Minimally Invasive Parathyroidectomy FAQ

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Parathyroid surgery at UCLA

Overview

Surgery for primary hyperparathyroidism (parathyroidectomy) is the most commonly performed operation at UCLA Health. The typical operation takes 20-30 minutes and is performed through a 1-inch neck incision. The success rate of parathyroid surgery is 99%. The complication rate is <1%. Most patients go home the same day, after a 4-hour observation period. After successful parathyroid surgery, patients go on to enjoy a number of long-term health benefits, chiefly an increase in bone density that substantially reduces the 10-year risk of major fractures.

Diagnosis

The diagnosis of primary hyperparathyroidism rests on blood and sometimes urine testing. Primary hyperparathyroidism is characterized by elevated blood calcium levels (generally 10.4 mg/dL or greater) and parathyroid hormone (PTH) levels that are either elevated (>65 pg/mL) or inappropriately normal (40-65 pg/mL). Urine testing (24-hour urine collection for calcium) is not necessary in all patients but may help clarify ambiguous cases.

In establishing the diagnosis of primary hyperparathyroidism, we often like to see at least two elevated calcium levels, because a single high calcium level can be spurious (meaning, related to dehydration or a laboratory error on a given day). Most cases of primary hyperparathyroidism are clear cut, allowing patients to move on to surgery within a few weeks.

There are 3 recognized subtypes of primary hyperparathyroidism:

Classic primary hyperparathyroidism is characterized by blood calcium levels ³10.4 mg/dL and PTH levels >65 pg/mL. The exact values may vary slightly depending on the individual laboratory. Patients with classic primary hyperparathyroidism make up about half of total cases and most of these patients benefit from parathyroid surgery.
Normohormonal primary hyperparathyroidism is characterized by blood calcium levels ³10.4 mg/dL and PTH levels 40-65 pg/mL. In these cases, the PTH level is inappropriately normal, meaning that though the PTH level is technically in the normal range (95% reference range), it is not normal in the context of a simultaneously high blood calcium level. In other words, in patients whose parathyroid glands are functioning normally, a high blood calcium level would push (suppress) the PTH level down below 20 pg/mL. A nonsuppressed PTH level is diagnostic of primary hyperparathyroidism. The diagnosis of normohormonal primary hyperparathyroidism is often missed. Patients with normohormonal primary hyperparathyroidism make up about half of total cases and usually benefit from parathyroid surgery.
Normocalcemic primary hyperparathyroidism is characterized by normal blood calcium levels (typically between 8.5 and 10.3 mg/dL) and PTH levels >65 pg/mL. To establish the diagnosis of normocalcemic primary hyperparathyroidism, secondary hyperparathyroidism (most often caused by vitamin D deficiency, kidney disease, or prior on the stomach/intestines) must first be ruled out. Most patients with normocalcemic patients do not require parathyroid surgery, as the benefits of surgery in this patient population are not clearly established. In our practice, we do offer surgery selectively to normocalcemic patients with PTH levels ³100 pg/mL and progressive unexplained bone loss. Patients with calcium levels in the 9s usually do not have surgery. Patients with calcium levels in the low 10s require careful evaluation with serial laboratory testing over time. About 15% of patients with normocalcemic primary hyperparathyroidism will eventually progress to the classic form of disease, with calcium levels rising to ³10.4 and remaining high. These patients should be re-evaluated for possible surgery.

Ambiguous cases

Though most cases of primary hyperparathyroidism are clearly diagnosed after 1-2 blood tests, we frequently see patients with ambiguous or borderline results. The best strategy for these patients is careful evaluation of blood test results over time, typically at least 3 complete sets of blood tests (calcium, PTH, phosphate, albumin, creatinine/eGFR, 25-hydroxy vitamin D) over a 6-week period and at least one urine test (24-hour urine collection for calcium and creatinine). Given that there is generally no urgency to this evaluation, we recommend prudent consideration of the diagnosis, including competing diagnoses such as familial hypocalciuric hypercalcemia (FHH) and not rushing into a potentially unnecessary operation.

