Do I really need surgery if I have primary hyperparathyroidism?

While every medical decision should be made in context with the severity of disease, other medical conditions, personal preference and other factors that make a person "whole", I almost always recommend surgery for primary hyperparathyroidism. The risks of surgery are extremely low and the benefits can be huge. There is no patient who is "too old" for surgery.

Fortunately, most people who have PHP are without major symptoms or disease. We often diagnose the disease in its early stages before major problems have occurred. However, if the disease is left untreated then we will all develop symptoms in time. The most common issues we aim to prevent are weak bones (osteopenia & osteoporosis) and kidney issues (stones and failure). Anxiety, depression, memory "fog" or loss, fatigue, abdominal pain, nausea, constipation (and sometimes diarrhea), joint pain, bone pain and muscle aches are among the most common symptoms people experience.

As there are no medications to treat PHP, I advocate for surgery early. Not just because I'm a surgeon, but because I would recommend it for my family. If the surgery is performed by an experienced parathyroid surgeon the risks are extremely low (less than 1%) while the benefit can be significant. The incision size is quite small and the recovery is quick. Most people only take one or two pain pills after surgery as Tylenol is often enough to cover any discomfort.

Many medical doctors follow an antiquated set of criteria as to when to refer patients to surgery for primary hyperparathyroidism. This isn't intentional ignorance or negligence. If those doctors trained in areas without access to excellent parathyroid surgeons the risks did not outweigh the benefit. Again, in the USA, that scenario isn't the reality we live in. Restricting surgery to those younger than age 50, calcium levels 1 above normal, and kidney or bone disease just doesn't make sense anymore as there are excellent parathyroid surgeons in nearly every state. Why wait until you have a potentially permanent side effect of uncontrolled primary hyperparathyroidism?

What to expect with parathyroid surgery

Your journey with parathyroid surgery begins from the moment you were discovered to have high blood calcium. Most commonly, this is discovered on routine blood work. Once a high blood calcium is noted, we should then recheck that calcium level with a parathyroid hormone (PTH) drawn at the same time. Knowing the relationship between these two at the same time provides the valuable information in deciding whether surgery can help you. (There are, of course, some exceptions where you can need parathyroid surgery when your calcium is still "normal". Normocalcemic hyperparathyoidism and renal hyperparathyroidism are examples of that.)

After the diagnosis of primary hyperparathyroidism has been made you should seek consultation with an experienced parathyroid surgeon. When a patient comes to my office for consultation, I always review labs, medical & surgical history, family history, medications and symptoms. I then perform a real time neck ultrasound to evaluate the thyroid gland and parathyroid glands (normal parathyroid glands don't show up on US). The information gathered from this is one of the most value tools we have prior to surgery. Next, I will evaluate your vocal cord to ensure they work prior to surgery.

I do ask for nuclear medicine imaging to be done. SPECT-CT scan is my preferred study. While most often they are read by the radiologist as "non-localizing", I can read the scans in conjunction with the ultrasound findings to provide insight to where a bad parathyroid gland may be located. Most importantly, this scan will help rule out a bad parathyroid gland in the chest so we don't perform surgery on the neck unnecessarily.

During the operation, a localizing parathyroid adenoma can take just 8 minutes to remove through a 2cm incision! If we need to look at all of the parathyroid glands (a decision we discuss based on a few factors) then it adds a few extra minutes. At this point, IOPTH levels are drawn. Once I'm confident that you are cured, you wake up and go to the recovery room. You're home within a few hours.

Fine Needle Aspiration explained

A brief overview of the unique needle aspiration process we have in place. In just a few minutes we can answers about the nodules in your thyroid and other neck masses.

We have a joint partnership with a unique, mobile pathology service called Doctors Pathology Services (DPS). A group of actual pathologists is onsite to assist with the diagnosis of your thyroid nodule. With their help, we have virtually eliminated the "non-diagnostic" Bethesda I result for needle aspiration.

Is Intraoperative PTH (IOPTH) really necessary?

I feel very strongly that intraoperative PTH (IOPTH) is a critical element to a successful parathyroid surgery. To date, there are no other technologies that can provide information as accurate as IOPTH regarding the removal of hyperfunctional parathyroid tissue.

Many things can be useful with identifying a hypercellular parathyroid gland (a.k.a parathyroid adenoma or hyperplasia) but none of these can tell you whether or not you are cured except IOPTH.

Some people would argue that seeing four parathyroid glands eliminates the need to check PTH levels for cure. I have seen numerous cases of supernumerary parathyroid adenomas that would have failed using the four gland exploration paradigm.

Your best chances of cure (~99%) are with the first operation. While using IOPTH does add time to surgery, it is still the best option available to date.