Skip to main content
SpringerLink
Log in

What Symptom Improvement Can Be Expected After Operation for Primary Hyperparathyroidism?

  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Background

The only cure for primary hyperparathyroidism (pHPT) is operative resection of the parathyroid gland(s) responsible for the disease. The 1990 National Institute of Health’s (NIH) consensus development conference on asymptomatic pHPT and its subsequent workshop in 2001 established which clinical criteria warranted parathyroidectomy (PTx) versus observation. While there is no debate that these NIH criteria capture a group of patients likely to benefit from PTx, there is concern that these guidelines miss a significant percentage of pHPT patients who actually are symptomatic. Unfortunately, these additional symptoms are often subtle, nonspecific, not traditionally measured, frequently not assessed or considered in this patient population, and are usually attributed to other diagnoses or simply advanced age.

Methods

An evidence-based literature review was performed assessing symptoms and clinical conditions associated with bone, neuropsychiatry, cognition, quality of life, and the neuromuscular system. The level of evidence and grade of recommendations were assigned to key studies to help determine recommendations regarding indications and potential benefits of parathyroidectomy (PTx).

Results

Symptoms ranging from decreased bone mineral density, increased fracture risk, neuropsychiatric symptoms and cognitive changes, lower quality of life, and neuromuscular symptoms were found to be associated with pHPT. The effects of PTx on these symptoms was addressed in a variety of studies that varied in quality.

Conclusion

Although there are few Level I randomized clinical trials addressing the benefit of PTx in patients with pHPT, there are supportive data to suggest that most patients with pHPT would benefit from operative cure.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Eigelberger MS, Cheah WK, Ituarte PH et al.(2004) The NIH criteria for parathyroidectomy in asymptomatic primary hyperparathyroidism: are they too limited? Ann Surg 239(4):528–535

    Article  PubMed  Google Scholar 

  2. Bilezikian JP, Potts JT Jr, Fuleihan Gel-H et al.(2002) Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st century. J Bone Miner Res 17(Suppl 2):N2–N11

    PubMed  Google Scholar 

  3. Mack LA, Pasieka JL (2004) Asymptomatic primary hyperparathyroidism: a surgical perspective. Surg Clin North Am 84(3):803–816

    Article  PubMed  Google Scholar 

  4. Okamoto T, Kamo T, Obara T (2002) Outcome study of psychological distress and nonspecific symptoms in patients with mild primary hyperparathyroidism. Arch Surg 137(7):779–783; discussion 784

    Article  PubMed  Google Scholar 

  5. Pasieka JL, Parsons LL (1998) Prospective surgical outcome study of relief of symptoms following surgery in patients with primary hyperparathyroidism. World J Surg 22(6):513–518; discussion 518–519

    Article  PubMed  CAS  Google Scholar 

  6. Sywak MS, Knowlton ST, Pasieka JL et al.(2002) Do the National Institutes of Health consensus guidelines for parathyroidectomy predict symptom severity and surgical outcome in patients with primary hyperparathyroidism? Surgery 132(6):1013–1019; discussion 1019–1020

    Article  PubMed  Google Scholar 

  7. NIH conference (1991) Diagnosis and management of asymptomatic primary hyperparathyroidism: consensus development conference statement. Ann Intern Med 114(7):593–597

    Google Scholar 

  8. Consensus conference (1991) Diagnosis and management of asymptomatic primary hyperparathyroidism. National Institutes of Health. Conn Med 55(6):349–354

  9. Proceedings of the NIH Consensus Development Conference on diagnosis and management of asymptomatic primary hyperparathyroidism (1991) Bethesda, Maryland, October 29-31, 1990. J Bone Miner Res 6(Suppl 2):S1–S166

    Google Scholar 

  10. Consensus development conference statement (1991). J Bone Miner Res 6(Suppl 2):S9–S13

    Google Scholar 

  11. Mihai R, Wass JA, Sadler GP (2008) Asymptomatic hyperparathyroidism—need for multicentre studies. Clin Endocrinol (Oxf) 68(2):155–164

    CAS  Google Scholar 

  12. Uden P, Chan A, Duh QY et al.(1992) Primary hyperparathyroidism in younger and older patients: symptoms and outcome of surgery. World J Surg 16(4):791–797; discussion 798

    Article  PubMed  CAS  Google Scholar 

  13. Chan AK, Duh QY, Katz MH et al.(1995) Clinical manifestations of primary hyperparathyroidism before and after parathyroidectomy. A case-control study. Ann Surg 222(3):402–412; discussion 412–414

