Parathyroid surgery

There are four parathyroid glands in your neck. Each gland is the size of a grain of rice. They are usually situated behind the thyroid gland. They lie very close to nerves that control your voice and help with swallowing and breathing.

The parathyroid glands produce parathyroid hormone which regulates the amount of calcium in your blood. If one or more of these glands produces too much parathyroid hormone, the calcium level in your blood will rise. When parathyroid glands produce too much hormone, patients suffer a condition called primary hyperparathyroidism.

You may not have any symptoms. However, high calcium levels in your blood can cause a number of problems such as tiredness, low mood, memory loss, constipation, pain in the bones and joint and muscle tenderness. You may need to drink more water because you feel thirsty and pass urine more often. In the long term, hyperparathyroidism can lead to the formation of kidney stones, weak bones and increased risk of a cardiovascular event, such as a stroke or heart attack.

Primary hyperparathyroidism can be diagnosed with simple blood and urines tests. Often, only one parathyroid gland is affected. Some patients may have a problem with more than one, or even all, of the glands.

Your doctor will request scans such as a neck ultrasound, a neck CT scan, a neck MRI or a nuclear medicine scan. The purpose of the scans is to try to identify which parathyroid glands are abnormal and where are they located. You will usually have two separate scans. The scans will help us to plan an operation to remove the abnormal gland or glands. Sometimes the scans will not show which gland or glands are causing the problem, but this is rare.

The only treatment to treat this condition in the long term is to have an operation to remove the gland or glands which are producing too much parathyroid hormone.

During your parathyroid surgery we will perform a special type of parathyroid hormone blood test which provides very fast results. The tests are done by a specialist biochemistry team in the operating theatre.

The tests help the surgical team to decide how many glands must be removed to treat the hyperparathyroidism.

Your surgeon will recommend one of the following procedures. This will depend on the results of your scans.

Minimally invasive parathyroidectomy (keyhole surgery)

This operation is done through a cut of less than three centimetres in your neck to remove one parathyroid gland. This procedure is only possible if the scans done before the operation clearly show which gland is causing the problem.

We will perform parathyroid hormone blood tests before and after the gland is removed to confirm the disease has been treated. Most patients will have only one gland removed. However, if the parathyroid hormone levels remain high, the surgeon may proceed with a bilateral neck exploration (see below). It is very important that you are prepared for a bilateral neck exploration even if the plan is to treat you with minimally invasive surgery.

Bilateral neck exploration and parathyroidectomy

This operation is done through a slightly longer cut of about five centimetres in the front of your neck. This procedure allows the surgeons to examine all four parathyroid glands and remove the abnormal ones. You will have this procedure if the scan or scans done before the operation do not show which gland is causing the problem. You may also need this if minimally invasive surgery is not successful. Parathyroid hormone blood tests done during the surgery will help the surgeons decide how many glands must be removed.

The operations are done under general anaesthetic which means you will be asleep during the procedure.

The operation will usually take between one and a half to three hours, depending on how many glands need to be removed.

The risks associated with the general anaesthetic will be discussed with you when you come for your pre-assessment appointment. You will also see an anaesthetist on the day of your operation.

As with any operation, there are risks associated with parathyroid surgery. They include:

Scarring: these operations are done through a cut on the front of your neck. Some patients develop thick scars but this is very rare. Although the scar usually fades with time, most patients will be left with a visible thin line.

Neck pain, swelling or stiffness: the area around the cut may be sore and swollen for a few days. This is part of the healing process and we will give you medication to help your pain and reduce the swelling while you are in hospital. Please tell us if you are pain so we can help as soon as possible. These symptoms should self-resolve within a week but if they persist or are too uncomfortable, please contact us.

Bleeding: this is a rare complication that can cause neck discomfort, bruising and swelling. In more severe cases it can make breathing difficult. Very rarely, patients may need to go back to the operating theatre to deal with the cause of the bleeding. This happens in less than 0.5 per cent (less than one in every two hundred) cases.

Infection: this is a rare complication which can occur four to seven days after the operation. An infection can usually be treated with antibiotics.

Voice changes: the nerves which control your voice are very close to your parathyroid glands. The surgeons will use a nerve monitor to find their location and check they are working. This will help us to avoid damage.

If the nerves are bruised, they may not work properly after surgery. This results in voice changes and very rarely swallowing and breathing difficulties. Most patients who develop these problems recover and return to normal in the following days or weeks. If the voice problems continue, we can refer you to a Speech and Language Therapist.

In our experience this risk is very rare. There is a very small risk that voice changes may be permanent.

Low calcium levels in your blood: if several glands (three or four) are removed you may be left with lower levels of parathyroid hormone than normal. This may cause low levels of calcium in your blood.

You will have a blood test on the day after the operation to check your parathyroid hormone and calcium levels.

If the calcium levels are too low you will need to take calcium supplements. Although this is a simple tablet you may need to take these supplements lifelong.

Failure to treat the disease: in our experience this happens in less than two percent (two in every hundred) cases. The main reason the procedure is not successful is because sometimes the surgeon is unable to find the abnormal gland during the operation, even when the gland is identified on the scans.

