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Endocrine Surgery

Thyroid Surgery

Primary Hyperparathyroidism

  • What causes primary hyperparathyroidism?
    • Primary hyperparathyroidism is usually (90-95%) caused by a single, hyperfunctioning benign parathyroid tumor that’s secretes too much parathyroid hormone.
    • The most common manifestation is high blood calcium levels, but symptoms such as kidney stones, osteoporosis, bone pain, fractures, reflux disease, and other may be the presenting symptoms.
    • About 5% of patients have 4-gland diffuse parathyroid hyperplasia which is an enlargement and overproduction of parathyroid hormone in all four glands. In some patients with this form of primary hyperparathyroidism, the condition runs in the family either by itself or with other tumors as a part of a multiple endocrine neoplasia syndrome (type 1, 2A, or familial hyperparathyroidism). 

  • What symptoms can hyperparathyroidism cause?
    Hyperparathyroidism can be asymptomatic, can cause mild symptoms, or in rare cases severe symptoms. Some of them are listed below:
    • Nervous System
      • Mood swings
      • Depression
      • Forgetfulness
      • Irritable
      • Concentration problems
      • Fatigue
    • Kidney / Urinary
      • Kidney Stones
      • Nocturia (going to the bathroom a lot at night)
      • Worsening kidney function
    • Digestive System
      • Stomach or duodenal ulcer
      • GERD (reflux)
      • Pancreatitis
      • Abdominal pain
      • Constipation
    • Muskuloskeletal
      • Bone pain 
      • Joint pain
      • Bone fractures
      • Osteoporosis
      • Generalized weakness
  • What workup should I have if I have been diagnosed with hyperparathyroidism?
    • Blood tests:
      • Calcium
      • PTH (parathyroid hormone)
      • Vitamin D 25-OH and vitamin D 1,25-hydroxy
      • Creatinine
    • Imaging:
      • Neck ultrasound (by your surgeon or a radiologist)
      • Sestamibi or sestamibi/SPECT-CT scan
    • Other tests your primary doctor or endocrinologist may order:
      • DEXA done scan

  • What are the benefits to having parathyroid surgery?
    • Improved bone density and decreased risk of bone fractures
    • Improved quality of life
    • Lower risk of kidney stones (up to 90% of patients do not develop any new stones)
    • Decreased risk of premature death

  • Will my symptoms go away after surgery?
    • There is the potential to fix and/or improve all your symptoms.
    • However, because many symptoms of hyperparathyroidism are vague and nonspecific, it is difficult to tell which symptoms are actually caused by the abnormal parathyroid gland and which are unrelated.  (see the previous question for definitive benefits of parathyroid surgery)

  • How many parathyroid glands are removed during surgery?
    • Most people are born with four parathyroid glands, though having an extra 5th is not all that uncommon.
    • The majority (90-95%) of patients with primary hyperparathyroidism have a single, benign, hyperfunctioning tumor involving one parathyroid gland.
    • Up to 5% of patients will have a second hyperfunctioning parathyroid gland that would also be removed at the time of surgery.
    • A small percentage of patients have hyperplasia, or diffuse enlargement of all four glands, and will undergo removal of 3 ½ parathyroid glands at the time of initial surgery, leaving enough parathyroid tissue behind to preserve its calcium-regulating functions.

  • What type of anesthesia will I have?
    • General anesthesia

  • How long does surgery take?
    • Surgery can take anywhere from 30 minutes to two hours once you are asleep. It depends on how quickly the surgeon can find and confirm the removal of the abnormal gland.

  • How long will I be hospitalized?
    • Most patients that undergo parathyroid surgery will be able to go home that same day.
    • Some reasons that you may stay overnight include: multiple other medical problems, more extensive surgery, and a far distance from the hospital

  • How long is the recovery? When can I go back to work?
    • Everyone can eat, drink, and talk that same day right after surgery.
    • While you may feel some fatigue for 2-3 days (general anesthesia), you will be able to perform your normal activities.
    • Most people only take a few days off from work.

  • Parathyroid gland removalHow will the surgeon know if the correct parathyroid gland was removed?
    • Your parathyroid hormone levels will be tested four times during surgery which will confirm while you are still asleep with intraoperative parathyroid hormone testing that the hyperfunctioning parathyroid gland has been successfully removed.

  • Will surgery affect my voice or cause any other side-effects?
    • One of the very rare side effects of parathyroid surgery is injury to the recurrent laryngeal nerve that controls your voice. This complication occurs in about 1% of patients.
    • If you had more extensive parathyroid surgery, you may be hoarse after surgery for a short period of time but this is generally temporary.

  • Parathyroid Surgery size of incisionWill I have a big scar?
    • The size of your incision will depend somewhat on if we are able to localize the hyperfunctioning gland before surgery. However, all parathyroid surgeries are “minimal access” with most incisions from 2 ½ to 3 ½ cm in size.
    • Most patients heal very well from surgery and have minimal residual scar at 6 months.
    • It is important to apply suntan lotion to the surgical site for up to one year after surgery to prevent darkening of any scar.

  • Will I have stitches?
    • You will not have any stitches that need to be removed.

  • When will I know the findings of the surgery?
    • Your parathyroid hormone levels will be tested four times during surgery which will confirm while you are still asleep that the hyperfunctioning parathyroid gland has been successfully removed.
    • A second confirmatory measure will be when you get your calcium level checked the morning after surgery.

  • Will I have to take medication after surgery?
    • Most people will not have to take any medication after surgery.
    • There are occasional patients who have very high calcium levels for a long time before they undergo surgery that need temporary calcium supplementation.
    • Patients that have 3 ½ parathyroid glands removed due to a familial syndrome or sporadic 4-gland hyperplasia have a higher risk for temporary calcium and/or vitamin D replacement.

  • Will I need follow-up appointments once my parathyroid gland has been removed?
    • You will return for a post-op visit 2-3 weeks after your surgery and again about 6 months later if you live locally; everyone will have repeat blood tests at this time.
    • For all patients, we monitor your calcium, parathyroid hormone, and vitamin levels on a yearly basis which can be arranged through USC or with your local physician and have the results sent to our office.

  • Can hyperparathyroidism come back?
    • It is rare, but published recurrence rates at 10 years after successful surgery are in the range of 3-4%. This is why we monitor your blood tests on a yearly basis.

 

Please refer to the American Association of Endocrine Surgeons patient education website for more detailed information: http://endocrinediseases.org/thyroid/index.shtml

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