Operative Treatment

Although successful parathyroid operations have been done since the first successful operation in Vienna in 1925 by Felix Mandl, there has been controversy regarding the surgical management of the parathyroid glands in patients with primary and secondary hyperplasia.39

Cope40 identified patients with primary hyperplasia and recommended subtotal parathyroidectomy. Stanbury,41 in 1960, recommended a similar operation for patients with secondary HPT resulting from renal failure. Ogg, in 1967, recommended total parathyroidectomy without autotransplantation in patients with secondary (renal) HPT.42"45 Although this operation may be acceptable for patients who are not candidates for kidney transplantation, aparathyroid patients are extremely difficult to manage metabolically after successful renal transplantation, and we do not believe these patients should undergo total parathyroidectomy. Aparathyroid patients with chronic renal failure can also acquire low-turnover bone disease with increased bone pain.

Alveryd and associates, in 1968,70 first recommended total parathyroidectomy with parathyroid autotransplantation into the muscle in the neck. Wells and colleagues,46 47 in 1973, recommended autotransplantation into the forearm muscle so that one could document whether the autotransplanted hyperplastic parathyroid tissue was functioning by sampling the blood for PTH in a vein just proximal to the transplant site.48 Wells,4647 Wagner,49 and Brennan50 and their colleagues subsequently documented the effectiveness of cryopreserving parathyroid tissue for patients who may or may not have any remaining parathyroid after parathyroidectomy. Unfortunately, cryopreserved parathyroid tissue functions adequately only in about 60% of patients, whereas primarily autotransplanted parathyroid tissue functions adequately in about 90% to 95% of patients.51"55

We recommend subtotal rather than total parathyroidectomy with autotransplantation for virtually all patients with primary or secondary HPT and parathyroid hyperplasia.56 We base this recommendation on our own experience as well as on a review of the literature. We realize that other endocrine surgeons recommend total parathyroidectomy with primary autotransplantation, especially for patients with familial disease or secondary HPT because of the higher recurrence rate in these patients.56"58 We also recommend total parathyroidectomy and autotransplantation for patients with neonatal HPT, because the recurrence rate is very high,4159 and in noncompliant patients with secondary HPT. We cryopreserve parathyroid tissue in virtually all our patients treated with either subtotal or total parathyroidectomy and for all patients requiring reoperation.

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