Which surgical procedures are performed in the treatment of secondary hyperparathyroidism?

Updated: Dec 24, 2020
  • Author: Lawrence Kim, MD, FACS, FACE; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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The general surgical technique in secondary hyperparathyroidism involves complete parathyroid exploration, as described previously for primary hyperparathyroidism. All four glands must be exposed, and biopsies are taken if needed to ensure correct identification. In most cases, diffuse hyperplasia is encountered, although the size of the glands can be significantly heterogeneous.

The treatment procedure of choice is either total parathyroidectomy with autotransplantation or subtotal parathyroidectomy. In a study by Rothmund et al, a randomized, controlled trial of total versus subtotal parathyroidectomy for secondary hyperparathyroidism, the investigators found that four of 17 subjects treated with subtotal parathyroidectomy developed recurrent hypercalcemia, with two requiring reexploration. None of the subjects treated with total parathyroidectomy developed recurrent hypercalcemia. [63] A subtotal parathyroidectomy has the advantage of less dramatic postoperative hypocalcemia. However, reoperative neck exploration is required in the case of recurrence, which can be very difficult. Another approach is to perform total parathyroidectomy without autotransplantation. Good results have been reported, but at present this procedure should be considered investigational and should be reserved only for patients in whom future transplantation is not an option. [64, 65, 66]

Parathyroid autotransplantation is usually performed after a total parathyroidectomy. Briefly, about 100 mg of parathyroid tissue is cut into approximately 12-20 pieces, each of which measures about 1 x 1 mm. These are inserted into pockets in the forearm, either in the subcutaneous tissue or the musculature (the forearm being chosen primarily for convenience). After surgery, blood draws from the antecubital fossa above the transplantation site can be compared with blood drawn from the contralateral side to assess graft function. The site may be marked with a polypropylene suture on the fascia for localization later, if necessary. We also use clips to facilitate localization with ultrasonography. Parathyroid tissue may also be cryopreserved in case the primary autotransplant fails.  

Most patients require admission after subtotal parathyroidectomy or total parathyroidectomy with autotransplantation. Hypocalcemia is to be expected and is often severe, especially in persons who have had a history of very high parathyroid hormone levels for many years. Although hypocalcemia is usually more severe after total parathyroidectomy with autotransplantation, it can occur after subtotal parathyroidectomy as well. A constant calcium infusion is often required, and oral calcium and calcitriol requirements can be quite high. The target calcium level should typically be below the normal range but above the level at which the patient is symptomatic. The patient can be discharged when he or she is able to maintain a safe calcium level on oral supplements. Typically, the patient can be weaned off of these over a period of weeks to a few months.

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