    Article  PubMed  CAS  Google Scholar 

  14. Flint RS, Harman CR, Carter J et al.(2002) Primary hyperparathyroidism: referral patterns and outcomes of surgery. ANZ J Surg 72(3):200–203

    Article  PubMed  Google Scholar 

  15. Walgenbach S, Hommel G, Junginger T (2000) Outcome after surgery for primary hyperparathyroidism: ten-year prospective follow-up study. World J Surg 24(5):564–569; discussion 569–570

    Article  PubMed  CAS  Google Scholar 

  16. Hasse C, Sitter H, Bachmann S et al.(2000) How asymptomatic is asymptomatic primary hyperparathyroidism? Exp Clin Endocrinol Diabetes 108(4):265–274

    Article  PubMed  CAS  Google Scholar 

  17. Pasieka JL, Parsons LL, Demeure MJ et al.(2002) Patient-based surgical outcome tool demonstrating alleviation of symptoms following parathyroidectomy in patients with primary hyperparathyroidism. World J Surg 26(8):942–949

    Article  PubMed  Google Scholar 

  18. Kebebew E, Duh QY, Clark OH (2003) Parathyroidectomy for primary hyperparathyroidism in octogenarians and nonagenarians: a plea for early surgical referral. Arch Surg 138(8):867–871

    Article  PubMed  Google Scholar 

  19. Mihai R, Sadler GP (2008) Pasieka’s parathyroid symptoms scores correlate with SF-36 scores in patients undergoing surgery for primary hyperparathyroidism. World J Surg 32(5):807–814

    Article  PubMed  Google Scholar 

  20. Mittendorf EA, Wefel JS, Meyers CA et al.(2007) Improvement of sleep disturbance and neurocognitive function after parathyroidectomy in patients with primary hyperparathyroidism. Endocr Pract 13(4):338–344

    PubMed  Google Scholar 

  21. Perrier ND, Coker LH, Rorie KD et al.(2006) Preliminary report: functional MRI of the brain may be the ideal tool for evaluating neuropsychologic and sleep complaints of patients with primary hyperparathyroidism. World J Surg 30(5):686–696

    Article  PubMed  Google Scholar 

  22. Prager G, Kalaschek A, Kaczirek K et al.(2002) Parathyroidectomy improves concentration and retentiveness in patients with primary hyperparathyroidism. Surgery 132(6):930–935; discussion 935–936

    Article  PubMed  Google Scholar 

  23. Burney RE, Jones KR, Christy B et al.(1999) Health status improvement after surgical correction of primary hyperparathyroidism in patients with high and low preoperative calcium levels. Surgery 125(6):608–614

    PubMed  CAS  Google Scholar 

  24. Solomon BL, Schaaf M, Smallridge RC (1994) Psychologic symptoms before and after parathyroid surgery. Am J Med 96(2):101–106

    Article  PubMed  CAS  Google Scholar 

  25. Dralle H (2007) Evidence-based endocrine surgery: thyroid cancer. World J Surg 31(5):877–878

    Article  PubMed  CAS  Google Scholar 

  26. Sackett DL (1989) Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest 95(2 Suppl):2S–4S

    Article  PubMed  CAS  Google Scholar 

  27. Heinrich S, Schäfer M, Rousson V et al.(2006) Evidence-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg 243(2):154–168

    Article  PubMed  Google Scholar 

  28. Minisola S, Rosso R, Romagnoli E (1998) Comment on marked improvement in bone mass after parathyroidectomy in osteitis fibrosa cystica. J Clin Endocrinol Metab 83(10):3760–3761

    Article  PubMed  CAS  Google Scholar 

  29. Chavda DV, Frock JT, Zielinski CM et al.(1998) Reversal of the histology of bone after parathyroidectomy in patients with hyperparathyroidism. J South Orthop Assoc 7(1):65–71

    PubMed  CAS  Google Scholar 

  30. Kanis JA (1994) Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. WHO Study Group. Osteoporos Int 4(6):368–381

    Article  PubMed  CAS  Google Scholar 

  31. Jorde R, Sundsfjord J (2000) Bone mineral density and blood pressure in patients with asymptomatic hyperparathyroidism. The Tromso Study. J Intern Med 247(3):325–330

    Article  PubMed  CAS  Google Scholar 

  32. Hagstrom E, Lundgren E, Mallmin H et al.(2006) Positive effect of parathyroidectomy on bone mineral density in mild asymptomatic primary hyperparathyroidism. J Intern Med 259(2):191–198

