Your Doctor Thinks You May Need Parathyroid Surgery

Your Doctor Thinks You May Need Parathyroid Surgery

Parathyroid glands are small, pea-shaped, hormone producing glands that reside in your neck in the area of your thyroid gland. They produce a hormone called parathyroid hormone (PTH) that helps control the amount of calcium that circulates in your body.

Why Might I Need Parathyroid Surgery?

The most common reason for needing parathyroid surgery is a diagnosis of primary hyperparathyroidism [hahy-per-par-uh-thahy-roi-diz-uhm]. Primary hyperparathyroidism is usually caused by a benign (non-cancerous) growth of one of four parathyroid glands that everyone has in their neck. This abnormal parathyroid gland overproduces PTH (parathyroid hormone), usually leading to high levels of calcium and PTH in your blood. This can cause symptoms such as those listed below.

Additionally, patients on dialysis because of kidney failure can develop hyperparathyroidism. This is called secondary hyperparathyroidism because the problem does not start in the parathyroid glands, which in this case enlarge due to kidney failure. Secondary hyperparathyroidism due to kidney failure may be referred for parathyroid surgery because of very high levels of PTH in the blood.

What are Some of the Benefits to Having Parathyroid Surgery?

After a successful parathyroid surgery, your blood levels of calcium and PTH will return to within the normal range. This will lead to improved bone density, decreased risk of bone fractures, lower risk of kidney stones and a potentially improved quality of life. Many of your initial symptoms will improve. However, since some of your symptoms such as fatigue are common, they may be caused by other medical conditions and non-condition-related factors. Therefore, they may not go away even after successful surgery.

What to Expect the Day of Surgery

You will be asked to arrive at the hospital about two hours before your scheduled surgery time. You should have stopped taking any aspirin, blood thinners or nonsteroidal anti-inflammatory agents (such as ibuprofen [Advil] or naproxen [Aleve]) one week before your surgery date. The majority of surgeons will perform parathyroid surgery under general anesthesia, though some specialized centers may also offer the surgery under local anesthesia. Surgery can take anywhere from 30 minutes to three hours once you are asleep. It depends on how quickly the surgeon can find and confirm the removal of the abnormal gland(s).

Nervous System Kidney/Urinary Digestive System Musculoskeletal
• Mood swings • Kidney Stones • Stomach or duodenal ulcer • Bone pain
• Depression • Nocturia (going to the bathroom a lot at night) • GERD (acid reflux) • Joint pain
• Forgetfulness • Worsening kidney function • Pancreatitis • Bone fractures
• Irritability • Abdominal pain • Osteoporosis
• Concentration problems • Constipation • Generalized weakness
• Fatigue

Most patients that undergo parathyroid surgery will be able to go home the same day. However, your surgeon may have you stay overnight if you have multiple other medical problems, undergo a more extensive surgery, or live a far distance from the hospital. You will be able to eat, drink, and talk that same day right after surgery and can go back to your normal activities as early as the next day, depending on how you feel.

The size of your incision will likely depend somewhat on if the surgeon is able to localize the hyperfunctioning gland(s) before surgery. However, in 2012, the majority of all parathyroid surgeries were “minimal access,” with most incisions ranging from three-quarters to 1 ½ inches across. There are generally no stitches that need to be removed.

Tools to Assist the Surgeon in Finding or Confirming the Removal of the Abnormal Parathyroid Gland

Before your scheduled surgery date, your surgeon will have you undergo “localization” imaging to help locate the abnormal parathyroid gland. This may be an ultrasound done by either a radiologist or an endocrinologist; a Sestamibi scan, which is a nuclear medicine test where a radiologist injectsa weakly radioactive diagnostic material that will hopefully concentrate in the abnormal gland; or, in special circumstances, a CT scan. The ability of each exam to accurately locate the abnormal gland can vary among radiologists, but in general two-thirds to three-quarters of patients will go into surgery with a localized gland, making it much easier for the surgeon. Your vitamin D level also should be checked before surgery, since a low vitamin D level can delay your recovery.

During surgery, most surgeons will test your PTH levels which will confirm, while you are still asleep, that the correct hyperfunctioning parathyroid gland has been successfully removed. Some surgeons may also utilize intraoperative ultrasound or a radioguided probe (another nuclear medicine technique) during surgery to help locate the abnormal gland.

What to Expect After Surgery, and Are There Any Side Effects?

The most common complaint after surgery is a mild sore throat, which generally doesn’t last more than three to seven days, and mild generalized fatigue. Some people may complain of a non-productive cough or some pain when swallowing, both of which will go away in one to two weeks. Sometimes, hypocalcemia [hahy-poh-kal-see-mee-uh] (low blood calcium levels) can happen in the first few days after surgery, and you would experience numbness or tingling around your mouth or in your fingertips. The treatment is taking more than the usual amount of calcium and vitamin D supplements until the symptoms resolve.

The majority of people who undergo the surgery only need to take off a few days from work. Your surgeon will usually check your blood calcium level the day after surgery as a second confirmation that your calcium level is now in the normal range. In addition, six months after surgery and yearly thereafter, depending on your endocrinologist and surgeon, you will have your blood checked for both calcium and PTH levels.

One to three weeks after surgery you will have a post-op visit with the surgeon to go over your pathology (what your parathyroid gland looked like under the microscope) and to check your wound. Most patients heal very well from surgery and have minimal residual scarring at six months. However, it is important to apply suntan lotion to the surgical site for up to one year after surgery to prevent darkening of any scar.

In the hands of an experienced surgeon, over 95 percent of parathyroid surgeries result in a “cure.” A failure is the result of either the surgeon being unable to find the abnormal parathyroid gland(s) at the time of surgery or your PTH level increasing during the first six months after surgery, which would indicate one or more of the remaining parathyroid glands in your neck are also hyperfunctioning.

One of the unusual complications of parathyroid surgery is injury to the recurrent laryngeal [luh-rin-jee-uhl] nerve. Each person has two of these nerves, a right and a left, that run along the side of your windpipe and control your voice. An injury to one of these nerves results in hoarseness. Many patients that experience hoarseness right after surgery have a temporary nerve injury that will get better over time. However, in about one percent of patients the injury will be permanent. This number is lower in the hands of an experienced surgeon. Another unusual complication of surgery, particularly in those who have more than one parathyroid gland removed or are undergoing repeat surgery for hyperparathyroidism, is a permanently low blood calcium level. This is known as hypoparathyroidism [hahy-po-par-uh-thahy-roidiz-uhm] (too little parathyroid hormone). Treatment consists of calcium supplements and taking more than the usual amount of recommended vitamin D supplements.

Questions to Ask Your Surgeon

You should be comfortable with your surgeon and feel confident that you are in good hands. Studies have shown that experienced surgeons have higher rates of successful surgeries and lower rates of complications, so you should ask your surgeon how many parathyroid operations he/she performs every year, what other surgeries they do in their practice, and what their complication rate and success rate are. You should also ask your surgeon what, if any, testing is performed in the operating room (such as measuring PTH hormone) to confirm that the operation was successful.

Dr. Melanie Goldfarb is a graduate of Brown University. She received her medical degree from the University of Illinois-Chicago and completed her general surgery residency at Beth Israel Deaconess Medical Center/Harvard Medical School. She then completed an endocrine surgery fellowship at University of Miami and is now an Assistant Professor of Surgery at University of Southern California Keck School of Medicine. Her clinical practice is focused on the surgical management of patients with thyroid, parathyroid and adrenal tumors and her research on adolescent and young adult thyroid cancer.