Some thoughts on surgery for primary hyperparathyroidism

[...]extended resection has an indication in parathyroid carcinoma (thyroidectomy, node clearance, etc.) and thymectomy is advised for all varieties of hereditary PHPT to decrease the recurrence rate after subtotal resections,2 the preferred surgical approach for these conditions. Persistent hypercalcemia after identification of four normal glands requires an occasionally difficult differential diagnosis between PHPT, due to an ectopic fifth gland, and Familial Hypocalciuric Hypercalcemia, a genetic syndrome with different biochemical phenotypes.8 In addition, some other questions require to be addressed: should the remaining two glands be explored after resection of a second “double adenoma” in sporadic PHPT? There is now compelling evidence that surgeons with higher case loads (>40 cases/year) obtain high cure rates and few complications when compared to less experienced surgeons.1 This is not just a technical issue since pre-, intra- and postoperative decision making requires a thorough understanding of this challenging endocrine disorder.