Primary Hyperparathyroidism: The Continuing Saga of Surgical Problems

Continuing problems in the management and surgical treatment of primary hyperparathyroidism include the localization of the elusive single tumor, the recognition and management of multiple gland involvement, prompt confirmation and operative treatment for hypercalcemic crisis, delineation of a liberal but selective policy relative to surgery for apparent uncomplicated hyperparathyroidism in the elderly, and recognition of the surgeon\u27s responsibility to determine the extent of the operation on the basis of operative findings, realizing that histologic study may not confirm apparent gross abnormalities despite subsequent clinical recovery. When all four glands are involved in primary hyperparathyroidism, subtotal parathyroidectomy is recommended except for patients with multiple endocrine neoplasia, type I (MEN I), in which cases, with great enlargement of all glands, total parathyroidectomy and autotransplantation appear justified. Selective removal of parathyroid glands is indicated for multiple involvement affecting fewer than four glands. Recent experience emphasizes the importance of benign familial hypocalciuric hypercalcemia, the late appearance of primary hyperparathyroidism after radiation therapy to the neck, and the association of primary hyperparathyroidism with a number of other clinical entities