Parathyroid Gland Disorders: Controversies and Debates

Preface
Acknowledgments
Contents
1: Parathyroid Glands: Historical Review
1.1 Introduction
1.2 Parathyroid Gland Discovery and Anatomy
1.3 Parathyroid Function and Relation to Calcium
1.4 Evolution of Parathyroid Surgery
1.5 Hyperparathyroidism (HPT)
1.6 Parathyroid Hormone (PTH)
1.7 Technological Advances
References
2: Embryology of the Parathyroid Glands
2.1 Embryogenic Origin
2.1.1 Parathyroid Gland (PTG) Organogenesis
2.1.2 Molecular Regulators of Initial Parathyroid Specification
2.1.2.1 Transcription Factors
2.1.2.2 Signaling Pathways
2.1.3 Differentiation and Survival of Parathyroids: Gcm2
2.2 Thymus–Parathyroid Connection
2.2.1 Do the Thymus and Parathyroids Have Overlapping Functions?
2.3 Stability of Parathyroid Fate
2.4 Parathyroid Hormone and Related Protein
2.4.1 Parathyroid Hormone (PTH)
2.4.2 Parathyroid Hormone-Related Protein (PTHrP)
References
3: Surgical Anatomy of the Parathyroid Glands
3.1 Overview
3.2 Recognizing Parathyroid Glands and their Number
3.2.1 Recognizing the Parathyroid Glands (PTGs)
3.2.2 Number of Parathyroid Glands
3.2.2.1 Anomalies of PTG Number
3.3 Location of Parathyroid Glands
3.3.1 Superior Parathyroid Glands
3.3.2 Inferior Parathyroid Glands
3.3.3 Variations in Location/Ectopic Glands
3.3.3.1 Superior PTG Variations
3.3.3.2 Inferior PTG Variations
3.3.3.3 Supernumerary PTG Location
3.3.4 Surgical Implications of Variations in Number and Location
3.4 Vascular Supply and Innervation
3.4.1 Arterial Supply
3.4.2 Venous Drainage
3.4.3 Lymphatic Drainage
3.4.4 Innervation
References
4: Histology of the Parathyroid Glands
4.1 Gross Appearance
4.2 Microscopic Appearance
4.2.1 Stroma (Capsule and Trabeculae)
4.2.2 Parenchyma
4.2.2.1 Chief Cells
4.2.2.2 Oxyphil Cells
4.2.2.3 Water-Clear Cells
4.2.2.4 Other Cells
4.3 Immunohistochemical (IHC) Features
4.4 Electron Microscopy
References
5: Physiology of the Parathyroid Glands
5.1 Basic Biology of Calcium Homeostasis
5.1.1 Plasma Levels of Calcium
5.2 Absorption and Excretion of Calcium and Phosphorus
5.3 Key Components of Calcium Homeostasis
5.3.1 Parathyroid Hormone (PTH)
5.3.1.1 Parathyroid Gland Biology
5.3.1.2 Parathyroid Hormone Biosynthesis
5.3.1.3 Parathyroid Hormone Function
Bones
Kidneys
Small Intestine
5.3.1.4 Summary of Mechanism of PTH Action
5.3.2 Vitamin D
5.3.3 Calcitonin
References
6: Calcium: Why Is It Important?
