Subtotal parathyroidectomy for primary hyperparathyroidism.

OBJECTIVE: To discuss the etiology of multiple gland disease in the context of primary hyperparathyroidism, as well as indications for surgery, operative management and technical considerations of subtotal parathyroidectomy, and postoperative/long-term management.
METHODS: We conducted a systematic review of the literature using evidence-based criteria.
RESULTS: Approximately 15% of patients with primary hyperparathyroidism have multiple gland disease, and a small subset of these cases is due to a familial syndrome. Subtotal parathyroidectomy is one operative approach to the management of multiple gland disease. Subtotal parathyroidectomy for multiple gland disease results in normocalcemia in at least 95% of cases. Intraoperative parathyroid hormone monitoring can help guide the extent of the operation and determine the need to perform a concurrent autograft. After subtotal parathyroidectomy, most patients develop postoperative hypocalcemia and require calcium and possibly calcitriol supplementation; approximately 10% to 15% develop permanent hypoparathyroidism. All patients after parathyroidectomy, especially those with familial primary hyperparathyroidism, should undergo long-term follow-up for surveillance of recurrent primary hyperparathyroidism. If persistent or recurrent primary hyperparathyroidism occurs after subtotal parathyroidectomy, completion total parathyroidectomy and parathyroid autotransplant should be performed.
CONCLUSIONS: Subtotal parathyroidectomy is an excellent surgical approach for patients with primary hyperparathyroidism due to multiple gland disease from either sporadic or familial causes.