    Article  PubMed  CAS  Google Scholar 

  33. Abdelhadi M, Nordenstrom J (1998) Bone mineral recovery after parathyroidectomy in patients with primary and renal hyperparathyroidism. J Clin Endocrinol Metab 83(11):3845–3851

    Article  PubMed  CAS  Google Scholar 

  34. Sitges-Serra A, Girvent M, Pereira JA et al.(2004) Bone mineral density in menopausal women with primary hyperparathyroidism before and after parathyroidectomy. World J Surg 28(11):1148–1152

    Article  PubMed  Google Scholar 

  35. Christiansen P, Steiniche T, Brixen K et al.(1999) Primary hyperparathyroidism: short-term changes in bone remodeling and bone mineral density following parathyroidectomy. Bone 25(2):237–244

    Article  PubMed  CAS  Google Scholar 

  36. Lundgren E, Ljunghall S, Akerström G et al.(1998) Case-control study on symptoms and signs of “asymptomatic” primary hyperparathyroidism. Surgery 124(6):980–985; discussion 985–986

    PubMed  CAS  Google Scholar 

  37. Bollerslev J, Jansson S, Mollerup CL et al.(2007) Medical observation, compared with parathyroidectomy, for asymptomatic primary hyperparathyroidism: a prospective, randomized trial. J Clin Endocrinol Metab 92(5):1687–1692

    Article  PubMed  CAS  Google Scholar 

  38. Miller PD, Bilezikian JP (2002) Bone densitometry in asymptomatic primary hyperparathyroidism. J Bone Miner Res 17(Suppl 2):N98–N102

    PubMed  Google Scholar 

  39. Silverberg SJ, Gartenberg F, Jacobs TP et al.(1995) Increased bone mineral density after parathyroidectomy in primary hyperparathyroidism. J Clin Endocrinol Metab 80(3):729–734

    Article  PubMed  CAS  Google Scholar 

  40. Lumachi F, Camozzi V, Ermani M et al.(2007) Bone mineral density improvement after successful parathyroidectomy in pre- and postmenopausal women with primary hyperparathyroidism: a prospective study. Ann N Y Acad Sci 1117:357–361

    Article  PubMed  CAS  Google Scholar 

  41. Ambrogini E, Cetani F, Cianferotti L et al.(2007) Surgery or surveillance for mild asymptomatic primary hyperparathyroidism: a prospective, randomized clinical trial. J Clin Endocrinol Metab 92(8):3114–3121

    Article  PubMed  CAS  Google Scholar 

  42. Rao DS, Phillips ER, Divine GW et al.(2004) Randomized controlled clinical trial of surgery versus no surgery in patients with mild asymptomatic primary hyperparathyroidism. J Clin Endocrinol Metab 89(11):5415–5422

    Article  PubMed  CAS  Google Scholar 

  43. Abe Y, Ejima E, Fujiyama K et al.(2000) Parathyroidectomy for primary hyperparathyroidism induces positive uncoupling and increases bone mineral density in cancellous bones. Clin Endocrinol (Oxf) 52(2):203–209

    Article  CAS  Google Scholar 

  44. Christiansen P, Steiniche T, Brixen K et al.(1999) Primary hyperparathyroidism: effect of parathyroidectomy on regional bone mineral density in Danish patients: a three-year follow-up study. Bone 25(5):589–595

    Article  PubMed  CAS  Google Scholar 

  45. Nakaoka D, Sugimoto T, Kobayashi T et al.(2000) Prediction of bone mass change after parathyroidectomy in patients with primary hyperparathyroidism. J Clin Endocrinol Metab 85(5):1901–1907

    Article  PubMed  CAS  Google Scholar 

  46. Nomura R, Sugimoto T, Tsukamoto T et al.(2004) Marked and sustained increase in bone mineral density after parathyroidectomy in patients with primary hyperparathyroidism: a six-year longitudinal study with or without parathyroidectomy in a Japanese population. Clin Endocrinol (Oxf) 60(3):335–342

    Article  Google Scholar 

  47. Silverberg SJ, Shane E, Jacobs TP et al.(1999) A 10-year prospective study of primary hyperparathyroidism with or without parathyroid surgery. N Engl J Med 341(17):1249–1255

    Article  PubMed  CAS  Google Scholar 

  48. Lal G, Clark OH (2003) Primary hyperparathyroidism: controversies in surgical management. Trends Endocrinol Metab 14(9):417–422

    Article  PubMed  CAS  Google Scholar 

  49. Silverberg SJ, Shane E, de la Cruz L et al.(1989) Skeletal disease in primary hyperparathyroidism. J Bone Miner Res 4(3):283–291