6.1 Introduction
6.2 Properties of Calcium
6.2.1 Solubility
6.2.2 Binding
6.2.3 Calcium Homeostasis
6.2.4 Bioavailability
6.3 Functions of Calcium
6.3.1 Structure of Bone and Teeth
6.3.2 Cell Signaling/Muscle Contraction
6.3.2.1 Skeletal Muscles
6.3.2.2 Smooth Muscles
6.3.2.3 Cardiac Muscles
6.3.3 Microbiological Functions/Regulation of Protein Function
6.4 Dietary and Pharmacological Uses of Calcium
6.4.1 Disease Prevention
6.4.1.1 Osteoporosis
6.4.1.2 Nephrolithiasis
6.4.1.3 Hypertensive Disorders of Pregnancy
6.4.1.4 Colorectal Cancer (CRC)
6.4.1.5 Lead Toxicity
6.4.2 Disease Treatment
6.4.2.1 Overweight and Obesity
6.4.2.2 Premenstrual Syndrome (PMS)
6.4.2.3 Hypertension
6.5 Food Sources and Recommended Dietary Allowance
6.5.1 Food Sources of Calcium
6.5.2 Calcium Supplements
6.6 Abnormal Serum Levels of Calcium
6.6.1 Calcium Deficiency
6.6.2 The Recommended Dietary Allowance (RDA)
6.6.3 Calcium Excess—Safety
6.6.3.1 Toxicity
6.6.3.2 Do High Calcium Intakes Increase the Risk of Prostate Cancer?
6.6.3.3 Do Calcium Supplements Increase the Risk of Cardiovascular Disease?
6.6.3.4 Drug Interactions
6.6.3.5 Calcium–Nutrient Interactions
Vitamin D
Iron
Zinc
Carotenoids
Sodium
Protein
Phosphorus
Caffeine
6.7 The Linus Pauling Institute Recommendations
6.8 Summary [5]
References
7: Hyperparathyroidism (HPT)
7.1 Introduction
7.2 Surgical Pathology
7.2.1 Classification of Hyperparathyroidism (HPT)
7.2.2 Hyperparathyroidism: Sporadic or Familial?
7.3 Primary Hyperparathyroidism (PHPT)
7.3.1 Epidemiology
7.3.2 Etiology of “PTH” Overproduction
7.3.2.1 Radiation Exposure
7.3.2.2 Calcium Intake
7.3.2.3 Chromosomal Defects
Cyclin D1/PRAD1 Gene
MEN-1 Gene
CDKI Genes
RET Gene
CDC73/HRPT2 Gene
CaSR Gene
7.3.3 Surgical Pathology
7.3.3.1 Parathyroid Hyperplasia
7.3.3.2 Parathyroid Adenoma
Gross Appearance
Microscopic (Histological) Appearance
Cytology Description
Electron Microscopy Description
Molecular/Cytogenetics Description
7.3.3.3 Parathyroid Carcinoma
7.3.4 Clinical Picture
7.3.4.1 Classic Presentations
Skeletal Involvement
Renal Involvement
Nephrolithiasis
Deteriorated Renal Functions
Nephrocalcinosis
Renal Hypertension
Neuro-Muscular Involvement
Neuro-Psychiatric Involvement
Gastrointestinal (GIT) Involvement
7.3.4.2 Emergency Presentation (Parathyroid Crisis)
7.3.4.3 Non-Classical Features
Cardiovascular Features
Hypertension
Cardiac Structure and Function
Large Vessel Involvement
Metabolic Abnormalities
Glucose Metabolism
Body Weight and Lipid Profile
Other Manifestations
Manifestations of Ectopic Calcification
Risk of Malignancy
Risk of Mortality
Reduced Quality of Life (QOL)
7.3.4.4 Asymptomatic Primary Hyperparathyroidism
Definition
Incidence
Natural History
Biochemically
Clinically
7.3.5 Investigations
7.3.5.1 Diagnostic Studies
Biochemical Laboratory Tests
Classical PHPT
Serum Calcium
Serum PTH
24-Hour Urinary Calcium
Serum Vitamin D
Other Laboratory Studies
Normo-Calcemic PHPT
Diagnostic Criteria
Mild PHPT
Genetic Mutations
Imaging Studies
Other Studies
7.3.5.2 Localizing Studies
Rationale and Principles
Imaging Modalities
Ultrasound (US) of the Neck
Nuclear Imaging (Scintigraphy)
Computed Tomography (CT) Scan/Four-Dimensional CT (4D-CT)
Definition
Technique
Approach
Advantages
Disadvantages
Magnetic Resonance Imaging (MRI)/4D-MRI
Other Modalities
7.3.6 Differential Diagnosis
7.3.6.1 Causes of Hypercalcemia
Endocrine Causes (PTH-Related)
Malignancy
Calcitriol (Active Vitamin D)-Mediated
Diseases Associated with Increased Ca++ Absorption or Resorption
Congenital Diseases
Diseases Associated with Hyper-Proteinemia
Renal Failure
Medications
Iatrogenic
Miscellaneous
7.3.6.2 Differences between HPT and Malignancy
Common Primary Sites
Diagnosis
7.3.7 Treatment
7.3.7.1 Surgical Treatment
Indications: When to Operate?
Aims of Surgery: Why Operate?
Surgical Procedure: Which Operation?
