Preserving and preventing damage to a child’s calcium-regulating parathyroid glands — a rice-sized organ — during thyroid surgery is important, though not always possible.
A recent study from researchers at Monroe Carell Jr. Children’s Hospital at Vanderbilt shows that a procedure known as parathyroid gland (PG) auto-transplantation, or reimplanting pieces of the tiny organ back into the body, shows promise as an effective option to restore the glands’ function in children.
Damage or removal of calcium-regulating parathyroid glands during endocrine surgery can put children at risk for poor growth and slow mental development. Ryan Belcher, MD, MPH, surgical co-director of the Vanderbilt Pediatric Thyroid Nodule and Cancer Program, has been studying ways to decrease, and possibly eliminate, any disease burden associated with permanent hypoparathyroidism resulting from a thyroidectomy or parathyroidectomy.
While the auto-transplantation procedure is not new, little research has been published about the technique and outcomes in children. During the procedure, the surgeon takes the removed parathyroid gland/glands (often attached to thyroid), cuts it into tiny pieces and transplants the pieces into the neck muscle (either in the sternocleidomastoid or strap muscles) or in the forearm.
“We found that overall that when we reimplanted the parathyroid glands in the sternocleidomastoid muscle, the success rate of avoiding hypocalcemia (low blood calcium) was better, possibly because the muscle is highly vascularized, compared to other muscles in the neck, making them more likely to receive the blood flow they require to work again,” said Belcher, associate professor of Otolaryngology–Head and Neck Surgery at Monroe Carell, study investigator and lead author.
Monroe Carell has become one of the leading pediatric surgery programs in the country for thyroidectomies, performing between 25 and 40 per year, in large part due to the multidisciplinary Vanderbilt Pediatric Thyroid Nodule and Cancer Program established at the hospital in 2021.
The study, “Outcome Analysis of Parathyroid Gland Auto-transplantation in Pediatric Patients: A Retrospective Review,” looked at pediatric patients, ages 18 and younger, who underwent parathyroid gland auto-transplantation following total thyroidectomy or parathyroidectomy at Monroe Carell between January 2000 and December 2022. Patients were identified through a comprehensive search of operative records and electronic medical records.
A total of 14 pediatric patients underwent PG auto-transplantation at Monroe Carell. Thirteen patients underwent thyroidectomy, and one underwent parathyroidectomy. In the study, 12, or 85.7%, of pediatric patients achieved normalized calcium levels within six months after PG auto-transplantation, indicating a high rate of successful engraftment. The remaining two patients, 14.3%, had permanent postoperative hypocalcemia.
Belcher says more research is needed to fully understand the impact of PG auto-transplantation in children. “There are certainly confounders in this retrospective research approach for this surgical technique and outcome, such as if the children had other functional parathyroid glands that were undisturbed during surgery,” Belcher said. “But given the limited information out there in the literature, we felt this was an important study to have some guidance on the procedure in the pediatric population.”
“It’s important not to draw large conclusions from a small subset of patients,” Belcher added. “It’s really important for us to evaluate this as a multi-institutional study — because children needing total thyroidectomies are decently rare — as the multi-institutional approach can accrue a high volume of data on this surgical technique. This surgical technique is another tool in the surgeon’s armamentarium to help us give a child every chance to prevent permanent hypocalcemia.”
The study was published in the Annals of Otology, Rhinology & Laryngology. Other Vanderbilt study authors are Andrea Lopez, Shilin Zhao, PhD, Kaitlin July O’Brien, MD, and Sarah Rohde, MD, MMHC.