    Article  PubMed  CAS  Google Scholar 

  50. Silverberg SJ, Bilezikian JP, Bone HG et al.(1999) Therapeutic controversies in primary hyperparathyroidism. J Clin Endocrinol Metab 84(7):2275–2285

    Article  PubMed  CAS  Google Scholar 

  51. Silverberg SJ, Gartenberg F, Jacobs TP et al.(1995) Longitudinal measurements of bone density and biochemical indices in untreated primary hyperparathyroidism. J Clin Endocrinol Metab 80(3):723–728

    Article  PubMed  CAS  Google Scholar 

  52. Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 312(7041):1254–1259

    PubMed  CAS  Google Scholar 

  53. Melton LJ 3rd, Atkinson EJ, O’Fallon WM et al.(1992) Risk of age-related fractures in patients with primary hyperparathyroidism. Arch Intern Med 152(11):2269–2273

    Article  PubMed  Google Scholar 

  54. Kochersberger G, Buckley NJ, Leight GS et al.(1987) What is the clinical significance of bone loss in primary hyperparathyroidism? Arch Intern Med 147(11):1951–1953

    Article  PubMed  CAS  Google Scholar 

  55. Larsson K, Ljunghall S, Krusemo UB et al.(1993) The risk of hip fractures in patients with primary hyperparathyroidism: a population-based cohort study with a follow-up of 19 years. J Intern Med 234(6):585–593

    Article  PubMed  CAS  Google Scholar 

  56. Khosla S, Melton J 3rd (2002) Fracture risk in primary hyperparathyroidism. J Bone Miner Res 17(Suppl 2):N103–N107

    PubMed  Google Scholar 

  57. Vestergaard P, Mollerup CL, Frøkjaer VG et al.(2000) Cohort study of risk of fracture before and after surgery for primary hyperparathyroidism. BMJ 321(7261):598–602

    Article  PubMed  CAS  Google Scholar 

  58. Vestergaard P, Mosekilde L (2003) Fractures in patients with primary hyperparathyroidism: nationwide follow-up study of 1201 patients. World J Surg 27(3):343–349

    Article  PubMed  Google Scholar 

  59. Kenny AM, MacGillivray DC, Pilbeam CC et al.(1995) Fracture incidence in postmenopausal women with primary hyperparathyroidism. Surgery 118(1):109–114

    Article  PubMed  CAS  Google Scholar 

  60. Khosla S, Melton LJ 3rd, Wermers RA et al.(1999) Primary hyperparathyroidism and the risk of fracture: a population-based study. J Bone Miner Res 14(10):1700–1707

    Article  PubMed  CAS  Google Scholar 

  61. Vanderwalde LH, Liu IL, Haigh PI (2009) Effect of bone mineral density and parathyroidectomy on fracture risk in primary hyperparathyroidism. World J Surg 33(3):406–411

    Article  PubMed  Google Scholar 

  62. Vestergaard P, Mosekilde L (2003) Cohort study on effects of parathyroid surgery on multiple outcomes in primary hyperparathyroidism. BMJ 327(7414):530–534

    Article  PubMed  Google Scholar 

  63. Vanderwalde LH, Liu IL, O’Connell TX et al.(2006) The effect of parathyroidectomy on bone fracture risk in patients with primary hyperparathyroidism. Arch Surg 141(9):885–889; discussion 889–891

    Article  PubMed  Google Scholar 

  64. Okamoto T, Gerstein HC, Obara T (1997) Psychiatric symptoms, bone density and non-specific symptoms in patients with mild hypercalcemia due to primary hyperparathyroidism: a systematic overview of the literature. Endocr J 44(3):367–374

    Article  PubMed  CAS  Google Scholar 

  65. Coker LH, Rorie K, Cantley L et al.(2005) Primary hyperparathyroidism, cognition, and health-related quality of life. Ann Surg 242(5):642–650

    Article  PubMed  Google Scholar 

  66. Dotzenrath CM, Kaetsch AK, Pfingsten H et al.(2006) Neuropsychiatric and cognitive changes after surgery for primary hyperparathyroidism. World J Surg 30(5):680–685

    Article  PubMed  Google Scholar 

  67. Joborn C, Hetta J, Johansson H et al.(1988) Psychiatric morbidity in primary hyperparathyroidism. World J Surg 12(4):476–481

    Article  PubMed  CAS  Google Scholar 

  68. Talpos GB, Bone HG 3rd, Kleerekoper M et al.(2000) Randomized trial of parathyroidectomy in mild asymptomatic primary hyperparathyroidism: patient description and effects on the SF-36 health survey. Surgery 128(6):1013–1020; discussion 1020–1021