Parathyroidectomy/Bilateral Neck Exploration (BNE)
Minimally Invasive Parathyroidectomy (MIP)
Intra-Operative Techniques Aiding Localization and Confirmation of Cure of PHPT
Frozen-Section
Fluorescence-Guided Parathyroidectomy
Radio-Guided Parathyroidectomy (RGP)
Intra-Operative Parathyroid Hormone (IOPTH) Monitoring
7.3.7.2 Conservative Treatment
Candidates
Outlines of Conservative Treatment
Monitoring
Vitamin D Repletion
Antiresorptive Therapy
Calcimimetic Agent
7.3.7.3 Special Situations of PHPT Disorder
PHPT in Children
PHPT in Pregnancy
PHPT in the Elderly
PHPT with Intra-Thoracic Parathyroids
Parathyroid Cancer in PHPT
Re-Do Parathyroidectomy
7.4 Secondary Hyperparathyroidism (SHPT)
7.4.1 Definition
7.4.2 Epidemiology
7.4.3 Etiology
7.4.4 Pathophysiology
7.4.5 Pathology
7.4.6 Clinical Picture
7.4.6.1 Osseous Manifestations
7.4.6.2 Extra-Osseous Manifestations
7.4.7 Evaluation/Diagnosis
7.4.7.1 Laboratory Tests
7.4.7.2 Imaging
7.4.8 Differential Diagnosis
7.4.9 Treatment
7.4.9.1 Medical Treatment
Phosphate Binders
Vitamin D Metabolites
Calcimimetics
7.4.9.2 Surgical Treatment
Indications
Surgical Techniques
7.4.10 Pertinent Studies and Ongoing Trials
7.4.11 Prognosis
7.5 Tertiary Hyperparathyroidism (THPT)
7.5.1 Definition
7.5.2 History
7.5.3 Etiology
7.5.4 Risk Factors and Genetics
7.5.5 Pathophysiology
7.5.6 Clinical Presentation
7.5.7 Investigations/Diagnosis
7.5.8 Treatment
7.6 Familial HPT in “Men” Syndromes
References
8: Osteitis Fibrosa Cystica
8.1 Overview
8.2 History
8.3 Epidemiology
8.4 Etiology
8.4.1 Primary Hyperparathyroidism (PHPT)
8.4.1.1 Parathyroid Adenoma
8.4.1.2 Parathyroid Hyperplasia
8.4.1.3 Parathyroid Carcinoma
8.4.1.4 Hereditary Factors
8.4.2 Secondary Hyperparathyroidism (SHPT)
8.4.2.1 Renal Complications
8.4.2.2 Fluoride Intoxication
8.4.3 Tertiary Hyperparathyroidism (THPT)
8.5 Pathophysiology
8.6 Clinical Presentation
8.7 Investigations/Diagnosis
8.7.1 Laboratory Tests
8.7.2 Imaging Studies
8.7.2.1 Bone Resorption
8.7.2.2 Osteosclerosis
8.7.2.3 Bone Deformities and Fragility (Pathological) Fractures
8.7.2.4 Brown Tumors
8.7.2.5 Metastatic (Ectopic) Calcification
8.7.3 Cytology/Histology
8.7.4 Differential Diagnosis/Comparison of Bone Pathology
8.8 Management
8.8.1 Medical Treatment
8.8.2 Surgical Treatment
8.9 Prognosis
References
9: Hypoparathyroidism
9.1 Overview
9.2 Epidemiology
9.2.1 North America
9.2.2 Europe
9.3 Etiology/Pathophysiology
9.3.1 PTH and Mineral Homeostasis
9.3.2 Post-surgical Hypoparathyroidism (Extirpation of the PTG—Parathyroidectomy)
9.3.3 Inherited (Genetic) Causes of Hypoparathyroidism
9.3.3.1 Pathophysiology of Inherited Causes of Hypoparathyroidism
9.3.3.2 Individual Hereditary Causes
Autoimmune Polyendocrine Syndrome—Type 1 (APS-1)
DiGeorge Syndrome: Type 1
DiGeorge Syndrome: Type 2
CHARGE Syndrome
Hypoparathyroidism, Sensorineural Deafness and Renal Disease (HRD) Syndrome
Mitochondrial Disorders Associated with Hypoparathyroidism
Inherited Bone Dysplasias Associated with Hypoparathyroidism
Autosomal Dominant Hypocalcemia
9.3.3.3 Autosomal Forms of Hypoparathyroidism
X-Linked Recessive Hypoparathyroidism
9.3.4 Non-hereditary Causes (Rare)
