What are possible postoperative complications from the treatment of primary hyperparathyroidism, and what are the treatment outcomes?

Updated: Dec 24, 2020
  • Author: Lawrence Kim, MD, FACS, FACE; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Answer

Answer

For a full parathyroid exploration, postoperative hypoparathyroidism and hypocalcemia are concerns, but they are extremely uncommon after a directed parathyroidectomy and limited neck exploration. Hypocalcemia is more common after bilateral parathyroid exploration, especially when subtotal parathyroidectomy is performed. The nadir of serum calcium usually occurs 24-72 hours postoperatively. Many patients become hypocalcemic, but few become symptomatic. On the other hand, even when a limited exploration has been done, mild symptoms of hypocalcemia can occur in the first few days after parathyroidectomy in the absence of verifiable hypocalcemia. Because of this, some practitioners routinely administer oral calcium supplements postoperatively.

Hypocalcemia after parathyroid surgery may be due to hungry bone syndrome where calcium and phosphorus are rapidly deposited in the bone. This is characterized by hypoparathyroidism and transient, but occasionally severe, hypocalcemia until the normal glands regain sensitivity.

If hypoparathyroidism persists, oral supplementation with calcium and vitamin D is required. Calcium citrate or calcium carbonate may be started at 400-600 mg of elemental calcium four times per day. Some patients require substantially more. Calcitriol is started at 0.5 mcg twice daily and increased as required. Patients in whom total parathyroidectomy and autotransplantation is performed can be expected to require temporary calcium supplementation.

If a recurrent laryngeal nerve is transected during parathyroidectomy, immediate repair is indicated. If the recurrent nerve is not known to be injured intraoperatively but dysfunction is suggested because the patient has developed new hoarseness, expectant management is chosen initially since most patients recover nerve function over a few weeks to months. Laryngoscopy is indicated to document both dysfunction and recovery of function.

A potential life-threatening emergency in the postoperative period is the development of an expanding hematoma in the pretracheal space. This complication must be recognized and treated immediately by opening the wound and evacuating the hematoma. If untreated, laryngeal edema may progress rapidly, causing airway obstruction. Moreover, the edema may prevent endotracheal intubation, and opening of the wound should precede any intubation attempt.

Most small hematomas do not require treatment. A subplatysmal fluid collection may occasionally form, and these are usually treated adequately with a single aspiration. In a few cases, aspiration may need to be repeated. Rarely, a drain may need to be placed for recurrent fluid collections.

Treatment outcomes

Cure rates after surgery for primary hyperparathyroidism are very high in expert hands, approximately 97-98%. [39] A cure is generally defined as normalized serum calcium. Parathyroid hormone levels, however, may be elevated postoperatively in as many as 20-40% of patients. If the serum calcium remains within the reference range, this elevated state does not usually suggest persistent disease but may indicate a higher risk of recurrence. [40, 41, 42, 43, 44, 45, 46, 47]  Many patients with primary hyperparathyroidism have vitamin D deficiency, and replacement may correct the elevated parathyroid hormone concentration. [48]  There is also some weak evidence that calcium supplementation may decrease an isolated elevation in parathyroid hormone after parathyroidectomy. [46]

Quality of life has been shown repeatedly to be improved after parathyroidectomy. [49, 4]  Notably, quality of life has also been found to undergo measurable improvement in “asymptomatic” patients, which underscores the fact that some mild symptoms may go unnoticed by patients and clinicians. [50]


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