    Article  PubMed  CAS  Google Scholar 

  69. Burney RE, Jones KR, Peterson M et al.(1998) Surgical correction of primary hyperparathyroidism improves quality of life. Surgery 124(6):987–991; discussion 991–992

    PubMed  CAS  Google Scholar 

  70. Burney RE, Jones KR, Coon JW et al.(1996) Assessment of patient outcomes after operation for primary hyperparathyroidism. Surgery 120(6):1013–1018; discussion 1018–1019

    Article  PubMed  CAS  Google Scholar 

  71. Sheldon DG, Lee FT, Neil NJ et al.(2002) Surgical treatment of hyperparathyroidism improves health-related quality of life. Arch Surg 137(9):1022–1026; discussion 1026–1028

    Article  PubMed  Google Scholar 

  72. Quiros RM, Alef MJ, Wilhelm SM et al.(2003) Health-related quality of life in hyperparathyroidism measurably improves after parathyroidectomy. Surgery 134(4):675–681; discussion 681–683

    Article  PubMed  CAS  Google Scholar 

  73. Caillard C, Sebag F, Mathonnet M et al.(2007) Prospective evaluation of quality of life (SF-36v2) and nonspecific symptoms before and after cure of primary hyperparathyroidism (1-year follow-up). Surgery 141(2):153–159; discussion 159–160

    Article  PubMed  Google Scholar 

  74. Pasieka JL, Parsons LL (2000) A prospective surgical outcome study assessing the impact of parathyroidectomy on symptoms in patients with secondary and tertiary hyperparathyroidism. Surgery 128(4):531–539

    Article  PubMed  CAS  Google Scholar 

  75. Greutelaers B, Kullen K, Kollias J et al.(2004) Pasieka Illness Questionnaire: its value in primary hyperparathyroidism. ANZ J Surg 74(3):112–115

    Article  PubMed  Google Scholar 

  76. Chou FF, Sheen-Chen SM, Leong CP (1995) Neuromuscular recovery after parathyroidectomy in primary hyperparathyroidism. Surgery 117(1):18–25

    Article  PubMed  CAS  Google Scholar 

  77. Turken SA, Cafferty M, Silverberg SJ et al.(1989) Neuromuscular involvement in mild, asymptomatic primary hyperparathyroidism. Am J Med 87(5):553–557

    Article  PubMed  CAS  Google Scholar 

  78. Deutch SR, Jensen MB, Christiansen PM et al.(2000) Muscular performance and fatigue in primary hyperparathyroidism. World J Surg 24(1):102–107

    Article  PubMed  CAS  Google Scholar 

  79. Edwards ME, Rotramel A, Beyer T et al.(2006) Improvement in the health-related quality-of-life symptoms of hyperparathyroidism is durable on long-term follow-up. Surgery 140(4):655–663; discussion 653–654

    Article  PubMed  CAS  Google Scholar 

  80. Kristoffersson A, Bostrom A, Soderberg T (1992) Muscle strength is improved after parathyroidectomy in patients with primary hyperparathyroidism. Br J Surg 79(2):165–168

    Article  PubMed  CAS  Google Scholar 

  81. Joborn C, Joborn H, Rastad J et al.(1988) Maximal isokinetic muscle strength in patients with primary hyperparathyroidism before and after parathyroid surgery. Br J Surg 75(1):77–80

    Article  PubMed  CAS  Google Scholar 

  82. Jansson S, Grimby G, Hagne I et al.(1991) Muscle structure and function before and after surgery for primary hyperparathyroidism. Eur J Surg 157(1):13–16

    PubMed  CAS  Google Scholar 

  83. Colliander EB, Strigård K, Westblad P et al.(1998) Muscle strength and endurance after surgery for primary hyperparathyroidism. Eur J Surg 164(7):489–494

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, University of British Columbia, Vancouver, BC, Canada

    Nadine R. Caron

  2. Department of Surgery, University of Calgary, North Tower, 1403 29th Street NW, Calgary, AB, T2N 2T9, Canada

    Janice L. Pasieka

Authors
  1. Nadine R. Caron
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Janice L. Pasieka
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Janice L. Pasieka.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Caron, N.R., Pasieka, J.L. What Symptom Improvement Can Be Expected After Operation for Primary Hyperparathyroidism?. World J Surg 33, 2244–2255 (2009). https://doi.org/10.1007/s00268-009-9987-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-009-9987-4

Keywords

Search

Navigation