9.4 Clinical Manifestations
9.4.1 Occult Condition
9.4.2 Peripheral Nervous System: Manifestations of Tetany
9.4.2.1 Overt Tetany
9.4.2.2 Latent Tetany
9.4.3 Central Nervous System (CNS)
9.4.3.1 Seizures
9.4.3.2 Ectopic Calcifications
9.4.4 Cardiovascular System
9.4.5 Renal System: Impairment Manifestations
9.4.6 Musculo-Skeletal and Dental System
9.4.6.1 Bones
9.4.6.2 Skeletal Muscles
9.4.6.3 Teeth
9.4.7 Ophthalmological System
9.4.8 Dermatological System
9.4.9 Neuro-Psychiatric System
9.5 Investigations/Assessment
9.5.1 Biochemical Tests
9.5.1.1 Measurement of Serum PTH Levels: Generations of PTH Assay
9.5.2 Imaging Studies
9.5.3 Electrocardiographic (ECG) Changes
9.5.4 Monitoring
9.6 Differential Diagnosis
9.7 Management
9.7.1 Screening
9.7.2 Prophylaxis
9.7.3 Conventional Therapy
9.7.3.1 Emergency Treatment (Acute Hypoparathyroidism)
9.7.3.2 Long-Term Treatment (Chronic Hypoparathyroidism)
Calcium Preparations
Magnesium (Mg) Supplements
Vitamin D (Metabolites and Analogues)
Thiazide Diuretics
Diet Control
9.7.4 Emerging Treatments
9.7.4.1 PTH Therapy: PTH 1–34 and PTH 1–84
Teriparatide (PTH 1–34) or (hPTH 1–34)
Natpara (Recombinant Human PTH) (rhPTH) 1–84
9.7.4.2 Safety of PTH Treatment
9.8 Quality of Life
9.9 Outlook
9.10 Pseudo-Hypoparathyroidism (PHP)
9.10.1 Epidemiology
9.10.2 Etiological Classification
9.10.2.1 Type 1a (PHP-1a)
9.10.2.2 Type 1b (PHP-1b)
9.10.2.3 Type 1c (PHP-1c)
9.10.2.4 Type 2 (PHP-2)
9.10.2.5 Pseudo-Pseudo-Hypoparathyroidism (PPHP)
9.10.3 Pathophysiology
9.10.3.1 Genetics
9.10.3.2 Testotoxicosis
9.10.3.3 Growth Plate Defects
9.10.4 Clinical Presentation
9.10.4.1 History (Symptoms)
9.10.4.2 Physical Examination
9.10.4.3 Albright Hereditary Osteodystrophy
9.10.5 Work-Up/Investigations
9.10.5.1 Laboratory Tests
9.10.5.2 Imaging Studies
9.10.5.3 Other Tests
9.10.5.4 Genetic Testing
9.10.6 Differential Diagnosis
9.10.7 Treatment
9.10.7.1 Approach Considerations
9.10.7.2 Calcium Salts
9.10.7.3 Vitamins (Fat-Soluble)
References
10: Metabolic Syndromes of Parathyroid Failure
10.1 Definitions of Parathyroid Failure Syndromes
10.1.1 Post-operative Hypocalcemia
10.1.2 Protracted Hypoparathyroidism
10.1.3 Permanent Hypoparathyroidism
10.2 Risk Factors of Parathyroid Failure
10.2.1 Post-operative Hypocalcemia
10.2.2 Protracted Hypoparathyroidism
10.2.3 Permanent Hypoparathyroidism
10.3 Likelihood of Recovery of Parathyroid Function
10.4 Summary
References
11: Hungry Bone Syndrome (HBS)
11.1 Definitions
11.1.1 Hungry Bone Syndrome
11.1.2 Factitious Hypocalcemia
11.2 “HBS” After Parathyroidectomy and Thyroidectomy
11.2.1 Introduction
11.2.2 Pathophysiology of HBS
11.2.3 Clinical Manifestations: Symptoms and Physical Examination
11.2.4 Epidemiology/Prevalence of HBS After Parathyroidectomy
11.2.5 Etiology
11.2.6 Risk Factors of Development of HBS
11.2.6.1 Age at Time of Surgery
11.2.6.2 Laboratory Investigations Before Surgery
Serum Calcium
Serum PTH
Alkaline Phosphatase
Vitamin D
11.2.6.3 Radiological Bone Disease Before Surgery
11.2.6.4 Volume and Weight of Resected Pathological Parathyroid Gland(s)
11.2.7 Biochemical Changes Associated with HBS
