Indications for Parathyroid Resection
Parathyroidectomy should be performed in patients with severe hyperparathyroidism when intact PTH persistently exceeds 800 pg/mL accompanied by hypercalcemia and/or hyperphosphatemia that fails to respond to medical management. 1
Primary Hyperparathyroidism
Absolute Surgical Indications
- All symptomatic patients should undergo parathyroidectomy regardless of biochemical parameters 2
- Asymptomatic patients should be strongly considered for surgery, as it is more cost-effective than observation or pharmacologic therapy 2
Specific Clinical Scenarios
- Hypercalcemia with elevated PTH represents the classic indication for surgical intervention 3
- Target organ disease (bone disease, kidney stones, cardiovascular dysfunction, neuropsychological symptoms) warrants surgery even in normocalcemic patients 4
- Normocalcemic primary hyperparathyroidism with symptoms or target organ damage should be treated surgically, as outcomes are equivalent to hypercalcemic patients 4
Secondary Hyperparathyroidism (CKD-Related)
Biochemical Thresholds
- PTH >800 pg/mL persistently with hypercalcemia and/or hyperphosphatemia refractory to medical therapy 1, 5
- Some centers use PTH >1000 pg/mL as the threshold when associated with hypercalcemia or medical refractoriness 6
Clinical Indications Beyond PTH Levels
- Calciphylaxis with PTH >500 pg/mL, as surgical intervention has documented clinical improvement 5
- Failure of optimal medical management despite dietary phosphate restriction, phosphate binders, and vitamin D sterols 5
- Severe bone disease or extraskeletal calcification refractory to medical therapy 6
Important Caveat
The indications are not rigidly defined, and no absolute biochemical criteria predict when medical therapy will fail 5. However, do not perform parathyroidectomy in calciphylaxis patients without documented hyperparathyroidism 5.
Post-Transplant Hyperparathyroidism
- Persistent hypercalcemia post-kidney transplant, particularly when serum calcium ≥11.5 mg/dL 5
- Calciphylaxis development in transplant recipients 5
Surgical Technique Options
Both approaches are equally effective, with choice at surgeon's discretion 1, 5:
Subtotal Parathyroidectomy
- Removes 3-3.5 glands with vascularized remnant left in situ 7
- Lower risk of permanent hypoparathyroidism 3
- May have higher persistent hyperparathyroidism rates 7
Total Parathyroidectomy with Autotransplantation
- Removes all parathyroid tissue with forearm autograft 1
- Faster PTH normalization and easier management of recurrence 1, 3
- Slightly higher hypoparathyroidism risk 3
- Avoid in potential kidney transplant candidates due to problematic calcium control 8
Total Parathyroidectomy Without Autotransplantation
- Fastest reduction in calcium and PTH 3
- Highest risk of permanent hypoparathyroidism 3
- Reserved for specific circumstances 6
Pre-operative Imaging
- Not routinely necessary for initial surgery 5
- Mandatory for re-exploration surgery: Use 99Tc-Sestamibi scan, ultrasound, CT, or MRI 1, 5
- Cervical ultrasonography recommended for operative planning in primary hyperparathyroidism 2
- Non-localizing imaging does not exclude surgical candidacy 2
Critical Pitfalls to Avoid
- Do not delay surgery waiting for arbitrary PTH thresholds if patient has symptomatic disease or target organ damage 2, 4
- Do not perform preoperative parathyroid biopsy 2
- Ensure surgeon has high-volume experience, as outcomes are volume-dependent 2
- Always consider multigland disease possibility, especially in normocalcemic patients (13% vs 6.8% in hypercalcemic) 4
- Transcervical thymectomy must accompany surgery in MEN-1 patients 7