Top

Published in:

Open Access 01-02-2019 | Hyperparathyroidism | Original Article

The prevalence and anatomy of parathyroid glands: a meta-analysis with implications for parathyroid surgery

Authors: Dominik Taterra, Linda M. Wong, Jens Vikse, Beatrice Sanna, Przemysław Pękala, Jerzy Walocha, Roberto Cirocchi, Krzysztof Tomaszewski, Brandon Michael Henry

Published in: Langenbeck's Archives of Surgery | Issue 1/2019

Abstract

Purpose

The anatomy of parathyroid glands (PTG) is highly variable in the population. The aim of this study was to conduct a systematic analysis on the prevalence and location of PTG in healthy and hyperparathyroidism (HPT) patients.

Methods

An extensive search of the major electronic databases was conducted to identify all studies that reported relevant data on the number of PTG per patient and location of PTG. The data was extracted from the eligible studies and pooled into a meta-analysis.

Results

The overall analysis of 26 studies (n = 7005 patients; n = 23,519 PTG) on the number of PTG showed that 81.4% (95% CI 65.4–85.8) of patients have four PTG. A total of 15.9% of PTG are present in ectopic locations, with 11.6% (95% CI 5.1–19.1) in the neck and 4.3% (95% CI 0.7–9.9) in mediastinum. The subgroup analysis of ectopic PTG showed that 51.7% of ectopic PTG in the neck are localized in retroesophageal/paraesophageal space or in the thyroid gland. No significant differences were observed between the healthy and HPT patients and cadaveric and intraoperative studies.

Conclusions

Knowledge regarding the prevalence, location, and anatomy of PTG is essential for surgeons planning for and carrying out parathyroidectomies, as any unidentified PTG, either supernumerary or in ectopic location, can result in unsuccessful treatment and need for reoperation.

Available only for authorised users

Apetrii M, Goldsmith D, Nistor I, Siriopol D, Voroneanu L, Scripcariu D, Vervloet M, Covic A (2017) Impact of surgical parathyroidectomy on chronic kidney disease-mineral and bone disorder (CKD-MBD)—a systematic review and meta-analysis. PLoS One 12:e0187025. https://doi.org/10.1371/journal.pone.0187025 CrossRefPubMedPubMedCentral

Akerström G, Malmaeus J, Bergström R (1984) Surgical anatomy of human parathyroid glands. Surgery 95:14–21PubMed

Policeni BA, Smoker WRK, Reede DL (2012) Anatomy and embryology of the thyroid and parathyroid glands. Semin Ultrasound CT MR 33:104–114. https://doi.org/10.1053/j.sult.2011.12.005 CrossRefPubMed

Higgins JP, Green S (2008) Cochrane handbook for systematic reviews of interventions. Wiley, ChichesterCrossRef

Henry BM, Tomaszewski KA, Walocha JA (2016) Methods of evidence-based anatomy: a guide to conducting systematic reviews and meta-analysis of anatomical studies. Ann Anat 205:16–21. https://doi.org/10.1016/J.AANAT.2015.12.002 CrossRefPubMed

Abboud B, Sleilaty G, Braidy C, Ghorra C, Abadjian G, Tohme C, Noun R, Sarkis R (2008) Enlarged parathyroid glands discovered in normocalcemic patients during thyroid surgery. Am J Surg 195:30–33. https://doi.org/10.1016/j.amjsurg.2007.01.033 CrossRefPubMed

Alveryd A (1968) Parathyroid glands in thyroid surgery. I. Anatomy of parathyroid glands. II. Postoperative hypoparathyroidism—identification and autotransplantation of parathyroid glands. Acta Chir Scand 389:1–120PubMed

Arnalsteen L, Proye C (2003) Surgery of hyperparathyroidism and of its potential recurrence in the MEN I setting. Ann Chir 128:706–709CrossRefPubMed

Botelho JBL, Cançado ARS, de Sousa EA (2004) Importância anatomocirúrgica das características macroscópicas, localização e suprimento vascular das glândulas paratireóides cervicais. Rev Col Bras Cir 31:132–138. https://doi.org/10.1590/S0100-69912004000200011 CrossRef

10.

Butterworth PC, Nicholson ML (1998) Surgical anatomy of the parathyroid glands in secondary hyperparathyroidism. J R Coll Surg Edinb 43:271–273PubMed

11.

de Andrade JSC, Mangussi-Gomes JP, da Rocha LA, Ohe MN, Rosano M, das Neves MC, Santos RO (2014) Localization of ectopic and supernumerary parathyroid glands in patients with secondary and tertiary hyperparathyroidism: surgical description and correlation with preoperative ultrasonography and Tc99m-Sestamibi scintigraphy. Braz J Otorhinolaryngol 80:29–34. https://doi.org/10.5935/1808-8694.20140008 CrossRefPubMed

12.

Edis AJ, Levitt MD (1987) Supernumerary parathyroid glands: implications for the surgical treatment of secondary hyperparathyroidism. World J Surg 11:398–401CrossRefPubMed

13.