11.2.8 Radiological Changes Associated with HBS
11.2.9 Differential Diagnosis
11.2.10 Management of HBS: Calcium, Vitamin D, and Magnesium
11.2.11 Preventive Option of HBS
11.2.11.1 Pre-operative Treatment with Vitamin D
11.2.11.2 Pre-operative Treatment with Bisphosphonates
11.2.11.3 Pre-operative Treatment with Active Metabolites of Vitamin D
11.2.12 Prognosis
11.3 Proposed Mechanisms in Graves’ Disease
11.4 Summary
References
12: Post-thyroidectomy Hypocalcemia: Incidence and Risk Factors
12.1 Introduction
12.2 General Incidence
12.3 Risk Factors/Predictors of Post-thyroidectomy Hypocalcemia
12.3.1 Pre-operative Serum Level of Calcium
12.3.2 Pre-operative Serum Level Vitamin D
12.3.3 Parathyroid Hormone (PTH) Level
12.3.4 Post-operative Level of Serum Phosphorus (P) and Magnesium (Mg)
12.3.5 Gender
12.3.6 Age
12.3.7 Ethnicity
12.3.8 Operative Procedure (Extent of Surgery)
12.3.9 Carbon Nanoparticle Suspension (CNs) Injection
12.3.10 Identification of All Parathyroid Glands
12.3.11 Parathyroid Auto-transplantation
12.3.12 Thyroid Cancer
12.3.13 Graves’ Disease/Hyperthyroidism
12.3.14 Hungry Bone Syndrome (HBS)
12.3.15 Diabetes Mellitus (DM)
12.3.16 Type of Hospital/Surgeon’s Experience
12.3.17 Summary of Risk Factors According to Definition of Hypocalcemia
12.3.18 Summary of Risk Factors Reported in the Literature
References
13: Post-thyroidectomy Hypocalcemia: Clinical Presentation
13.1 Symptoms of Hypocalcemia
13.2 Signs of Hypocalcemia
13.3 Recovery from Hypocalcemia
References
14: Post-thyroidectomy Hypocalcemia: Prevention
14.1 Introduction
14.2 Modification of Operative Technique
14.3 Selective Calcium and Vitamin D Supplementation Post-operatively
14.4 Routine Calcium and Vitamin D Supplementation Post-operatively for All Patients
14.5 Pre-operative Calcium Supplementation for Patients with Graves’ Disease
14.6 Intravenous Calcium Injection Intra-operatively
14.7 Administration of iPTH Post-operatively
14.8 Parathyroid Auto-transplantation
References
15: Parathyroid Transplantation
15.1 Introduction
15.2 History of Parathyroid Gland Transplantation
15.3 Burden of Disease and Defining Parathyroid Failure
15.4 Risk Factors and Prevention of Hypoparathyroidism
15.4.1 Identifying Devascularized Glands
15.5 Parathyroid Transplantation: Modes of Application
15.5.1 Fresh Parathyroid Tissue Auto-Transplantation
15.5.1.1 Techniques
15.5.1.2 Sites for Auto-transplant
15.5.1.3 Selective Versus Routine Parathyroid Auto-Transplantation
15.5.1.4 IOPTH during Thyroidectomy for Selective Parathyroid Auto-Transplantation
15.5.1.5 Results of Fresh Parathyroid Auto-Transplantation
15.5.2 Cryo-Preserved Parathyroid Tissue Auto-Transplantation
15.5.2.1 Indications of Cryo-Preservation
Initial Neck Operations
Re-Do Neck Operations
15.5.2.2 Cryo-Preservation Technique
Parathyroid Tissue Preparation
Freezing Media
Freezing Process
15.5.2.3 Auto-Transplantation Technique
Thawing and Washing
Re-implantation
15.5.2.4 Functionality Assessment and Outcomes
Fully Functional Graft
Partially Functional Graft
Non-functional Graft
15.5.2.5 Effects of Cryo-Preservation—Cell Viability and Cell Function
15.5.2.6 Conclusion