Further workup with bone density measurement

The skeleton is the principal target organ that is affected by primary hyperparathyroidism. For this reason, bone mineral density measurement (also known as bone densitometry) with dual-energy X-ray absorptiometry (DXA or DEXA) is usually performed as part of initial evaluation. This is especially important for post-menopausal women. DXA results are typically reported as T-scores, which compare the patient’s bone density to that of healthy young adults. Parathyroid surgery is clearly necessary in patients with osteoporosis (T-scores worse than -2.5, indicating severe bone loss). Those with osteopenia (T-scores ranging from -1 to -2.5, indicating mild to moderate bone loss) also benefit from surgery, as bone mineral density rises substantially in the 2-5 years following surgery, reducing major fracture rates by up to 65% over 10 years. This degree of benefit greatly exceeds what is seen with medical treatment.

Effect of parathyroidectomy on Bone Mineral Density, adapted from Lundstam et al, J Bone Miner Res. 2023

Results of the largest prospective study to date demonstrated a significant beneficial effect of parathyroid surgery on bone mineral density. As you can see in the blue lines, bone density declines rapidly in patients with primary hyperparathyroidism who are not treated. Parathyroid surgery yields bone density gains in some areas of the body and at least stabilizes bone density in other areas. Previous work done by our group has shown that bone mineral density gains after parathyroid surgery translate into reductions in the rate of major fracture for 10 years after surgery. No such benefit was seen in patients treated with medications for osteoporosis. For more information see Benefits of Parathyroid Surgery.

Parathyroidectomy Reduces Fracture Risk Primary Hyperparathyroidism

Parathyroid Imaging (Scans)

Preoperative imaging may be performed after the diagnosis of primary hyperparathyroidism has been established using blood and urine testing. Imaging should not be used to select patients for surgery, but only to guide the strategy of the operation. Today, parathyroid imaging is more sensitive and accurate than ever. However, scans are still incorrect from time to time and therefore there is no substitute for having an experienced surgeon who is skilled at identifying all four parathyroid glands and adapting to situations when scans are wrong or misleading. Scans provide a window into the true condition of the patient. The full truth is only revealed at the time of surgery. Despite improvements in imaging, we still see patients in whom all scans are negative. These patients should still undergo parathyroid surgery if the diagnosis is well established. We operate on patients with negative scans every week. These operations may take a little longer than average, but are still highly successful.

Ultrasound. Ultrasound is usually the first-line scan that patients receive after a diagnosis of primary hyperparathyroidism. It is painless, involves no radiation, and can often be performed in the surgeon’s office. A skilled operator can find about 85% of parathyroid glands using ultrasound.
Sestamibi scans. Developed in the 1980s, sestamibi scans were the workhorse of parathyroid imaging for decades until the advent of parathyroid 4D-CT. Sestamibi scans are still performed today, based on physician preference or in centers that have not developed parathyroid 4D-CT. Sestamibi scans involve the injection of a radioisotope (a tiny, harmless amount of radiation is administered) followed by image acquisition over 1.5 hours. Sestamibi scans are about 80% sensitive.
Parathyroid 4-D CT. Developed in the mid-2000s,parathyroid 4D-CT is the definitive imaging test for patients with primary hyperparathyroidism today, with sensitivity approaching 98%. Parathyroid 4D-CT involves the injection of iodinated contrast media followed by image acquisition for several minutes, at very specific times after the injection. The team at UCLA spent several years refining parathyroid 4D-CT: fine tuning patient positioning, minimizing the amount of radiation, and training both our radiologists and surgeons in the interpretation of these scans. Our program of continuous quality improvement involves monthly joint conferences where past scans are compared to surgical findings.
18F Fluorocholine PET/MRI and C11 choline PET/CT. These new scans for primary hyperparathyroidism are offered by only a few centers in the nation, and are only necessary in patients who have had prior failed parathyroid surgery who have negative parathyroid 4D-CT scans.

Getting ready for parathyroid surgery

Parathyroid surgery is usually performed on an outpatient basis 3-6 weeks after initial consultation. Prior to surgery, patients should undergo a preoperative “head to toe” physician exam by their primary care physician within 30 days of the proposed surgery date. This may include additional tests such as routine bloodwork and an electrocardiogram at the discretion of the primary care physician. Patients with a history of heart disease are asked to see their cardiologist prior to surgery and follow through with any additional testing (stress test, myocardial perfusion scan, or echocardiogram) prior to surgery. A good way to get ready for surgery is to get 30 minutes of exercise daily for several weeks leading up to the surgery date.

