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Parathyroid exploration for primary hyperparathyroidism

Authors
Nancy D Perrier, MD, FACS
Paxton V Dickson, MD
Angelica Silva Figueroa, MD
Section Editors
Sally E Carty, MD, FACS
Clifford J Rosen, MD
Deputy Editor
Wenliang Chen, MD, PhD

INTRODUCTION

Primary hyperparathyroidism (PHPT) is typically diagnosed when hypercalcemia is detected incidentally on routine biochemical screening [1]. However, hyperparathyroidism and hypercalcemia can lead to an array of symptoms, as described below. Parathyroidectomy provides definitive therapy for PHPT and is recommended for all patients with symptomatic disease, selected patients with asymptomatic disease, and patients with familial disease.

The surgical treatment for PHPT will be reviewed here. The medical management of hyperparathyroidism, surgical anatomy of the parathyroid glands, multiple endocrine neoplasia type 1, and the role of preoperative localization are discussed elsewhere. (See "Surgical anatomy of the parathyroid glands" and "Preoperative localization for parathyroid surgery in patients with primary hyperparathyroidism" and "Primary hyperparathyroidism: Management" and "Multiple endocrine neoplasia type 1: Clinical manifestations and diagnosis".)

INDICATIONS

Once a diagnosis of primary hyperparathyroidism has been biochemically confirmed, a decision regarding surgical intervention versus observation must be made. The recommendations vary depending on whether the patient is symptomatic, asymptomatic, or has familial hyperparathyroidism. (See "Primary hyperparathyroidism: Management".)

Symptomatic primary hyperparathyroidism — Surgical intervention is recommended for patients with biochemically confirmed hyperparathyroidism who present with symptomatic disease. Clinical manifestations include polydipsia and polyuria, nephrolithiasis, osteoporosis, fragility fractures, pancreatitis, peptic ulcer disease, gastroesophageal reflux, and significant neurocognitive dysfunction [2]. (See "Primary hyperparathyroidism: Clinical manifestations".)

Asymptomatic primary hyperparathyroidism — Asymptomatic primary hyperparathyroidism refers to patients without objective features of disease such as osteoporosis or nephrolithiasis. Although some of these patients may be truly asymptomatic, many have nonspecific and often subtle symptoms such as fatigue, depression, irritability, anxiety, anorexia, and difficulty with concentration or memory impairment. These subjective symptoms are often difficult to quantify and are frequently not fully appreciated until successful surgical intervention unmasks an improvement in these complaints [3]. Completely asymptomatic primary hyperparathyroidism is uncommon. Surgical intervention is indicated in asymptomatic patients who are <50 years of age and in patients considered likely to progress to symptomatic disease based upon their serum calcium level (>1 mg/dL above normal), glomerular filtration rate, and bone density (revealing a T score <-2.5) [3,4]. The management of asymptomatic patients is discussed in detail elsewhere. (See "Primary hyperparathyroidism: Management".)

                                                 

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