Subtotal Glandectomy in Hyperparathyroidism
Hypercalcemia was detected in a 52-year-old female while being investigated because of recurrent renal stones. Metabolic profile revealed hypercalcemia with hypophosphatemia and elevated parathyroid hormone level. No pathological focus was demonstrated neither on neck ultrasonography nor 99mTechnetium-MIBI scintigraphy with single-photon emission computed tomography. Bilateral neck exploration was performed with the diagnosis of primary hyperparathyroidism (pHPT). All four parathyroid glands were observed to be enlarged during the exploration. Subtotal parathyroidectomy (sPTX) was performed. PHPT is a common endocrine disorder characterized by the excess production of PTH, resulting in the dysregulation of calcium metabolism. The diagnosis of pHPT is established due to biochemical examination. Imaging studies are not used to confirm the diagnosis but should be used for localization of the pathologic glands and determine the surgical strategy. Negative preoperative localization studies are highly predictive of multiglandular disease (MGD) in sporadic pHPT. Parathyroidectomy is indicated for all symptomatic patients and should be considered for most of the asymptomatic patients. MGD may not be excluded before surgery. The possibility of MGD in pHPT should always be kept in mind. sPTX is the standard treatment approach for patients with sporadic pHPT, whose all parathyroid glands are enlarged.
KeywordsPrimary hyperparathyroidism Multiglandular disease Bilateral neck exploration Subtotal parathyroidectomy Negative preoperative imaging
- 3.Bilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marcocci C, et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. J Clin Endocrinol Metab. 2014;99:3561–9. https://doi.org/10.1210/jc.2014-1413.CrossRefPubMedPubMedCentralGoogle Scholar
- 7.Siperstein A, Berber E, Barbosa GF, Tsinberg M, Greene AB, Mitchell J, Milas M. Predicting the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi, and intraoperative parathyroid hormone: analysis of 1158 cases. Ann Surg. 2008;248:420–8. https://doi.org/10.1097/SLA.0b013e3181859f71.CrossRefPubMedGoogle Scholar
- 12.Khan AA, Hanley DA, Rizzoli R, Bollerslev J, Young JE, Rejnmark L, et al. Primary hyperparathyroidism: review and recommendations on evaluation, diagnosis, and management. A Canadian and international consensus. Osteoporos Int. 2017;28:1–19. https://doi.org/10.1007/s00198-016-3716-2.CrossRefPubMedGoogle Scholar
- 14.Lorenz K, Bartsch DK, Sancho JJ, Guigard S, Triponez F. Surgical management of secondary hyperparathyroidism in chronic kidney disease--a consensus report of the European Society of Endocrine Surgeons. Langenbeck’s Arch Surg. 2015;400:907–27. https://doi.org/10.1007/s00423-015-1344-5.CrossRefGoogle Scholar