Anticoagulants (blood thinners) should be stopped prior to parathyroid surgery:

Aspirin – stop 7 days prior to surgery
Clopidogrel (Plavix) – stop 7 days prior to surgery
Apixaban (Eliquis) or rivaroxaban (Xarelto) – stop 2 days prior to surgery

If you are taking a blood thinner because you had a recent heart attack or stroke within the past 6 months, or if you had a coronary stent placed within the past 6 months, it may be advisable to avoid elective surgery for now and stay on the blood thinner for up to one full year.

Diet instructions leading up to surgery

Stop eating solid food 8 hours prior to your scheduled arrival time to the hospital or surgery center.
You may continue drinking clear liquids until 2 hours prior to your scheduled arrival time to the hospital or surgery center. These liquids must be “see-through” to be considered clear liquids. This means no milk products (including no milk or cream in your coffee!), no juice containing pulp, and no smoothies.
Any medications can be taken with a small sip of water, ideally at least 2 hours before your scheduled arrival time.

The day of surgery

Ask a family member or trusted friend to bring you to the hospital and take you home.
Please check-in to the hospital or surgery center 2 hours ahead of your scheduled surgery time.
If you live far from UCLA, please plan to be in the West Los Angeles area 3 hours ahead of your scheduled surgery time, in case you are called in early for surgery.
Wear comfortable clothes and avoid bringing valuables.
After you check in, you will be taken to the pre-op area to have your vital signs taken. After you change into a hospital gown, an intravenous catheter (IV) will be placed in your arm or hand. You will be assessed by a nurse, and then the anesthesiologist will see you. The surgeon will stop by to answer any questions. When the pre-op assessment and all necessary forms are complete, you will be given some medication to help you relax before you are taken to the operating room for surgery.

Anesthesia

Patients undergoing parathyroid surgery at UCLA have general anesthesia, meaning they are completely asleep during surgery. General anesthesia can be administered using an endotracheal tube or with a laryngeal mask airway. The anesthesiologist will examine you prior to surgery to determine which is the safest method for you. General anesthesia is safe and effective. Over thousands of cases, we have had no anesthesia-related complications during parathyroid surgery. If you have a history of post-operative nausea and vomiting (feeling sick after anesthesia), please notify our team in advance so that your anesthetic can be adjusted accordingly.

Technique of surgery

Incision and exposure. A 1-inch incision is made. The muscles are separated in the midline to expose the thyroid gland. The thyroid gland is gently rolled aside to reveal the neighboring parathyroid glands.

Removal of parathyroid glands. Parathyroid surgery with examination of all 4 parathyroid glands is the preferred approach. In 85% of cases, a single parathyroid adenoma is removed. The remaining 15% of cases are split between double adenomas and parathyroid hyperplasia. Surgery for double adenomas involves removal of 2 glands and inspection of the other 2. Parathyroid hyperplasia is managed with 3.5 gland removal, leaving a small remnant of parathyroid tissue that has a good blood supply.

Intraoperative PTH measurement. We use the Roche Elecsys rapid PTH assay, which yields results in 9 minutes.

Intraoperative PTH levels are drawn from an IV placed in the foot while the patient is asleep. The rapid turnaround time for the assay gives the surgeon valuable feedback regarding the completeness of parathyroid surgery in real time.

PTH Dynamics During Parathyroid Surgery

Typical intraoperative PTH dynamics during parathyroid surgery. The pre-incision value is drawn before surgery begins. The pre-excision value is drawn when the blood supply of the parathyroid adenoma is clipped. Often, the pre-excision value is the highest one because dissection of the adenoma can cause some PTH to be released. A fall of >50% from the peak level after 10 minutes is highly predictive of cure. The 30-minute value is drawn in the recovery room, after surgery is complete. A 30-minute value ranging from 11-39 pg/mL is ideal.

Closure. Three layers are closed: the strap muscles, the platysma, and the skin. The skin closure is performed using running subcuticular sutures, as is done during plastic surgery. The sutures are absorbable, so they do not need to be removed.

Recovery

Parathyroid surgery is usually performed on an outpatient (same-day) basis. After surgery, we observe patients for 4 hours to address any pain, nausea, or swelling. Patients may be discharged home thereafter if they live within 1-hour drive of UCLA and are accompanied by a responsible adult who will stay with them that night. Patients from out of town are usually discharged to nearby hotels and can travel (drive or fly) the next day. We sometimes prefer to keep patients overnight in the hospital for the following reasons:

They live alone.
They have other significant medical conditions that require longer observation. These conditions include heart disease, lung disease, kidney disease, obesity, sleep apnea, neurological disease, or any disability that would make self-care more difficult after surgery.
They prefer to stay overnight.

