(FAQ)Minimally Invasive Radioguided Parathyroidectomy (MIRP) Author：Bechara Ghorayeb | Size：38.71 K | View：364 | Page：2____________________________________________________________________________ PARATHYROIDECTOMY Frequently AskedQuestions (FAQ)Minimally InvasiveRadioguided Parathyroidectomy (MIRP)EndoscopicVideo-Assisted Minimal Parathyroidectomy (MIVAP) What are the parathyroid glands?Normally, humans have fourpa
____________________________________________________________________________ PARATHYROIDECTOMY Frequently AskedQuestions (FAQ)Minimally InvasiveRadioguided Parathyroidectomy (MIRP)EndoscopicVideo-Assisted Minimal Parathyroidectomy (MIVAP) What are the parathyroid glands?Normally, humans have fourparathyroid glands , two upper and two lower. They arelocated near or attached to the posterior surface of the thyroid gland. Eachgland is no larger than a grain of rice. They secrete parathyroid hormone (PTH)which controls the calcium level in the body. Normal anatomicalvariations may occur, where an individual has only one or two or three glands.Sometimes, a parathyroid gland may be found in the mediastinum, several inchesbelow the neck.Posterior surface of thethyroid gland and pharynx, showing the 4 parathyroid glands.Whatis parathyroidectomy and what are the indications for parathyroid surgery?Parathyroidectomy isan operation in which one or more parathyroid glands are removed. Thisoperation is performed to control hyperparathyroidism (overactivity of the parathyroid glands) which is either causedby a benign tumour of one or more of the glands (parathyroidadenoma), or generalizedgrowth and overactivity of all of the glands (parathyroid hyperplasia). In rare instances, surgery is performed on the parathyroid glands in order toremove a parathyroid cancer. Whatare the symptoms of hyperparathyroidism?Hyperparathyroidism(overactivityof the parathyroid glands) may be associated with osteoporosis(loss of calcium from the bones), generalized fatigue and lethargy,kidney stones, stomach ulcers, joint aches and pains and constipation. Ablood test would show elevation of the serum calcium and PTH. Whathappens before surgery?We will schedule apre-operative visit during which the doctor will fill-out hospital forms, goover your medical history, current medications, allergies etc. and perform acomplete physical examination. You will also be given the opportunity toask questions about the procedure, hospitalization, complications, etc. Youwill sign the pre-operative surgical consent form and receive yourpost-operative instructions, and prescriptions for antibiotics, pain killersand other medications you may need after surgery. Whatis pre-operative assessment?After you finishwith the doctor, you will then go to the hospital for pre-operativeregistration and assessment. This is where pre-operative blood tests,EKG, chest x-rays, etc. are carried out. You will also have theopportunity to talk to the anesthesiologist and ask questions or expressconcerns about anesthesia. Here also, you will be informed of the time ofthe operation and given instructions about when to take your medications andwhat to wear. You may also be asked to sign consent forms for surgery andanesthesia. Sometimes, this assessment may not be necessary and may be carriedout on the telephone.Whattime do I show up on the day of surgery?The assessment nursewill tell you the exact time of your operation and when to come to thehospital. In general, you are expected to be in the hospital, about twohours prior to your scheduled procedure. Whathappens on the day of surgery?You will be directedto the pre-operative holding area in Day Surgery. Your family may remain withyou or wait in the Surgery waiting area. It would be helpful if familymembers or friends notify the nurses’ desk or the waiting room receptionist oftheir whereabouts, so that we can find them to let them know that your surgeryis over. In pre-op holding,the nurses will start an IV line and review your history and medications. Theywill ask you questions to make sure you understand what is going to be done andthat you have consented. They may make you sign the consent forms if you havenot signed them during assessment. They will also mark the operative sitewith ink and if applicable, write on your neck LEFT or RIGHT so that there willbe no confusion as to which side is being operated on. You may request asedative if you are very anxious. DoI have to go for another parathyroid scan?About twohours before the scheduled surgery, you may have to go to NuclearMedicine to receive a dose of Techetium 99m Sestamibi. This radioactiveisotope initially goes to the thyroid gland. But, two hours later, it washesoff from the thyroid gland and concentrates in the parathyroids. Thisallows us to see it on a scan in which the overactive parathyroid or theparathyroid adenoma would light up. This radioactivity is also picked up by theNeoprobe and allows us to