15.5.3 Parathyroid Allo-Transplantation
15.5.3.1 Allo-Transplantation of Parathyroid Tissue
15.5.3.2 Allo-Transplantation of Cultured Parathyroid Cells
15.6 A Novel Device for Parathyroid Auto-Transplantation
15.7 Summary
References
16: Parathyroid Cancer
16.1 Introduction
16.2 Epidemiology
16.3 Etiology/Risk Factors
16.4 Pathogenesis
16.5 Clinical Presentation
16.6 Diagnosis
16.6.1 Pre-operative Diagnosis
16.6.1.1 Clinical Features
16.6.1.2 Laboratory Studies
16.6.1.3 Fine-Needle Aspiration Cytology (FNAC)
16.6.1.4 Imaging Techniques
Ultrasonography (US)
Sestamibi Scintigraphy (MIBI)/SPECT
Contrast Computed Tomography (CT) Scan
Magnetic Resonance Imaging (MRI)
Positron Emission Tomography (PET) Scan
Selective Venous Catheterization with PTH Measurements
16.6.2 Intra-operative Diagnosis
16.6.3 Post-operative Diagnosis
16.6.3.1 Gross Appearance
16.6.3.2 Histopathological Pathognomonic Criteria
16.6.3.3 Electron Microscopy
16.6.3.4 Flow Cytometry
16.6.3.5 Immunohistochemistry (IHC)
16.6.3.6 Genetics
16.7 Staging
16.7.1 Staging: New AJCC
16.8 Prognosis
16.9 Treatment
16.9.1 Surgical Treatment
16.9.1.1 En-Bloc Resection
16.9.1.2 More Extended Procedures
16.9.1.3 Lymph Node Dissection
16.9.1.4 When Diagnosis Is Made Post-operatively
16.9.1.5 Recurrent Disease
16.9.1.6 Distant Metastases
16.9.2 Medical and Adjuvant Treatments
16.9.2.1 Fluid Volume Restoration and Diuretics
16.9.2.2 Bisphosphonates
16.9.2.3 Mithramycin (Plicamycin)
16.9.2.4 Calcitonin
16.9.2.5 Corticosteroids
16.9.2.6 Amifostine and Gallium Nitrate (Ganite)
16.9.2.7 Calcinomimetic: Cinacalcet
16.9.2.8 Octreotide
16.9.2.9 WR-2721
16.9.2.10 Anti-parathyroid Immunotherapy
16.9.2.11 Dendritic Cell Immunotherapy
16.9.2.12 Denosumab
16.9.2.13 Radiotherapy
16.9.2.14 Chemotherapy
16.9.2.15 Embolization
16.9.3 Ablative Therapy
16.9.4 New Developments/Future Treatment
16.9.5 Surveillance/Follow-Up
16.10 Summary
References
17: Intra-operative Tools in Parathyroidectomy
17.1 Background
17.2 Methylene Blue (MB)
17.3 Frozen-Section (FS)
17.4 Gamma Probe
17.5 Intra-operative 3-D Mapping Using F-Spect
17.6 Intra-operative Parathyroid Hormone (IOPTH)
17.7 Intra-operative Ultrasound (IOUS)
17.8 Intra-operative Fluorescence
References
18: Parathyroidectomy
18.1 Background
18.2 Indications
18.3 Contraindications
18.4 Pre-procedural Care
18.4.1 Pre-procedural Planning
18.4.2 Pre-operative Parathyroid Localization
18.4.3 Equipment
18.4.4 Anesthesia
18.4.5 Positioning
18.5 Technique
18.5.1 Approach Considerations
18.5.2 Steps of the Procedure
18.6 Methods of Parathyroidectomy
18.6.1 Bilateral Neck Exploration (BNE)
18.6.2 Minimally Invasive Parathyroidectomy (MIP) (Non-endoscopic)
18.6.3 Minimally-Invasive Radio-Guided Parathyroidectomy (MIRP)
18.6.4 Video-Assisted Parathyroidectomy (VAP)
18.6.4.1 Advantages and Disadvantages
18.6.4.2 Contraindications
18.6.4.3 Patient’s Position
18.6.4.4 Anesthesia
18.6.4.5 Parathyroid Hormone Level Measurement
18.6.4.6 Site Preparation
18.6.4.7 Position of the Surgical Team
18.6.4.8 Instruments
18.6.4.9 Steps of the Procedure
18.6.4.10 Special Situations
18.6.4.11 Outcome
18.7 Complications
References