Indications for Parathyroidectomy

The indications for parathyroidectomy in patients with parathyroid hyperplasia resulting from secondary HPT are (1) a calcium-to-phosphorus product greater than 70; (2) a serum calcium greater than 11.5 mg/dL; (3) symptoms of bone pain and pruritus; (4) osteitis fibrosa cystica; (6) tumoral calcinosis; and (7) calciphylaxis.33,34

With primary HPT, it is difficult to know preoperatively whether a patient will have a solitary adenoma or multiple abnormal parathyroid glands. The diagnosis of primary HPT is usually relatively easy to establish on the basis of hypercalcemia and an increased intact or two-site PTH level in a patient without hypocalciuria. Most patients with hypercalcemia lasting longer than 6 months have primary HPT. Some patients with primary HPT can be suspected of having multiple abnormal parathyroid glands on the basis of preoperative localization studies, although localization studies are unreliable in patients with multiple abnormal parathyroid glands35; that is, they often identify only one abnormal gland when more are present.

Because virtually all patients with primary HPT benefit symptomatically and metabolically and have improved survival after successful parathyroidectomy, we recommend parathyroid exploration and parathyroidectomy for most patients when a surgeon experienced in this field is available.36 When parathyroidectomy is performed by an experienced surgeon, the complication rate is less than 1 %, blood transfusions are not required, and the duration of hospitalization is usually 1 day, unless the patient has severe osteitis fibrosa cystica or other serious preoperative medical problems.36'37 Patients with osteitis fibrosa cystica can be identified preoperatively because they have elevated serum alkaline phosphatase levels.38 Radiographs of the hands in such patients are useful for documenting subperiosteal resorption (Fig. 53-6).

FIGURE 53-6. Radiograph of hands in patient with hyperparathyroidism; osteitis fibrosa cystica is also shown. Subperiosteal resorption is best seen on the radial aspect of the middle digit of the second and third phalanges.
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