Monitoring

After surgical intervention, clinicians should monitor for the development of a cervical hematoma, observe wound healing, check voice quality, and perform laboratory evaluation as necessary. Postoperative management involves determining surgical success and monitoring for complications.

Some guidelines recommend considering short-term prophylaxis against hypocalcemia following parathyroidectomy with calcium and/or vitamin D supplementation, although the evidence in favor of this is weak.[2] Twenty-four to 36 hours after surgery, the serum calcium level should be at an all-time low. In patients who develop hypocalcemia, onset of symptoms most commonly occurs on postoperative day number 2 or 3; only patients with extreme elevations of calcium preoperatively occasionally present with symptoms on postoperative day 1. Patients almost never develop symptoms on the day of surgery.[102] The serum intact parathyroid hormone (PTH) level should be normal within 30 hours, but the secretory response may not restore to normal for weeks. Standard surveillance for seizures should be maintained.

Outpatient management is appropriate for selected patients. An overnight stay is more likely to be required for patients undergoing reoperation, extensive surgery or subtotal parathyroidectomy, and for those with severe vitamin D deficiency.[2]

After parathyroidectomy, monitoring of serum calcium levels for 6 months is advisable, and can be done on an outpatient basis.[2] This is necessary, especially if a particularly large adenoma was removed. If calcium and serum PTH levels are elevated postoperatively, another adenoma or incomplete resection is a possible cause. Also, malignancy or misdiagnosis is possible. Cure of primary hyperparathyroidism is defined as the re-establishment of normal calcium homeostasis. In a subset of patients, serum PTH will remain elevated despite normalization of serum calcium; causes of secondary hyperparathyroidism need to be carefully investigated and managed appropriately.[109]

Annual serum calcium checks are recommended on a long-term basis. Around 8% of patients with a sporadic parathyroid adenoma will go on to develop recurrent primary parathyroidism.[12]​ Recurrent primary hyperparathyroidism is defined as a recurrence of hypercalcemia after a normocalcemic interval of greater than 6 months post-parathyroidectomy.[2] Management for recurrent primary hyperparathyroidism should take place within a specialist center and involves localization studies (to identify ectopic glands) followed by reoperation, if necessary.[110]​​[12]

In patients being monitored without parathyroid surgery, serum calcium, vitamin D, and creatinine clearance should be measured every 12 months and bone density measured every 1 to 2 years.[1]​ Patients should avoid medications that increase serum calcium levels (e.g., thiazide diuretics, lithium). Vitamin D levels should be sufficient.[12]​ A definitive parathyroidectomy can be performed at any point if symptoms or indications ensue, or if the patient prefers surgery and is a surgical candidate.

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