There is no extra charge to stay overnight. Overall, we are very careful with our patients on the day of surgery. People trust us with their safety, and we take this responsibility very seriously.

The day after surgery is a normal day. Patients can work at the computer, go outside, and generally take care of themselves without assistance right away. Patients can eat their usual diet. Most patients feel ready to return to “desk jobs” 2-3 days after surgery. If you have a strenuous job, you may wish to take a week off. Patients are able to exercise 5-6 days after surgery. If you swim regularly, please request a waterproof bandage on the day of surgery so that you may go back in the water 5-6 days after surgery. Otherwise, the wound can be immersed 14 days after surgery.

Wound care

Steri-strips are used to cover the wound. These will begin to fall off on their own 10-14 days after surgery. Patients may shower immediately after surgery, though it is best to avoid direct spray to the wound area and immersion for 14 days, after the dressing falls off.

Dr. Masha Livhits talks about scars after thyroid and parathyroid surgery.

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Dr. Masha Livhits discusses scar massage after thyroidectomy and parathyroidectomy.

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Medications after parathyroid surgery

After parathyroid surgery, patients are discharged with 3 new medications:

Calcium carbonate (regular strength Tums, 500 mg) 1000 mg by mouth twice per day.
Vitamin D (cholecalciferol) 2000 units by mouth daily.
Prescription pain medicine (hydrocodone, Norco or similar) if needed.

The amount of calcium prescribed will vary based on the blood calcium level before surgery as well as lab results from the day of surgery. Though the typical patient is discharged on 4 Tums per day, some who have higher preoperative calcium levels may be discharged on up 12 Tums per day. After successful removal of an abnormal parathyroid gland or glands, the PTH level falls within 10 minutes. The blood calcium level falls over the course of several days, often reaching its lowest point 48 bours after surgery. Patients who have had successful parathyroid surgery are likely to feel some symptoms of low calcium at that time, most commonly numbness and tingling in the fingers, lips, and sometimes toes. Tingling related to low blood calcium levels is symmetrical, meaning it is felt equally in both hands/feet. This is a cue to take some extra calcium – we instruct our patients to take 4 Tums immediately if they feel tingling, and then wait about 20 minutes to see if they experience relief. Patients may need up to 12 Tums per day during the first 2 weeks after surgery, but rarely more than that. If you have questions about this after surgery or are experiencing tingling that won’t go away, please call the office or page your doctor.

Interestingly, when the blood calcium level is checked 48 hours after successful parathyroid surgery, it is usually normal (between 8.5 and 10.5 mg/dL). This means that the body is actually sensing blood calcium levels that are low relative to the high calcium levels present before surgery. It takes most people 2-6 weeks to become accustomed to the new, healthier calcium level. We ask patients to take calcium tablets during this transition period to maximize patient comfort.

Signs and symptoms of low blood calcium after parathyroid surgery

Symptoms of low blood calcium levels after parathyroid surgery including numbness and tingling in the fingers, lips, and feet. If untreated, muscles spasms/cramps of the hands (most often the thumb) and calves may occur. Most of the time, these symptoms can be treated by taking calcium tablets by mouth.

Laboratory tests after parathyroid surgery

A number of blood tests will be drawn during and immediately after parathyroid surgery while you are still in the hospital. After discharge, we ask that patients have their blood calcium levels checked 3 and 6 months after surgery by their referring doctor or primary care doctor. Thereafter, calcium levels only need to be checked once per year as part of a routing physical exam.

Parathyroid surgery FAQs:

