Figure 2. IPM indicates intraoperative parathyroid hormone monitoring. Audio Author Interview Parathyroid Carcinoma in Large Retrospective Series. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop.
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The long-term benefit of parathyroidectomy in primary hyperparathyroidism: a year prospective surgical outcome study. Prospective surgical outcome study of relief of symptoms following surgery in patients with primary hyperparathyroidism. Surgical treatment of hyperparathyroidism improves health-related quality of life. Arch Surg. Surgery or surveillance for mild asymptomatic primary hyperparathyroidism: a prospective, randomized clinical trial. Cost-effectiveness analysis of parathyroidectomy for asymptomatic primary hyperparathyroidism.
Vestergaard P, Mosekilde L. Cohort study on effects of parathyroid surgery on multiple outcomes in primary hyperparathyroidism. Symptoms of gastroesophageal reflux disease improve after parathyroidectomy.
Risk of renal stone events in primary hyperparathyroidism before and after parathyroid surgery: controlled retrospective follow up study. Age as a criterion for surgery in primary hyperparathyroidism.
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The natural history of primary hyperparathyroidism with or without parathyroid surgery after 15 years. Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography. Minimizing cost and maximizing success in the preoperative localization strategy for primary hyperparathyroidism.
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Diagnosis and Management of Primary Hyperparathyroidism. This JAMA Insights article reviews the presentation and diagnostic workup of primary hyperparathyroidism, and indications for surgical vs surveillance management. Save Preferences. Privacy Policy Terms of Use. This Issue. Views , Citations View Metrics. Twitter Facebook More LinkedIn. Special Communication. October Scott M.
Wilhelm, MD 1 ; Tracy S. Ruan, MD 3 ; et al James A. Lee, MD 4 ; Sylvia L. Doherty, MD 7 ; Miguel F. Pasieka, MD 9 ; Nancy D. Perrier, MD 10 ; Shonni J. Silverberg, MD 11 ; Carmen C. Carty, MD Invited Commentary. JAMA Insights. Diagnosis and Evaluation. Establishing the Diagnosis: Laboratory Testing. Investigation of Symptoms, Features, and Complications. Epidemiology and Pathogenesis.
Indications and Outcomes of Intervention. Guiding Principles. Preoperative Management. Intraoperative PTH Monitoring. Minimally Invasive Parathyroidectomy. Bilateral Exploration. Familial pHPT. Surgical Adjuncts. Concurrent Thyroidectomy. Parathyroid Carcinoma. Autotransplantation and Cryopreservation. Immediate Postoperative Care. Cure and Failure. Management of Other Complications.
Subsequent Operation. Back to top Article Information. Access your subscriptions. Access through your institution.
Add or change institution. Free access to newly published articles. Purchase access. Rent article Rent this article from DeepDyve. Access to free article PDF downloads. When the calcium level in the bloodstream is higher than normal and the parathyroid glands stop responding appropriately to this elevation by shutting down production of PTH, this leads to the condition called primary hyperparathyroidism.
Surgery is the only way to cure this problem. While many patients elect to undergo surgery so that they do not develop complications from their parathyroid disease, some patients may have mildly elevated calcium levels and mild complications from their disease. Some patients may decide not to have surgery in this situation, which is acceptable. These patients need to be followed closely for the rest of their life.
Parathyroid surgery takes place in the operating room. Most operations are done under general anesthesia, although local anesthesia with I. Protecting the nerves that cause movement of the vocal cords and the remaining parathyroid glands so they will function normally is an important part of your surgery. It is not uncommon to have a low calcium level after a successful surgery. You may have read about minimally invasive, or "keyhole" parathyroid surgery. This is the preferred approach by endocrine surgeons at the University of Michigan, but requires identification of an abnormal parathyroid gland prior to surgery.
Most patients go home within 2 hours after surgery. The "gold standard" operation for primary hyperparathyroidism for almost years has been the four gland parathyroid exploration. This involves making a small incision in the lower neck and examining all parathyroid glands. Endocrine surgeons at the University of Michigan have been performing minimally invasive parathyroid surgery for nearly 20 years. This approach to parathyroid surgery was developed in the late 's and gained acceptance during the 's.
During minimally invasive parathyroid surgery, the surgeon makes a small incision at the base of the neck. The surgeon then removes the enlarged gland that had been identified by imaging studies performed prior to surgery.
Instead of looking at all four parathyroid glands, parathyroid hormone levels are measured just before removal of the enlarged gland and several times after removal of the abnormal gland. If the PTH levels decrease appropriately suggesting that the other three glands are functioning normally, then the operation is concluded.
If the PTH levels do not decrease appropriately suggesting cure, then the surgeon goes on to look at the remaining parathyroid glands and removes any additional abnormal tissue. Currently, the success rate for minimally invasive parathyroidectomy equals that of the more conventional four gland exploration when performed appropriately.
If there is any concern for multigland disease identified during a minimally invasive procedure, all four parathyroid glands will be examined. All monitoring of PTH levels is done while the patient is in the operating room.
Endocrine surgeons at the University of Michigan have developed more advanced techniques for monitoring parathyroid hormone production during parathyroid surgery. Our techniques lead to higher cure rates than techniques used in other centers. Surgery is the only cure for primary hyperparathyroidism. In such cases, patients have often complained of fatigue, weakness, decreased appetite and difficulties with mental tasks.
The classical symptoms of primary hyperparathyroidism are a depressed mood, nausea, poor appetite, increased thirst, increased urination, kidney stones and, very rarely, bone pain and psychosis. Of note, people with this condition have a two- to threefold increased risk of bone fractures. Further, when primary hyperparathyroidism is severe, the high calcium levels can lead to confusion and even coma.
In such severe cases, surgery is obviously warranted. That said, people who have had surgery due to mild calcium elevations have noted increases in bone density, decreased incidence kidney stones and slight improvement of mood. For a less invasive surgery, it is important to determine which of the parathyroid glands is overproducing parathyroid hormone. In the hands of an experienced surgeon, this assessment will lead to a smaller incision, less operating time and less damage to surrounding tissues.
However, when high parathyroid levels are caused by multiple glands over-producing parathyroid hormone which occurs 15 percent of the time or if a thyroid abnormality is also found, then a more extensive surgical exploration is needed. A significant drop in blood calcium levels can happen after surgery, so the levels need to be monitored afterward.
Not everyone is a candidate for surgery.
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