The rationale against routine subtotal parathyroidectomy for primary hyperparathyroidism

Our therapeutic approach to the treatment of primary hyperparathyroidism has been the resection of only the abnormally enlarged parathyroid gland, the normal-appearing parathyroids being left intact. During the past twenty-five years we have operated on 292 patients with primary hyperparathyroidism. In all cases the serum calcium levels returned to within normal limits during the immediate postoperative period, and there were no instances of permanent hypoparathyroidism. To determine the long-term efficacy of this therapeutic approach, a retrospective study of 101 patients operated on for primary hyperparathyroidism during a nine year period from July 15, 1965 through June 30, 1974 was made. Of the 101 patients, eight were dead and nine could not be located. Of the remaining eighty-four patients, only two required reoperation because of recurrent hypercalcemia; one had MEA-I and eventually three and a half glands were removed, and the other had recurrent hypercalcemia after a three year normocalcemic interval, and after a second operation with resection of an enlarged parathyroid gland, he has remained normocalcemic. The other eighty-two patients (97 per cent of those reevaluated and 82 per cent of the total operated on) have remained symptom-free and normocalcemic for periods ranging from three to twelve years. Only one patient (if we exclude the patient with MEA-I) has elevated serum parathormone levels with borderline levels of serum calcium. Our results suggest that the optimal surgical treatment of primary hyperparathyroidism, except for cases of MEA, is resection of only the abnormally enlarged parathyroid glands after exploration and identification of all four glands in every case. If all four glands are enlarged, three and a half should be resected.