: Parathyroidectomy is the most common operation performed at UCLA Health. The UCLA Endocrine Surgery team performs parathyroid surgery 3 days per week, completing up to 10 operations per day.
: No, but most patients we see (>90%) stand to benefit from parathyroid surgery. Primary hyperparathyroidism causes human disease principally by affecting the skeleton. The daily removal of calcium from the skeleton by an overactive parathyroid gland or glands eventually leads to measurable bone loss (osteopenia or osteoporosis) in most people if given enough time. Parathyroid surgery is proven to be beneficial in patients with 3 or more years of life expectancy. The average patient we see with primary hyperparathyroidism has more than 10 years of life expectancy.
Having said this, if your blood calcium level is mildly elevated (between 10.4 and 11.4 mg/dL), your bone density is normal, you have not had kidney stones or other kidney problems, and you are feeling well, you can delay having parathyroid surgery. Patients being observed for primary hyperparathyroidism without surgery should have their blood calcium level checked twice per year and bone density checked every other year.
: Medications for primary hyperparathyroidism are generally not effective. Cinacalcet is a calcimimetic drug that reduces the blood calcium level but does not improve bone density. Osteoporosis medications, such as alendronate/Fosamax, ibandronate/Boniva, zoledronate/Reclast, and denosumab/Prolia, may improve bone density but have not been proven to reduce fractures in patients with primary hyperparathyroidism. Overall, parathyroid surgery is a better choice for most people.
: Constitutional and cognitive symptoms may sometimes improve after parathyroid surgery, but improvements in these domains is inconsistent and of variable magnitude. In other words, because symptoms such as fatigue and memory loss have many potential causes, not everyone feels better after parathyroid surgery. A small number of patients seem to feel much better after parathyroid surgery, but this is the exception rather than the rule. In our experience, about 2/3 of patients experience some improvement, with the remaining 1/3 feeling about the same. Improvements in constitutional and cognitive symptoms may occur immediately after surgery in some cases, and after several weeks in others.
: Yes. It is performed using a 1-inch (2.5 cm) incision.
: No. Laparoscopic/endoscopic surgery is best suited to areas like the abdomen and chest, where there is a body cavity that can be filled with carbon dioxide gas to create sufficient space to perform the operation. The neck does not have a cavity per se. Therefore, a small conventional open incision is made.
: Yes. Four-gland examination is the preferred approach at UCLA.
: Usually just one. About 85% of patients with primary hyperparathyroidism have a single parathyroid adenoma that is responsible for their problem. The remaining patients are split between double adenoma (2 abnormal glands) and hyperplasia (4 abnormal glands). In double adenoma, 2 glands are removed. In parathyroid hyperplasia, 3.5 glands are removed.
: In patients with 4-gland parathyroid hyperplasia, 3.5 glands are removed. This is called a subtotal parathyroidectomy. Subtotal parathyroidectomy is performed by carefully inspecting all 4 parathyroid glands, identifying the best one, removing the others, and shaving the remnant (“keeper”) gland down to a healthy size (25-35 mg) while keeping its blood supply intact. Because parathyroid hyperplasia is often asymmetrical, we have the opportunity to find the healthiest gland of the four. Healthy glands are smaller, flatter, and more pale colored than diseased glands, which are larger, more rounded in shape, and darker colored.
Patients who undergo subtotal parathyroidectomy for parathyroid hyperplasia are then cured of primary hyperparathyroidism and go on to lead normal, healthy lives. Calcium supplementation is necessary for the first several weeks after parathyroid surgery, just as in patients who have had 1-2 parathyroid glands removed, and can usually be tapered off after that.
: No. All patients need to have some parathyroid tissue present in order to avoid permanent HYPOparathyroidism. HYPOparathyroidism is a debilitating condition in which the PTH level is too low (in the single digits or close to zero). These patients have low blood calcium levels and must take both calcium and prescription strength vitamin D several times per day to avoid complications such as severe muscle cramps and seizures.
: Similar to almost all expert centers in the nation, we use general anesthesia for parathyroid surgery. We are often asked if we can use a “light” anesthetic, which is a strange question – we can’t even figure out what this question means, as there is no definition of a “light” anesthetic. We use short-acting anesthetic agents that are rapidly eliminated from the body. Patients wake up just a few minutes after completion of the operation. We have never had any complications related to anesthesia during parathyroid surgery. To protect the airway and deliver inhaled anesthetic agents during surgery, either an endotracheal tube or laryngeal mask airway is used. The anesthesiologist will examine you before surgery and determine which is the safest option for you.
: The operation is performed by the attending surgeon, who has an assistant. Parathyroid surgery requires 4 hands to complete. The assistant helps to retract (hold tissues aside) and provide exposure as directed by the attending surgeon.
: Yes. PTH levels are checked every 5 minutes starting at the moment when the abnormal parathyroid gland is removed. A decline of 50% or more in the intraoperative PTH level after 10 minutes is highly predictive of cure.
