For primary hyperparathyroidism, the only cure is an operation.
Fortunately, when performed by an experienced surgeon, the operation is a quick outpatient procedure - meaning that you can go home the same day, no need to stay overnight at the hospital.
During the operation, one or more diseased parathyroid glands are removed. Primary hyperparathyroidism is most often caused by a benign tumor on one or two of the parathyroid glands. Removing those glands, and leaving the other normal glands behind, cures the disease.
Sometimes, all four parathyroid glands are diseased, and we need to remove three parathyroid glands and part of the fourth during the operation. We never want to remove all four parathyroid glands, because you do need some parathyroid hormone to keep your calcium in normal range.
There are no medications that cure primary hyperparathyroidism. There are medications that can help bring your calcium levels down if they are extremely high, but this is a temporary measure and should be followed up with surgery when possible.
Surgeons have different ways of doing parathyroid operations. We will cover the most common approaches here, along with the benefits and risks of each, and when you might want to use them.
About the term "minimally invasive": With regard to parathyroid surgery, the term minimally invasive does not have a concrete definition. It usually refers to incision size - if the incision is small, it is called minimally invasive, regardless of the extent of the internal dissection. Most parathyroid operations are "minimally invasive" because they can be done through small neck incisions, even if both sides of the neck are opened during a four-gland operation.
Note about risks: All operations have risks. We operate when we believe that the benefits of surgery outweight the risks of the operation. The risks of parathyroid surgery generally are minimal, but are not zero. All of the surgical approaches listed below have the potential for complications. The risk of complications is not correlated with the surgical approach, but with the surgeon's level of experience. To give yourself the best chance of a good outcome, choose the surgeon with the most experience.
In this method, the surgeon opens the neck and examines all four parathyroid glands, two on each side. This method will fully expose the thyroid and surrounding structures in the neck. Since many patients (about 30%, and more in older patients) will have multiple parathyroid glands involved, this is a good method of viewing all of the glands together and determining which need to be removed. This can be done through a 1 to 1.5 inch neck incision in most people. When all four glands have been seen, or a thorough attempt has been made to see all four, and the abnormal glands have been removed, the operation is concluded.
Benefits of four-gland approach:
Risks of four-gland approach:
Benefits of focused parathyroidectomy:
Risks of focused parathyroidectomy:
Benefits of ioPTH-guided focused parathyroidectomy:
Risks of ioPTH-guided focused parathyroidectomy:
Benefits of radioguided parathyroidectomy:
Risks of radioguided parathyroidectomy:
Benefits of scarless parathyroidectomy:
Risks of scarless parathyroidectomy:
The optimal parathyroid procedure depends on the patient and the surgeon's experience. The operation routinely performed at our center is the four-gland approach. This is typically done through a 1 to 1.5 inch incision, and all four parathyroid glands are evaluated. Most operations are less than half an hour. For first-time operations (when the patient has not had prior neck surgery) this is the method that will give the highest chance of cure. We have found numerous parathyroid tumors that would not have been found with a focused approach, because they were never seen on a scan.
There are situations when a focused operation is the best approach. Because finding all four parathyroid glands can be very challenging, surgeons who have minimal experience with this should perform focused operations. If finding the glands could take four hours, then the surgeon is better off just going after the one gland seen on scan.
There are select scenarios when we will perform focused operations at our center:
We do not use intraoperative PTH at our center, but many surgeons do. In theory, it provides some reassurance that the person is cured without having to see all four glands. Unfortunately, as discussed above, it is often inaccurate, and we believe its use can lead surgeons to make poor decisions (either digging around more than they should because the PTH took a while to drop, or stopping the operation when another tumor was present because the PTH dropped quickly). In most cases, it also significantly prolongs the operation and time under anesthesia, while surgeons wait for PTH results. For these reasons, we do not recommend the routine use of ioPTH.
Using radioguidance can be helpful in some situations. At the Norman Parathyroid Center, where Dr. Boone started, nearly all operations are performed with radioguidance. When starting out, it was very nice to be able to measure the radioactivity of every parathyroid. Over time she realized that while radioguidance was very helpful in select circumstances, in most cases it did not add enough value to justify the extra radiation to the patient and the OR staff. For most patients, it didn't help at all. While sestamibi scans are invaluable for planning parathyroid surgery, it is not necessary to perform a separate scan or injection of radioactive material on every patient on the day of surgery. Patients who do benefit from radioguidance include those with normocalcemic primary hyperparathyroidism and those for whom the diagnosis of primary hyperparathyroidism is not 100% certain.