determine the exact location of the parathyroidadenoma and mark the site of the surgical incision. It is not uncommonto skip the injection of technetium and take you directly to the operatingroom. Whatare the complications of parathyroidectomy?Most surgerynowadays is safe, however, any operation has general risks including reactionsto the anesthetic, chest infections, blood clots, heart and circulationproblems, and wound infection. In addition there are specific risks associatedwith parathyroid surgery as follows: • Post-operative bleedingmay cause swelling in the throat and difficulty breathing due to pressure onthe windpipe. It is usually fixed by a further operation to remove the bloodclot • Injury to thelaryngeal nerves may cause hoarseness of the voice. This is usuallytemporary, but may be permanent in up to 1 to 2% of cases. It may improve withspeech therapy or further surgery to the vocal cords. If you are a singer orpublic speaker, any surgery to the thyroid may cause subtle long-term changesto your performing voice. • Interference withthe other parathyroid glands may cause the calcium level in the blood to drop (hypocalcemia).It is treated with calcium and vitamin D tablets and usually improves in a fewweeks. • A keloid,or overgrowth of scar tissue, may form in any surgical scar. It willresult in a tender, pink raised scar but may be treated with silicone gel tapesor steroid injections. • Even in the mostexpert hands, up to 5% of parathyroid tumors cannot be found at operation andthe blood calcium will remain elevated (persistent hyperparathyroidism).Sometimes after successful surgery, one of the other parathyroid glands mayalso then become overactive and cause the blood calcium level to rise again (recurrenthyperparathyroidism). • For a couple ofdays after surgery, patients who have received methylene blue tolocalize the parathyroids, will continue to notice a bluish greendiscoloration of the urine. Although methylene blue has been successfullyused for more than 30 years in parathyroid surgery, there are some extremelyrare side effects that could happen from the administration of this dye. These include confusion, hallucinations and abnormal limb movements that maylast a few days before slowly subsiding. Whathappens during surgery?During surgery, youmay receive an intravenous infusion of a blue dye called methylene blue. Thisdye concentrates in the parathyroid adenomas and stains them blue, thus makingit easier to localize them. Remember that this dye will cause your urineto turn greenish blue for several days. When the parathyroid is removed,it is sent for frozen section. This means that they freeze a pieceof the gland, slice it very thin and color it for the pathologist to examine itunder the microscope. The pathologist would confirm that the tissue removed isindeed a parathyroid tissue. A blood sample is drawn (usually from thefoot) and sent to the laboratory for patayhyroid hormone (PTH) andcalcium assay. The calcium and PTH levels drop after the removal of theparathyroid adenoma. In general, we have to wait for the result of thistest before waking the patient from anesthesia. Whathappens after surgery?When you wake upfrom surgery, you will be transported to the recovery room (PACU), wherewould spend about 30 minutes to an hour, until you are fully awake and stablefor transportation to Day Surgery, where you would spend another hour or twoprior to your discharge. Please bring with you some sleepware in case youare too sleepy to go home, in which case, we would admit you overnight. You will be asked tospeak to find out if your voice is hoarse. Many patients,especially smokers, have a raspy or hoarse voice when they wake up fromanesthesia. In general, thewound is sealed with a thin clear acrylic layer (Dermabond) and the suturesare buried under the skin. There is no need to apply antibiotic ointment onthe wound. You are allowed to take a shower without covering thewound. This acrylic film will peel off in a couple of weeks. When yougo home, please keep the wound exposed and do not hide it with a dressing orscarf. Do not apply any antibiotic cream or any other ointments. For 2 – 3 days aftersurgery, it is not unusual to have pain or difficulty on swallowing. You may have to takecalcium tablets for a couple of weeks after surgery, if your calcium is toolow. Whendo I go home?In general, mostpatients are discharged 2 - 3 hours after the the operation. By then,they should be able to eat, walk and go to the bathroom. Occasionally,however, some patients may feel too groggy to stand or too sleepy. Inthat case, they would be admitted to the hospital overnight. Sometimes,we admit patients overnight to control excessive nausea or vomiting. Finally,it is not uncommon for older men, especially those with large prostates, todevelop urinary retention after general anesthesia. In all theseinstances, discharge is delayed until the problem is resolved.