Surgical management of hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common endocrine condition frequently diagnosed after incidental finding of hypercalcaemia on routine blood tests. This article addresses questions that guide the surgical management of such patients. 1. Is there convincing biochemical diagnosis of primary hyperparathyroidism? Biochemical investigations are detailed and common pitfalls are discussed. 2. Is there an indication to proceed with surgery or could/should the patient be offered medical review and long-term monitoring? The pros and cons for proceeding with parathyroidectomy in distinct patients subgroups are discussed. 3. Do localization studies demonstrate the position of the parathyroid adenoma? The sensitivity of commonly used imaging techniques (sestamibi scan and high-frequency neck ultrasound) is detailed. 4. Is minimally invasive parathyroidectomy feasible? The indications and limitations of a minimally invasive approach are detailed.Parathyroidectomy is also indicated in some patients with secondary hyperparathyroidism (SHPT) who have end-stage renal disease and patients with tertiary hyperparathyroidism (THPT), where there is autonomous parathyroid function after years of secondary stimulation. The indication for operative management and the extent of operation in these scenarios are presented.