Surgery is the only known treatment to treat primaryhyperparathyroidism in the long term. If your calcium levels in your blood are very high but you want to avoid an operation, an Endocrinologist may be able to give advice on medication to reduce it. However, this treatment is usually temporary and not appropriate for all patients. We can discuss this with you in detail if you would like more information.

While you are waiting for your operation you should try to stay well hydrated. Try to drink two and a half litres of water each day. This helps to prevent a build-up of calcium deposits in the body.

Before your operation, we will organise a pre-assessment appointment. We will ask you for details of your medical history and carry out any tests we need to make sure you are fit for the anaesthetic and the operation. Staff in pre- assessment will tell you how to prepare for your operation, when to stop eating and drinking and about the admission process.

You will be admitted to hospital on the day of your operation. You will meet a member of the anaesthetic team and a member of the surgical team before the operation.

They will again explain the risks and benefits of the procedure, answer any questions you may have, and will obtain your consent. The nursing team will do some safety checks before we go ahead with the surgery.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please speak with a senior member of staff again.

Sometimes, we may also ask you for consent to participate on research projects. If this is the case, we will discuss this with you in detail.

After the operation you will wake up in the Recovery Area. You will have a covering on your neck wound and an intravenous drip that will help us provide you with painkillers or any other medication you may need. A recovery nurse will look after you until you are ready to go to the ward.

Once you are awake, we will ask you to sip some water: when you are able to swallow safely, we will allow you to eat and drink. A member of the surgical team will review you every day while you are in hospital after the operation.

Some patients who have a minimally invasive parathyroidectomy may be able to go home on the day of the operation. If this is the case for you, your doctor will tell you before the operation.

If you stay in hospital a member of the surgical team will review you the day after the operation.

We will perform blood tests the day after your operation to check parathyroid hormone and calcium levels.

You will probably be discharged on the day after your operation. You will need someone to drive you home and provide support for the first few days.

Medication

We will advise you to take over the counter medication to help you manage your pain. It is a good idea to have a supply of paracetamol or ibuprofen at home before you come in for your operation.

You may experience tingling in your fingers and toes, numbness around the mouth in the days after your surgery, as the body adapts to normal calcium level in your blood. We will prescribe calcium supplements to ease the symptoms. These symptoms are short term and reduce quickly, usually in a few days.

Exercise and going back to work

You should rest for two or three days when you get home. It is normal to feel tired for a few days after surgery. You can move your neck gently and regularly to prevent stiffness and improve healing. The medical team will provide instructions on specific exercises should you develop stiffness around your neck.

We advise you to avoid strenuous activities such as heavy lifting or vigorous exercise for two weeks after the operation. Also avoid swimming for at least two weeks and contact sports for one month.

We usually advise patients to take one or two weeks off work, but this can vary, depending on the type of work you do. You should be able to resume most of your normal activities a week after surgery.

Wound care

You may shower from the day after the operation, but we advise you not to have a bath for at least two weeks. You can remove the wound covering three to four days after the operation. You will have dissolvable stitches which do not need to be removed. The glue will peel off over the next few days. Your scar will fade over time and become less noticeable.

If you have any concerns about your wound or medication, please contact the surgical team (see Contact details section).

Driving

Avoid driving until you are comfortable turning your head and have stopped taking pain killers that might affect your alertness. Check with your insurance company, as they may have specific rules about driving after surgery.

Travelling

Please discuss with your medical team if you are planning to travel after surgery. We normally recommend that you remain in your local area until we review you in clinic three to four weeks after surgery. This is to ensure you are fit and we can provide you with medication or further advice should you need it. This will also allow us to address any possible urgent problems in the meantime.

Other symptoms

You may experience some voice changes or swallowing difficulty after surgery. This should gradually resolve but it may persist for up to six months. If you are still experiencing problems six months after surgery, we will organise further tests and treatment by a specialist.

Urgent problems

If you have an urgent problem please come to the Emergency Department at University College Hospital. Please seek urgent medical advice if you develop:

• redness around the surgical wound
• fever
• more swelling in your neck after you have gone home
• tingling or pins and needles in your fingers or toes which does not go away after you have taken calcium supplements.

We will give you an appointment to review you in outpatient clinic a few weeks after the operation. It is important that you come to the hospital two or three days before this appointment for a blood test to check your parathyroid hormone and calcium levels.

When you come to clinic, we will check your wound, voice and general recovery. We will review the blood test results and we will organise further follow-up.

The British Association of Endocrine and Thyroid Surgeons (BAETS) provides some information on their website about surgery.

Parathyroid UK is a charity that represents and supports patients who suffer from parathyroid conditions.

UCLH cannot accept responsibility for information provided by other organisations.

Pathway Co-ordinator (Monday to Friday 09:00-17:00)

Direct line: 0203 447 9460 / 07890 945 294

Switchboard: 08451 555 000 / 020 3456 7890 ext. 79460

E-mail: uclh.endocrinesurgery@nhs.net

Address: Endoscopy Unit, University College Hospital, 2nd Floor Podium, 235 Euston Road, London, NW1 2BU