Ghandur-Mnaymneh L, Cassady J, Hajianpour MA et al (1986) The parathyroid gland in health and disease. Am J Pathol 125:292–299PubMedPubMedCentral

14.

Gilmour JR (1938) The gross anatomy of the parathyroid glands. J Pathol Bacteriol 46:133–149. https://doi.org/10.1002/path.1700460113 CrossRef

15.

Gomes EMS, Nunes RC, Lacativa PGS, Almeida MH, Franco FM, Leal CTS, Patrício Filho PJM, Farias MLF, Gonçalves MDC (2007) Ectopic and extranumerary parathyroid glands location in patients with hyperparathyroidism secondary to end stage renal disease. Acta Cir Bras 22:105–109. https://doi.org/10.1590/S0102-86502007000200005 CrossRefPubMed

16.

Heinbach WF (1933) A study of the number and location of the parathyroid glands in man. Anat Rec 57:251–261. https://doi.org/10.1002/ar.1090570305 CrossRef

17.

Hellman P, Skogseid B, Öberg K et al (1998) Primary and reoperative parathyroid operations in hyperparathyroidism of multiple endocrine neoplasia type 1. Surgery 124:993–999. https://doi.org/10.1016/S0039-6060(98)70040-6 CrossRefPubMed

18.

Hibi Y, Tominaga K, Uchida K et al (2002) Cases with fewer than four parathyroid glands in patients with renal hyperparathyroidism at initial parathyroidectomy. World J Surg 26:314–317. https://doi.org/10.1007/s00268-001-0224-z CrossRefPubMed

19.

Hojaij F, Vanderlei F, Plopper C, Rodrigues CJ, Jácomo A, Cernea C, Oliveira L, Marchi L, Brandão L (2011) Parathyroid gland anatomical distribution and relation to anthropometric and demographic parameters: a cadaveric study. Anat Sci Int 86:204–212. https://doi.org/10.1007/s12565-011-0111-0 CrossRefPubMed

20.

Kawata R, Kotetsu L, Takamaki A, Yoshimura K, Takenaka H (2009) Ultrasonography for preoperative localization of enlarged parathyroid glands in secondary hyperparathyroidism. Auris Nasus Larynx 36:461–465. https://doi.org/10.1016/j.anl.2008.10.008 CrossRefPubMed

21.

Lappas D, Noussios G, Anagnostis P, Adamidou F, Chatzigeorgiou A, Skandalakis P (2012) Location, number and morphology of parathyroid glands: results from a large anatomical series. Anat Sci Int 87:160–164. https://doi.org/10.1007/s12565-012-0142-1 CrossRefPubMed

22.

Milas M, Wagner K, Easley KA, Siperstein A, Weber CJ (2003) Double adenomas revisited: nonuniform distribution favors enlarged superior parathyroids (fourth pouch disease). Surgery 134:995–1003. https://doi.org/10.1016/j.surg.2003.07.009 CrossRefPubMed

23.

Nanka O, Sedý J, Vítková I, Libánský P, Adámek S (2006) Surgical anatomy of parathyroid glands with emphasis on parathyroidectomy. Prague Med Rep 107:261–272PubMed

24.

Numano M, Tominaga Y, Uchida K, Orihara A, Tanaka Y, Takagi H (1998) Surgical significance of supernumerary parathyroid glands in renal hyperparathyroidism. World J Surg 22:1098–1102 discussion 1103 CrossRefPubMed

25.

Okada M, Tominaga Y, Yamamoto T, Hiramitsu T, Narumi S, Watarai Y (2016) Location frequency of missed parathyroid glands after parathyroidectomy in patients with persistent or recurrent secondary hyperparathyroidism. World J Surg 40:595–599. https://doi.org/10.1007/s00268-015-3312-1 CrossRefPubMed

26.

Pacini P, Biondi G, Cicchi P et al. (1983) The number and topographical location of parathyroid glands in man. Arch Ital Anat Embriol 88:177–190PubMed

27.

Périé S, Fessi H, Tassart M, Younsi N, Poli I, St Guily JL, Talbot JN (2005) Usefulness of combination of high-resolution ultrasonography and dual-phase dual-isotope iodine 123/technetium Tc 99m sestamibi scintigraphy for the preoperative localization of hyperplastic parathyroid glands in renal hyperparathyroidism. Am J Kidney Dis 45:344–352. https://doi.org/10.1053/J.AJKD.2004.10.021 CrossRefPubMed

28.

Pool EH, Falk HC (1916) Concerning the surgrical anatomy of the thyroid with special reference to the parathyroid glands. Ann Surg 63:71–77CrossRefPubMedPubMedCentral

29.

Praženica P, O’Keeffe L, Holý R (2015) Dissection and identification of parathyroid glands during thyroidectomy: association with hypocalcemia. Head Neck 37:393–399. https://doi.org/10.1002/hed.23613 CrossRefPubMed

30.

Pyrtek L, Painter RL (1964) An anatomic study of the relationship of the parathyroid glands to the recurrent laryngeal nerve. Surg Gynecol Obstet 119:509–512PubMed

31.

Wang C (1976) The anatomic basis of parathyroid surgery. Ann Surg 183:271–275CrossRefPubMedPubMedCentral

32.

