A 36-year-old woman on long-term haemodialysis has refractory secondary hyperparathyroidism with calcium 11.8 mg/dL despite calcitriol and cinacalcet, pruritus, bone pain and radiographic brown tumours. Sestamibi shows enlargement of all four glands. After successful kidney transplantation she remains hypercalcaemic with PTH 480 pg/mL. The recommended operation is:

• A Subtotal parathyroidectomy leaving a 100 mg remnant in situ in the neck
• B Excision of the largest gland only with intraoperative PTH monitoring
• C Total parathyroidectomy with autotransplantation of minced parathyroid tissue into the forearm ✓
• D Transcervical thymectomy alone with biopsy of all glands

Explanation

Persistent hyperparathyroidism after successful transplantation, termed tertiary hyperparathyroidism, arises from autonomously functioning hyperplastic glands and requires surgery when medical therapy fails. Total parathyroidectomy with autotransplantation of minced tissue into the forearm is preferred in dialysis and transplant populations because recurrence can be managed by partial removal of the graft under local anaesthesia, avoiding a repeat neck exploration. Excision of a single gland fails in four-gland hyperplasia, and an in-neck remnant makes recurrent surgery hazardous.

Reference: Sabiston Textbook of Surgery, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.