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What are the benefits of Parathyroid Surgery

What are the benefits of parathyroid surgery? What is it aimed to achieve?

If you have hyperparathyroidism (HPT) amenable to surgery (primary or tertiary) then the potential benefits are discussed here.  

We describe the impact of hyperparathyroidism as either objective (complications due to hyperparathyroidism) or subjective (symptoms of high blood calcium levels).

Objective complications can be renal stones, chronic renal failure and osteoporosis.

Many websites now claim that cardiac function is impaired by HPT, but the evidence is still weak, no one really understands it or can evidence this. But that doesn’t mean it is not having an impact, we just cannot promise solving your HPT will improve blood pressure or heart function.

 

Symptoms frequently referred to include: Tiredness, thirst, excessive need to urinate (especially getting up at night) muscle aches/pains, abdominal pains, and poor memory, cognition and emotional lability/upset.

Many patients wanting treatment for hyperparathyroidism have a combination of these symptoms or complications. The aim is that by treating your hyperparathyroidism we can either remedy the complications or improve them and improve symptoms.

So how well does surgery achieve this?
Patients with kidney stones due to high calcium levels in the urine should stop making new stones. If you can pass or have existing stones removed, your risk of forming new ones is removed or much lower. Nephrocalcinosis is the deposition of calcium along the renal tubules causing chronic renal impairment. Normal urine calcium and normal PTH levels prevent this from happening

Osteoporosis and Bone Mineral Density
Osteoporosis will improve over time. Frailty progression slows and fracture risk reduces - especially the risk of a broken wrist. Hyperparathyroidism is not the only factor causing this bone disease, but removing hyperparathyroidism as a factor in your development of bone mineral loss that leads to osteoporosis will slow down the eventual loss of bone mineral density that aging leads to. Attached is a graph of changes in bone mineral density after parathyroid surgery compared to controls that did not have HPT. It is powerful reminder that osteoporosis is a marker for frailty and onset of ageing. We may all experience this in time, but successful parathyroid surgery slows its progression giving you longer at the healthier stage of your life. Successful surgery is akin to slowing down the ageing process.

Common symptoms experienced in Hyperparathyroidism
  • Graph compares patients with primary HPT against random controls matched for age, race and gender.

Does successful surgery improve these symptoms?

The graph here demonstrates what symptoms improved and by how much with successful parathyroid surgery. This paper was based on a large amount of data but it is still hard to know what symptoms are going to get better and how much by in any individual. These patients may have reported some improvement but how much?

2 good quality research papers from Oxford, UK and Calgary, Canada found a way of answering that. By formally quantifying quality of life scores it was shown that a patient’s perception of their quality of life improved significantly after surgery that cured them of HPT in over 70% of patients.
  • Because this does not include the objective complication improvements it is safe to assert that you have a minimum 70% chance of significantly benefitting from successful parathyroid surgery.

 Should I have to wait till my calcium is high or above a certain level?

 The short answer to this is – No.

We used to think that symptoms corresponded to high your calcium level or even PTH level was.  The higher it got the more symptoms you must have and the greater the benefit you would derive from surgery. This has not been shown to be the case. The graph shows that serum calcium level has less impact on symptoms than initially believed.
  • Graph shows symptom frequency alters with a raised adjusted calcium >2.75mmol/l (Severe)Compared with a raised calcium <2.75mmol/l(Mild)

Patients with mild disease do just as well as patients with severe disease. Which brings us to our last topic – normocalcaemic hyperparathyroidism. In this scenario a patient has high PTH levels, acceptable vitamin D levels (so excluding secondary HPT), and a higher-than-expected serum adjusted calcium, but one that is still within the normal range. If your serum adjusted calcium is the higher end of normal, then your PTH levels should be low or lower end of normal in the absence of severe Vitamin D deficiency.  The balance of your adjusted calcium, PTH and Vitamin D levels taken at the same time give a snapshot of how your body responds to this balance of the chemicals and hormones involved. When they are out of balance there is something wrong with the mechanism that controls them.  

The data presented here does not include outcomes after surgery for normocalcaemic hyperparathyroidism, but the condition does exist. There is no reason to believe that treating it wouldn’t help. You do need to see an endocrine surgery specialist that understands the physiology of this to get the best advice. 

The caveat though is that localisation is less successful we think in this patient group and the adenoma or abnormal parathyroids are harder to find. This makes surgery more difficult and less successful. It makes complication rates higher too. Success from non-localised surgery is around 88-90% based on registry outcome data. Compared to over 95-96% in localised primary hyperparathyroidism.