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uated in a series of 350 patients with sporadic primary hyperparathyroidism A single gland was predicted by sestamibi in 83%, by ultrasound in 85%, and by concordance of both in 59% of patients Unilateral neck exploration, directed by these studies, resulted in success rate of only 73%, 77%, and 82%, respectively, despite the intraoperative quick PTH assay predicting success Even in patients with concordant sestamibi and ultrasound scans, and an intraoperative PTH drop of > 50%, at least one additional abnormal parathyroid gland is left behind in the contralateral neck in 15% of patients Bilateral neck exploration is usually advisable for all patients without preoperative localization studies for the following: (1) patients with a family history of hyperparathyroidism, (2) patients with a personal or family history of MEN, and (3) patients wanting an optimal chance of success with a single surgery Patients undergoing unilateral neck exploration can have the incision widened for bilateral neck exploration if two abnormal glands are found or if the serum quick PTH falls by < 50% Parathyroid glands are not uncommonly supernumerary (five or more) or ectopic (eg, intrathyroidal, carotid sheath, mediastinum) Parathyroid hyperplasia is commonly seen with chronic renal failure When surgery is performed, a subtotal parathyroidectomy is optimally treated surgically; three and one-half glands are usually removed, and a metal clip is left to mark the location of residual parathyroid tissue Parathyroid carcinoma can cause severe hypercalcemia associated with very high serum levels of PTH Preoperative localizing studies usually detect a large invasive tumor Therapy consists of en bloc resection of the tumor and the ipsilateral thyroid lobe Metastases to local and to distant sites occur in about 50% of patients Reoperation for neck recurrence is usually necessary Adjuvant treatment includes radiation therapy Intravenous bisphosphonate (zoledronic acid) and calcimimetic agents (NPS R-568) are used for treatment of hypercalcemia Complications: Serum PTH levels fall below normal in 70% of patients within hours after successful surgery, commonly causing hypocalcemic paresthesias or even tetany Hypocalcemia tends to occur the evening after surgery or on the next day Therefore, frequent postoperative monitoring of serum ionized calcium (or serum calcium plus albumin) is advisable beginning the evening after surgery Once hypercalcemia has resolved, liquid or chewable calcium carbonate is given orally to reduce the likelihood of hypocalcemia Symptomatic hypocalcemia is treated with larger doses of calcium; calcitriol (025 1 mcg daily orally) may be added, with the dosage depending on symptom severity Magnesium salts are sometimes required postoperatively, since adequate magnesium is required for functional recovery of the remaining suppressed parathyroid glands In about 12% of patients having successful parathyroid surgery, PTH levels rise above normal (while serum calcium is normal or low) by 1 week postoperatively This secondary hyperparathyroidism is probably due to hungry bones and is treated with calcium and vitamin D preparations Such therapy is usually needed only for 3 6 months but is required long-term by some patients Hyperthyroidism commonly occurs immediately following parathyroid surgery It is caused by release of stored.



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benign hypocalciuric hypercalcemia is characterized by hypercalcemia, hypocalciuria (usually < 50 mg/24 h), variable hypermagnesemia, and normal or minimally elevated levels of PTH These patients do not normalize their hypercalcemia after subtotal parathyroid removal and should not be subjected to surgery The condition has an excellent prognosis and is easily diagnosed with a family history and urinary calcium clearance determination

Hypercalcemia is common in untreated Addison s disease This is partly due to disinhibition of calcium uptake by the renal tubule and gut Additionally, Addison s disease can cause dehydration and hyperproteinemia, resulting in higher levels of nonionized calcium





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Other causes of hypercalcemia are shown in Table 21 9 Modest hypercalcemia is also occasionally seen in patients taking thiazide diuretics or lithium; such patients may have an inappropriately nonsuppressed PTH level with hypercalcemia Prolonged immobilization at bed rest may also cause hypercalcemia, especially in adolescents and patients with extensive Paget s disease of bone Hypercalcemia is noted in up to one-third of acutely ill patients being treated in intensive care units, particularly patients with acute renal failure Serum PTH levels are usually slightly elevated, consistent with mild hyperparathyroidism Bisphosphonates can increase serum calcium in 20% and serum PTH becomes high in 10%, mimicking hyperparathyroidism

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Parathyroidectomy is recommended for patients with symptomatic hyperparathyroidism, kidney stones, bone disease, and pregnancy Some patients with seemingly asymptomatic hyperparathyroidism may be surgical candidates for other reasons such as (1) serum calcium 1 mg/dL above the upper limit of normal with urine calcium excretion > 50 mg/24 h (off thiazide diuretics), (2) urine calcium excretion over 400 mg/24 h, (3) cortical bone density (wrist, hip) 2 SD below normal, (4) relative youth (under age 50 60 years), (5) difficulty ensuring medical follow-up, or (6) pregnancy During pregnancy, parathyroidectomy is performed in the second trimester Patients who undergo surgery for asymptomatic hyperparathyroidism have been reported to have modest benefits in social and emotional function, with improvements in anxiety and phobias being reported in comparison to similar patients who are monitored without surgery Preoperative parathyroid imaging has been used in an attempt to allow unilateral minimally invasive neck surgery The usefulness of preoperative parathyroid imaging was eval-

thyroid hormone during surgical manipulation of the thyroid Short-term treatment with propranolol may be required for several days

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