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Surgical treatment of primary hyperparathyroidism: from bilateral neck exploration to minimally invasive surgery
M R Pelizzo1, C Pagetta, A Piotto
1Institute of Surgical Pathology and Clinical Propedeutic, Hospital University of Padua, Padua, Italy. mariarosa.pelizzo@unipd.it
Abstract:
The human parathyroid glands, first described by Sandström in 1880, attracted interest because they were subject to inadvertent removal or ischemic injury during radical thyroid surgery. That this caused metabolic derangements was not known until many years later. Following on Kocher's studies, research continued to improve techniques sparing the parathyroids during thyroid surgery but without developing parathyroid surgery as such. For over a century, the lack of suitable surgical instruments, accurate preoperative localizing imaging techniques, and reliable laboratory tests hindered the evolution of parathyroid surgery, relegating it a marginal existence. Only after 1930, when it became clear that hyperparathyroidism is caused by an increased production of parathyroid hormone (PTH) by overactive parathyroid glands in the neck and/or the mediastinum, could parathyroid surgery, which shares a similar approach with thyroid surgery, be developed for treating hyperparathyroidism. The aim of parathyroid surgery is to cure hyperparathyroidism. Until advanced surgical and laboratory diagnostic technologies became available, concern about the risk of failure led surgeons to search all four glands by bilateral neck exploration, which proved unnecessary in 80% of cases. Recent years have seen parathyroid surgery evolve with the introduction of more efficacious preoperative localization imaging techniques and the use of rapid intraoperative parathormone assay, so that parathyroid surgery is now more selective and can be performed as a minimally invasive procedure in some cases.
Insights
Parathyroid surgery has evolved from a challenging procedure to a more selective, minimally invasive approach. Advances in imaging and intraoperative testing now allow for targeted treatment of hyperparathyroidism.
Area of Science:
- Endocrinology
- Surgical Oncology
- Medical History
Background:
- The human parathyroid glands, identified in 1880, were initially of interest due to inadvertent surgical injury during thyroidectomies, leading to metabolic disturbances.
- Early surgical efforts focused on preserving parathyroid glands during thyroid surgery, but parathyroid surgery as a distinct field lagged due to technological limitations.
Purpose of the Study:
- To trace the historical development and evolution of parathyroid surgery.
- To highlight the advancements that have transformed parathyroid surgery into a more precise and minimally invasive procedure for treating hyperparathyroidism.
Main Methods:
- Historical review of surgical techniques and diagnostic advancements related to parathyroid glands.
- Analysis of the progression of understanding hyperparathyroidism and its surgical management.
Main Results:
- Parathyroid surgery's evolution was hindered for over a century by a lack of specialized instruments, accurate imaging, and reliable lab tests.
- The understanding that hyperparathyroidism stems from overactive parathyroid glands (producing excess parathyroid hormone - PTH) after 1930 enabled the development of specific surgical treatments.
- Historically, bilateral exploration of all four glands was common, but modern techniques make this unnecessary in most cases (80%).
Conclusions:
- Modern parathyroid surgery is more selective and minimally invasive due to improved preoperative localization imaging and rapid intraoperative parathormone assays.
- These advancements have significantly enhanced the efficacy and safety of surgical treatment for hyperparathyroidism.
