Original Article
Surgical Management of Primary Hyperparathyroidism

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Abstract

Primary hyperparathyroidism (PHPT) is a common endocrine disorder in which the inappropriate elevation in serum parathyroid hormone level results in hypercalcemia. Most cases are caused by a single adenomatous parathyroid gland and less than 15% are caused by multiglandular disease. The incidence of PHPT appears to be increasing. More patients are being identified earlier and often before symptoms develop. Parathyroidectomy is the only definitive management; with it, the patient can achieve biochemical homeostasis and symptom relief, and sequelae are prevented. Even for asymptomatic patients with PHPT, there is a growing trend to recommend early surgical intervention. Controversy continues regarding the role of and reliance on various technologies, such as preoperative localization imaging, intraoperative parathyroid hormone level measurements, and minimally invasive surgery. Although both traditional bilateral 4-gland exploration and targeted approaches are accepted surgical techniques, there is a growing trend in unilateral targeted operations often using these technologies. Regardless of surgical approach, the expected success rate is greater than 95%. This article provides an overview of the contemporary surgical management of PHPT.

Introduction

Primary hyperparathyroidism (PHPT) is the third most common disorder of the endocrine system characterized by persistently elevated serum calcium caused by an inappropriately elevated serum parathyroid hormone (PTH) level (1). The incidence appears to be increasing with PHPT being diagnosed in approximately 1% of the population (2). The disease disproportionately affects females with a ratio of 3:1 3, 4, 5, 6, 7, 8.

In 80%–85% of cases, PHPT is due to a single parathyroid adenoma (PTA). The remaining cases include multiglandular diseases, such as multiple adenomas, parathyroid gland hyperplasia, and rarely, parathyroid carcinoma. Most cases of PTA are spontaneous but rarely may be related to an underlying familial condition such as the multiple endocrine neoplasia (MEN) syndromes, familial hypocalciuric hypercalcemia syndrome, or hyperparathyroidism-jaw tumor syndrome (9).

Parathyroidectomy is the only definitive treatment for PHPT, with expected success rates of more than 95%. Since Felix Mandl performed the first parathyroidectomy for a functioning PTA in 1925 (10), there have been numerous advances in both preoperative investigation and surgical approach. This review article serves to summarize current surgical management for PHPT by describing contemporary surgical techniques, popular imaging modalities, intraoperative tools, and emerging technologies.

Section snippets

Criteria for Surgical Intervention

Where “bones, groans, stones, and psychic overtones” described the classic clinical presentation of patients with PHPT, currently more than 85% of individuals present with asymptomatic disease (2). Furthermore, symptoms such as nonspecific pain, mood disturbances, or concentration and memory deficits are often mild or vague (11). Because of improved clinical awareness of the proven benefit of early intervention for asymptomatic patients or those with mild clinical manifestations of PHPT, most

Surgical Management

Surgery is the only definitive management for patients with PHPT in achieving biochemical homeostasis, symptom relief, and preventing sequelae 11, 16. For symptomatic patients, there is clear evidence that quality of life, as measured with validated assessment tools, has demonstrated significant improvements after surgical management 17, 18. However, as the available screening and diagnostic tests have increased in sensitivity, the dilemma of when to offer surgery particularly in asymptomatic

Preoperative Localization Imaging

The role and value of preoperative localization studies remains controversial and is often based on the philosophy of managing physicians. For surgeons who feel preoperative imaging is unnecessary, they argue in favor of bilateral exploration. This is based on the plan to explore both sides and that imaging is least helpful in the most difficult settings, such as smaller adenomas or multiglandular diseases. In contrast, a treatment algorithm that includes a targeted unilateral surgical

Parathyroidectomy

There has been a trend toward earlier detection and earlier surgical intervention for patients with PHPT. In addition to these changes, the differing views on operative techniques have arisen. At present, controversy persists between unilateral and bilateral neck exploration for the optimal surgical management of PHPT. Concurrent with these debates are differing views on the role of minimally invasive surgery (MIS), the role and optimal approach to preoperative radiological assessment and

Intraoperative PTH

Since the development of the rapid PTH assay, surgeons have used this technology in an attempt to confirm successful parathyroidectomy intraoperatively. Because the intact form of PTH has a half-life of less than 5 min, rapid intraoperative measurements are possible. The Miami criteria of successful parathyroidectomy require a more than 50% fall in PTH levels 10 min after removal of the suspected abnormal gland as compared with the highest preoperative PTH level 50, 51, 52, 53, 54. In addition

Conclusion

Parathyroidectomy is the only definitive treatment of PHPT and offers high cure rates. Both unilateral and bilateral surgical explorations are acceptable approaches, with specific surgical techniques that are dependent on patient, surgeon, and institution variables. Advances in preoperative localization imaging and the availability of rapid IOPTH have led to more patients treated by focused approaches to parathyroidectomy instead of mandatory bilateral exploration. Published NIH guidelines have

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