: Generally not, because the nerve monitor has not been demonstrated to improve outcomes in parathyroid or thyroid surgery.
: Yes. Most patients go home after a 4-hour observation period.
: Recovery from parathyroid surgery is rapid. The day after surgery is a normal day: patients can go outside, work at a computer, and perform regular activities of daily living. Patients may return to exercise 5-6 days after surgery. Patients can go swimming 14 days after surgery. If you wish to return to swimming sooner than that, please request a waterproof bandage (placed at the time of surgery) over your incision.
: We see many patients who have had failed parathyroid surgery at other hospitals. Unfortunately, this is a common problem in the United States, as the failure rate of parathyroid surgery may be as high as 30% for inexperienced surgeons. The first thing we recommend is to wait, rather than jumping into a second operation. The neck needs several months to heal after surgery, for the amount of scar tissue to diminish naturally. This makes subsequent imaging more accurate and reduces the risk of complications during a second operation. The minimum waiting time is 3 months unless the calcium level is critically high, with 6 months being preferred. Thereafter, we recommend re-confirming the diagnosis of primary hyperparathyroidism with blood and sometimes urine testing, followed by imaging with parathyroid 4D-CT. The imaging results must be carefully considered alongside information from the prior operation (operation report and pathology report). Patients who are good candidates for repeat parathyroid surgery generally have: (a) high calcium levels >10.5 mg/dL; (b) demonstrable health problems from hyperparathyroidism, such as osteoporosis; and (c) a clear target lesion on parathyroid 4D-CT.
: Probably yes. This biochemical profile reflects normohormonal primary hyperparathyroidism (see above). Most of these patients benefit from parathyroid surgery.
: Probably not. Having a normal blood calcium level (8.5-10.3 mg/dL) is a sign to pump the brakes and strongly consider avoiding surgery. This biochemical profile is compatible with normocalcemic primary hyperparathyroidism (see above). We only recommend surgery to about 5% of patients, most of whom have blood calcium levels ranging from 10.0-10.3 md/gL.
: Yes. Patients who have had bariatric (weight loss) surgery often have elevated PTH levels because of malabsorption. The blood calcium level is usually normal. These patients can generally avoid parathyroid surgery.
: No. There is no scientific evidence to support age-related differences in the normal blood calcium level.
: Almost never. Parathyroid surgery is usually elective, meaning that it can be scheduled months after the diagnosis. If you are being rushed to have parathyroid surgery, we advise caution. Creating a false sense of urgency is a common characteristic of scams.
: You should likely still pursue parathyroid surgery, but be sure to do so at an experienced center. Here at UCLA, we perform parathyroid surgery on patients with negative scans several times per week. Remember that the diagnosis of primary hyperparathyroidism rests on blood and sometimes urine tests. Scans are not considered in making the decision for surgery; rather, they inform the strategy of the operation after surgery has been deemed the best course for the patient. Many patients who come to see us with negative scans have had sestamibi scans or outside ultrasounds, which are 80% sensitive at best. In these patients, we are often able to find enlarged parathyroid glands on surgeon-performed ultrasound or parathyroid 4D-CT. Though 4D-CT is 95% sensitive, they can still be negative sometimes. Patients with negative scans are more likely to have multiple-gland parathyroid disease; these operations are generally more difficult than operations on patients with positive scans. Therefore, the surgeon must be prepared to perform a thorough 4-gland exploration. We often will allocate slightly more time in the operating room for patients with negative scans, 45-60 minutes as opposed to 20-30 minutes.
: Yes. Many different formulations of calcium are available over the counter. Most contain calcium carbonate (contains 40% elemental calcium) and others contain calcium citrate (21% elemental calcium). Some people find calcium citrate easier to tolerate and less constipating.
: Check the PTH level. More than 90% of patients with elevated blood calcium levels have an underlying diagnosis of primary hyperparathyroidism. Our study in 2022 revealed that 99% of patients within UCLA Health with elevated blood calcium levels on 2 or more occasions were found to have primary hyperparathyroidism after the PTH level was checked.
: This likely means that you have persistent or recurrent hyperparathyroidism. You may require a second operation if your blood calcium levels remain at 10.4 mg/dL or above. If you are considering a second parathyroid operation, it is best to seek out a highly experienced parathyroid surgeon.
: Elevated PTH levels after successful surgery for primary hyperparathyroidism are actually quite common, affecting up to 40% of patients. If the blood calcium level is normal, there is no need for concern. The first step is to check the vitamin D level and provided vitamin D supplementation as needed. The blood calcium and PTH levels should be checked 1-2 times per year thereafter. Again, if the blood calcium level remains normal, no further action is needed. However, if the blood calcium level rises to 10.4 mg/dL or greater, further evaluation for possible persistent or recurrent hyperparathyroidism is advised.

References

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