Removal of the parathyroid glands: in which cases is it recommended?

The parathyroid or parathyroid glands, as their name suggests, are endocrine glands located in the neck, behind the thyroid lobes. They make parathyroid hormone (PTH), which helps the body maintain a balance between calcium and phosphorus, among other things.

At a general level, the functionality of PTH can be summarized on the following fronts: in bone it activates the function of osteoclasts, to increase calcium reabsorption (loss) from bone and thus raise its blood concentration. On the other hand, in the kidney it activates the reabsorption of calcium and the excretion of phosphorus, while in the intestine it favors the absorption of the mineral at the level of the intestinal mucosa.

Thus, in excess this hormone produces hypercalcemia (excess circulating calcium) while its deficit causes hypocalcemia (low levels of the mineral). Parathyroid cancer, hyperparathyroidism and hypoparathyroidism are the best known pathologies related to this glandular conglomerate. If you want to know when the removal of the parathyroid glands is necessary and what are its effects on the body, read on.

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When is removal of the parathyroid glands necessary?

The parathyroid glands are 4 organs the size of a pea measuring approximately 5x3x3 millimeters and weighing 30 milligrams each. These are found in the neck, near the thyroid gland (hence its name).

As we have said in introductory paragraphs, the parathyroid glands are essential to regulate the mechanisms of absorption and excretion of circulating calcium and phosphorus. Sometimes its extraction is necessary, since an excess of parathyroid hormone in the blood can cause the following events:

• Osteoporosis: As PTH stimulates bone resorption, bones become brittle, brittle and break easily. For this reason, untreated parathyroidism usually involves osteoporosis in severe cases.
• Kidney stonesWhen there is too much calcium in the blood, solid deposits of this mineral can form in the kidneys.
• Cardiovascular disease: The physiological mechanism is not entirely clear, but it seems that the excess of circulating calcium is associated with cardiovascular diseases and arterial hypertension.
• Neonatal hypoparathyroidism- An excessive amount of circulating calcium in the mother can deprive the fetus of healthy levels of the mineral.

As can be seen, some of these complications can seriously endanger the life of the patient and their offspring. Next, we will explore two of the most important pathologies that require removal of the parathyroid glands. Do not miss it.

1. Hyperparathyroidism

Hyperparathyroidism is a pathology that arises from an overproduction and secretion of PTH by the parathyroid glands. This disease can be primary or secondary, with different underlying reasons in each case.

Primary hyperparathyroidism is one that occurs when circulating calcium levels in the blood are normal. Calcemia (healthy blood calcium level) is tightly regulated with values of total calcium between 2.2-2.6 mmol / L (9-10.5 mg / dL), and an ionized calcium of 1.1-1.4 mmol / L (4.5-5.6 mg / dL). Despite this mineral "normality," the parathyroids produce more parathyroid hormone than they should.

The approximate prevalence of this variant is 1-3 patients per 1,000 individuals. of the general population, with a clear preference towards the female gender (at a ratio of 2: 1). In addition to this, the highest frequency is observed from the age of 60. The most common causative agent is the appearance of adenomas, benign tumors that form in the parathyroids.

On the other hand, secondary hyperparathyroidism occurs when, indeed, circulating calcium levels are lower than they should be. This variant is usually linked to chronic kidney failure, as up to 20% of those who suffer from it end up developing secondary hyperparathyroidism. There are also more varieties, although these two are the most relevant on a medical level.

2. Parathyroid cancer

Cancer of the parathyroid is an exceptionally rare type of neoplasm that occurs when malignant cells form in the parathyroid tissue, resulting in the formation of tumors. 85% -95% of tumor processes in these glands are benign (the previously named adenomas), while only 3% of cases are attributed to parathyroid cancers.

This type of neoplasm affects men and women equally, although it is much more common in people over 30 years of age. The underlying causes are not known, but it is suspected that certain genetic diseases or exposure to radiation-based treatments may contribute to its appearance.

What is the removal of the parathyroid glands?

Surgery may be necessary for both pathologies, depending on the condition of the patient and the progression of the disease. The parathyroid glands are commonly removed through a 5 to 10-centimeter surgical incision in the center of the neck..

It should be noted that it is not usually necessary to remove all 4 parathyroid glands at the same time. The surgeon can select only one of them and, through a minimally invasive procedure (a 2-3 centimeter cut), it is extracted without touching any other anatomical structure. Fortunately, this is enough to treat primary hyperparathyroidism in 6-7 out of 10 patients. This operation is known as selective parathyroidectomy.

In the rare cases in which all 4 glands must be removed (or rather 3 and a half), one of them is selected and a part is transplanted to the forearm or next to the thyroid. This is done to ensure that the patient continues to produce the hormone PTH, in order to maintain stable calcium levels in the blood.

Based on the invasiveness of the process and how many glands are to be removed, the postoperative period can be of the ambulatory (the same day of the operation the patient is at home) or with a short admission of 1 to 3 days of duration. It should be noted that parathyroidectomy is very painless and no more than 3 doses of analgesics are usually required to manage the discomfort it causes. Daily activities can be resumed within a few days after the process and complete healing is achieved in 1-3 weeks.

Risks of parathyroidectomy

Like any surgical procedure, there are certain risks inherent to this operation. For example, during the operation the patient may have adverse reactions to medications, problems breathing, uncontrolled bleeding, the formation of clots and an increased risk of processes infectious. These types of problems are not common, but they need to be mentioned anyway.

Another accessory condition that is a bit more common is the involvement of the nerves of the vocal cords, due to their proximity to the parathyroid glands. Approximately 5% of patients have a transient aphonia after the operation, which usually lasts from 2 to 10 weeks. More rarely (in 1-2% of the most complicated cases) this aphonia and voice weakness are permanent.

The last risk, while extremely rare, is very dangerous. The patient may have overwhelming respiratory distress after the intervention. Fortunately, it almost always goes away several weeks or months after the operation.

What to do in the face of hypoparathyroidism?

We have said that there are 3 typical diseases of the parathyroid glands: cancer (related to primary hyperparathyroidism in a few cases), hyperparathyroidism and hypoparathyroidism. The removal of the parathyroid glands can be the solution to the first two pathologies but, without a doubt, it is not useful to address hypoparathyroidism.

When too little PTH is produced, circulating calcium levels drop and phosphorus levels rise. In general, this is the product of a misdirected autoimmune attack that damages parathyroid hormone-producing cells.

Calcium carbonate and vitamin D supplementation is often used in patients with hypoparathyroidism, which may be necessary for a lifetime. PTH injections may also be helpful in some patients and even intravenous calcium administration in the most serious events.

Resume

The parathyroid glands are essential for the proper functioning of the body and bone integrity of the individual, as it directly regulates the proportion of circulating calcium, with all that this entails. Unfortunately, when excess PTH is produced, different symptoms of varying severity may appear, being osteoporosis one of the most striking.

For this reason, removal of one or more parathyroid glands may sometimes be necessary. In any case, the 4 are not completely extracted, since it is necessary that at least one segment of one of they continue to produce PTH to maintain stable blood calcium levels and thus avoid a hypocalcemia.