Pedicled parathyroid gland autotransposition in secondary and tertiary hyperparathyroidism.

INTRODUCTION Symptomatic hyperparathyroidism (HPT) refractory to medical management requires surgical intervention with subtotal parathyroidectomy. Primary HPT commonly manifests as a parathyroid adenoma affecting a single gland and can be treated with excision of this single gland. However, secondary HPT in the setting of renal failure or familial diseases often presents with multiglandular hyperplasia requiring resection of several, if not all, parathyroid glands. Subtotal parathyroidectomy became the standard operative strategy after the first successful surgical intervention by Stanbury et al. in 1960. However, in 1975, parathyroid hormone (PTH) assay demonstrated parathyroid autograft function after forearm autotransplantation and total parathyroidectomy with heterotopic autotransplantation became popular. The standard technique for preserving part of the parathyroid tissue is to implant part of it in the brachioradialis muscle. As these patients will continue to have potential hyperplasia of the autotransplanted gland, the brachioradialis muscle offers easy accessibility in the event of gland reresection. However, until the preserved gland undergoes neovascularization, these patients may have persistent hypocalcemia that makes management difficult. Guidelines for end-stage renal disease (ESRD) patients suggest maintaining intact parathyroid hormone (iPTH) levels in the range of approximately two to nine times the upper normal limit for the assay. ESRD patients undergo parathyroidectomy when they develop tertiary hyperparathyroidism or fail medical management for secondary hyperparathyroidism. In this study, we report a new, less invasive, surgical technique to preserve parathyroid tissue in patients with secondary and tertiary hyperparathyroidism who undergo parathyroid exploration and excision of all four parathyroid glands. We report this technique in four patients and evaluate their postoperative iPTH levels as a marker to evaluate efficacy.