What is the evaluation for a parathyroidectomy (surgical removal of a parathyroid gland)?

From the Guidelines

Parathyroidectomy evaluation should prioritize a comprehensive approach, including preoperative localization of the abnormally functioning gland, intraoperative PTH monitoring, and postoperative calcium level monitoring, to ensure optimal outcomes and minimize complications, as supported by the most recent guidelines 1.

Preoperative Evaluation

Preoperatively, patients should undergo serum calcium, parathyroid hormone (PTH), vitamin D, phosphorus, and creatinine measurements to confirm the diagnosis of primary hyperparathyroidism (PHPT) and assess the severity of the disease. Localization studies such as ultrasound, sestamibi scan, or 4D-CT are essential to identify the abnormal gland and guide the surgical approach, with the goal of achieving a targeted curative surgery 1.

Intraoperative Evaluation

Intraoperatively, rapid PTH monitoring is crucial, with a drop of >50% from baseline within 10 minutes after gland removal indicating successful surgery. This approach helps to confirm the removal of the hyperfunctioning gland and reduces the risk of persistent or recurrent PHPT 1.

Postoperative Evaluation

Postoperatively, calcium levels should be monitored every 6 hours for 24 hours, then daily until stable, to prevent hypocalcemia and other complications. Patients should receive calcium supplementation with calcium carbonate 1000-2000mg three times daily and calcitriol 0.25-0.5mcg twice daily for 1-2 weeks to prevent hypocalcemia. Symptoms of hypocalcemia like tingling, muscle cramps, or tetany require immediate evaluation and treatment.

Long-term Follow-up

Long-term follow-up should include calcium and PTH measurements at 1 week, 6 months, and annually thereafter to confirm the surgical cure of hyperparathyroidism and monitor for potential complications or recurrence. This comprehensive approach is necessary because parathyroid surgery alters calcium homeostasis, and proper monitoring prevents complications like hungry bone syndrome or permanent hypoparathyroidism 1. Some key points to consider in parathyroidectomy evaluation include:

• The role of imaging in PHPT is to localize the abnormally functioning gland or glands with high accuracy and high confidence to facilitate targeted curative surgery 1.
• Parathyroid reoperations are surgically challenging, with lower cure rates than first-time surgery and higher complication rates, emphasizing the importance of accurate preoperative localization and intraoperative PTH monitoring 1.
• The choice of surgical approach, either bilateral neck exploration (BNE) or minimally invasive parathyroidectomy (MIP), depends on the specific patient characteristics and the presence of multigland disease (MGD) 1.

From the Research

Parathyroidectomy Evaluation

• Parathyroidectomy is advised in patients younger than 50 years old and in the presence of either significant hypercalcemia, impaired renal function, renal stones or osteoporosis 2
• The procedure is always appropriate in suitable surgical candidates, however, medical management may be considered in those with mild asymptomatic disease, contraindications to surgery or failed previous surgical intervention 2
• Studies have shown that parathyroidectomy can result in an increase in bone mineral density (BMD) and a reduction in nephrolithiasis 3
• A review of the literature on parathyroidectomy in the treatment of normocalcaemic primary hyperparathyroidism (nPHPT) revealed that nPHPT patients were more likely to present with multi-glandular disease and significantly less nPHPT patients had an intra-operative PTH fall of >50% compared with those with hypercalcaemic PHPT (hPHPT) 4
• Following surgery, improvements in bone mineral density (BMD) and renal stones are generally observed in those with nPHPT 4
• Parathyroidectomy compared to observation probably results in a large increase in cure rate at six to 24 months follow-up, with an overall cure rate of 99% 5
• The evidence suggests that parathyroidectomy compared to observation may have little or no effect on serious adverse events, all-cause mortality, and hospitalisation for hypercalcaemia 5

Indications for Parathyroidectomy

• Significant hypercalcemia
• Impaired renal function
• Renal stones
• Osteoporosis
• Patients younger than 50 years old
• Symptomatic patients

Outcomes of Parathyroidectomy

• Increase in bone mineral density (BMD)
• Reduction in nephrolithiasis
• Cure of primary hyperparathyroidism (PHPT)
• Improvement in renal stones
• Possible improvement in quality of life, although the evidence is very uncertain 5