superior gland is not found, the tracheoesophageal groove below the inferior artery and lower gland should be investigated. Other possible sites are in the thymus, buried within the thyroid, in the carotid sheath, or lateral to the carotid sheath. Bilateral exploration is recommended.
PERSISTENT AND RECURRENT HYPERPARATHYROIDISM (FIG. 36-1)
FIGURE 36-1 Algorithm of the approach to the patient with persistent/recurrent hyperparathyroidism.
An improperly performed primary operation is the cause for the majority of patients with persistent (elevated serum calcium levels that do not return to normal after surgery) or recurrent hyperparathyroidism. The possibility of benign familial hypocalciuric hypercalcemia in which 24-h urine calcium excretion is less than 100 mg must be excluded. Reoperative cure rates of 80–90 percent are reported. Postoperative recurrent laryngeal nerve palsy or permanent hypoparathyroidism occurs in 3–5 percent. Nonoperative alternatives (angiographic embolization or, preferably, ultrasound-guided alcohol ablation) should be considered. The surgeon should review the prior operative report, and the pathologist should review previously excised tissue. The radiologist should be consulted about localizing with technetium-99m sestamibi and ultrasound (with FNAC). Localization allows focused exploration (unilateral or lateral cervical approach, thoracoscopy, or mediastinal exploration). If all localizing modalities are negative, blind exploration should not be performed.
This is uncommon. There is appropriate parathyroid hyperplasia with elevation of PTH secretion in patients with chronic renal failure
Clinical Manifestations Symptoms include bone pain or fractures, renal osteodystrophy or soft-tissue calcifications (calciphylaxis), and pruritus.
Treatment Treatment is nonsurgical dietary restriction of phosphate and oral phosphate binders, oral calcium, and vitamin D. Surgery is performed for hyperplasia involving all glands and uncontrollable symptoms.
This is the continuation of secondary hyperparathyroidism. PTH secretion becomes autonomous, and the serum calcium level becomes elevated. It is
Multiple endocrine neoplasia (MEN) has an autosomal dominant pattern of inheritance. The hallmark is multicentricity and bilaterality.
MEN type I includes pituitary (15–50 percent), parathyroid (100 percent), or pancreatic (30–80 percent) neoplasms. MEN type IIA (Sipple's syndrome) includes C-cell hyperplasia and, subsequently, medullary thyroid carcinoma if total thyroidectomy is not done prophylactically, adrenal medullary hyperplasia/pheochromocytoma (50 percent), and parathyroid abnormality (10–25 percent). MEN type IIB patients can develop medullary thyroid cancer and
Clinical Manifestations Seventy-five percent of patients have a family history of endocrine abnormalities. With time patients present with visual changes, kidney stones, ulcer pain or diabetes (MEN I), neck masses and hypertension (MEN IIA), or buccal and lingual nodules, hypertension, neck masses, and marfanoid habitus (MEN IIB). Patients should have serologic surveillance of appropriate markers.
Testing for the RET proto-oncogene is indicated for those with a family history of medullary cancer, and prophylactic thyroidectomy is performed if the history is positive. Parathyroid surgery is performed to prevent the ravages of primary hyperparathyroidism. It is not uncommon for these patients to have 5–6 parathyroid glands. Exploration should be thorough and should include transcervical thymectomy. Treatment includes removal of all but 50 mg parathyroid tissue or total parathyroidectomy with autotransplant of heterotopic tissue.
This life-threatening systemic condition is accompanied by an elevation of serum calcium to 13 mg/dL or higher. Symptoms vary from neuromuscular changes with mild fatigue and irritability to coma. Dehydration is common. GI manifestations include
Intravenous saline is advanced to achieve a diuresis of 100 mL/h or higher. About 4–5 L is required to
This occurs in less than 1 percent of cases of hyperparathyroidism.
There is evidence of a parathyroid mass, which is firmer than the usual. The gland is not the normal bean-shaped kidney
Most masses weigh more than 2 g and are composed of a thick fibrous capsule, with fibrous septa interdigitating throughout the tumor, and enlargement, hyperchromasia, and variation in
En bloc resection of the tumor and involved surrounding structures is performed, usually by thyroid lobectomy. If lymph nodes are involved, appropriate resection is needed. Radiation and chemotherapy are of limited
For a more detailed discussion, see Sadler GP, Clark OH, van Heerden JA, and Farley DR: Thyroid and Parathyroid, chap. 36 in Principles of Surgery, 7th ed.
Copyright 1998 McGraw-Hill
Seymour I. Schwartz
Principles of Surgery Companion Handbook