Tomaszewski KA, Henry BM, Pękala PA, Standring S, Tubbs RS (2018) The new frontier of studying human anatomy: introducing evidence-based anatomy. Clin Anat 31:4–5. https://doi.org/10.1002/ca.22994 CrossRefPubMed

33.

Anderson K, Ruel E, Adam MA et al (2017) Subtotal vs. total parathyroidectomy with autotransplantation for patients with renal hyperparathyroidism have similar outcomes. Am J Surg 214:914–919. https://doi.org/10.1016/j.amjsurg.2017.07.018 CrossRefPubMed

34.

Stephen AE, Mannstadt M, Hodin RA (2017) Indications for surgical management of hyperparathyroidism. JAMA Surg 152:878–882. https://doi.org/10.1001/jamasurg.2017.1721 CrossRefPubMed

35.

Rubin MR, Bilezikian JP, McMahon DJ et al (2008) The natural history of primary hyperparathyroidism with or without parathyroid surgery after 15 years. J Clin Endocrinol Metab 93:3462–3470. https://doi.org/10.1210/jc.2007-1215 CrossRefPubMedPubMedCentral

36.

Bilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marcocci C, Potts JT Jr (2014) Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the fourth international workshop. J Clin Endocrinol Metab 99:3561–3569. https://doi.org/10.1210/jc.2014-1413 CrossRefPubMedPubMedCentral

37.

Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh QY, Doherty GM, Herrera MF, Pasieka JL, Perrier ND, Silverberg SJ, Solórzano CC, Sturgeon C, Tublin ME, Udelsman R, Carty SE (2016) The American Association of Endocrine Surgeons Guidelines for definitive management of primary hyperparathyroidism. JAMA Surg 151:959. https://doi.org/10.1001/jamasurg.2016.2310 CrossRefPubMed

38.

Carneiro-Pla D (2009) Recent findings in the use of intraoperative parathyroid hormone monitoring in parathyroid disease. Curr Opin Oncol 21:18–22CrossRefPubMed

39.

Gilat H, Cohen M, Feinmesser R, Benzion J, Shvero J, Segal K, Ulanovsky D, Shpitzer T (2005) Minimally invasive procedure for resection of a parathyroid adenoma: the role of preoperative high-resolution ultrasonography. J Clin Ultrasound 33:283–287. https://doi.org/10.1002/jcu.20131 CrossRefPubMed

40.

Borley NR, Collins REC, O’Doherty M, Coakley A (1996) Technetium-99m sestamibi parathyroid localization is accurate enough for scan-directed unilateral neck exploration. Br J Surg 83:989–991. https://doi.org/10.1002/bjs.1800830734 CrossRefPubMed

41.

McHenry CR, Lee K, Saadey J, Neumann DR, Esselstyn CB Jr (1996) Parathyroid localization with technetium-99m-sestamibi: a prospective evaluation. J Am Coll Surg 183:25–30PubMed

42.

Haber RS, Kim CK, Inabnet WB (2002) Ultrasonography for preoperative localization of enlarged parathyroid glands in primary hyperparathyroidism: comparison with (99m) technetium sestamibi scintigraphy. Clin Endocrinol 57:241–249CrossRef

43.

Mohebati A, Shaha AR (2012) Imaging techniques in parathyroid surgery for primary hyperparathyroidism. Am J Otolaryngol 33:457–468. https://doi.org/10.1016/j.amjoto.2011.10.010 CrossRefPubMed

44.

Harari A, Zarnegar R, Lee J, Kazam E, Inabnet WB III, Fahey TJ III (2008) Computed tomography can guide focused exploration in select patients with primary hyperparathyroidism and negative sestamibi scanning. Surgery 144:970–977. https://doi.org/10.1016/j.surg.2008.08.029 CrossRefPubMed

Title: The prevalence and anatomy of parathyroid glands: a meta-analysis with implications for parathyroid surgery
Authors: Dominik Taterra
Linda M. Wong
Jens Vikse
Beatrice Sanna
Przemysław Pękala
Jerzy Walocha
Roberto Cirocchi
Krzysztof Tomaszewski
Brandon Michael Henry
Publication date: 01-02-2019
Publisher: Springer Berlin Heidelberg
Keywords: Hyperparathyroidism
Parathyroidectomy
Parathyroidectomy
Published in: Langenbeck's Archives of Surgery / Issue 1/2019
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI: https://doi.org/10.1007/s00423-019-01751-8

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

The prevalence and anatomy of parathyroid glands: a meta-analysis with implications for parathyroid surgery

Abstract

Purpose

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2019

Poorly differentiated thyroid carcinoma and poorly differentiated area in differentiated thyroid carcinoma: is there any difference?

Can preoperative vitamin D deficiency predict postoperative hypoparathyroidism following thyroid surgery?

Stringent fluid management might help to prevent postoperative ileus after loop ileostomy closure

Red blood cell transfusion in liver resection

Contemporary practice and short-term outcomes after liver resections in a complete national cohort

Main pancreatic duct dilation greater than 6 mm is associated with an increased risk of high-grade dysplasia and cancer in IPMN patients