Secondary Bleeding
The risk of secondary bleeding is greatest within the first 4-6 hours postoperatively, but persists up to 36 hours. Deep secondary bleeding can rapidly lead to a life-threatening condition through tracheal compression and vagus pressure.
Avoidance through meticulous intraoperative hemostasis and careful surgical technique. At the end of the operation, Valsalva maneuver and adequate blood pressure to check for blood dryness. Calm, uneventful emergence and extubation.
First signs of bleeding: Cervical pressure and tightness, lump in throat speech, swallowing difficulties. In case of sweating, shortness of breath, stridor, tachycardia and hypotension, immediate surgical revision. Laboratory tests and ultrasound are not reliable diagnostic measures for detecting the bleeding and must be deferred or omitted due to the acuity.
Therapy:Securing the airway takes precedence, but if possible, timely transfer to the operating room to perform orderly reintubation and revision under sterile conditions.
Hungry Bone Syndrome
Chronic elevated PTH stimulates bone resorption, causing the bone to continuously lose calcium and become demineralized (osteopenia/osteitis fibrosa cystica).
After removal of the overactive parathyroid gland(s), the PTH level drops abruptly, leading to massive remineralization (calcium, magnesium, and phosphate are shifted from the blood into the bone). This results in hypocalcemia despite normal or low PTH. Symptoms usually begin 1–4 days postoperatively.
Risk factors: severe long-standing hyperparathyroidism, high preoperative PTH and calcium, advanced bone disease (e.g., osteitis fibrosa cystica)
Therapy: Intensive calcium substitution, usually intravenous immediately postoperatively, additionally vitamin D (e.g., calcitriol), long-term oral substitution over weeks to months.
Recurrent Nerve Palsy (Vocal Cord Paralysis)
Transient recurrent nerve palsy after focused initial procedures for pHPT <1%, in reoperations the rate increases to up to 9%.
Recurrent nerve lesions are usually the result of compression or traction on the nerve, rarely transection, so they are often reversible
Hypoparathyroidism
Mild transient hypocalcemia after pHPT in up to 42%. This leads to tingling paresthesias in fingers and feet and increased muscle contractility.
Therapy: oral administration of calcium and active vitamin D (calcitriol).
Permanent hypoparathyroidism is extremely rare in focused procedures and solitary adenoma.
Persistence/Recurrence
If the laboratory constellation of pHPT is detected again either immediately after the operation or within the first 6 months postoperatively, there is persistence of the disease.
If pathological laboratory values appear for the first time later than 6 months after the operation, it is a recurrence. The frequency of an unsuccessful operation and thus persistence in pHPT is 2 - 5%.
Causes of persistence (80-90% of reoperations): Failure to locate (negative exploration), incomplete removal (of a possibly lobulated PTG), unrecognized multigland disease, unidentified supernumerary PTG with adenoma, parathyroid carcinoma
Causes of recurrence (10-20% of reoperations): delayed adenomas or hyperplasias in retained PTGs, PTG carcinoma, parathyromatosis see below.
Therapy:For every reoperation, the indication must be critically evaluated. Prerequisite is extended localization diagnostics, ideally the operative report of the initial procedure with validation of each named PTG by a corresponding finding in the histology at that time. If necessary, intraoperative PTH determination from bilateral jugular venous blood, possibly step catheter to rule out or detect a PTG located in the mediastinum not accessible cervically.
In recurrent h(hereditary)pHPT and lack of localization, surgical success is questionable, so long-term treatment with calcimimetics should be considered, the same applies to the patient's refusal.
Local Parathyromatosis
A rare cause of recurrent pHPT is parathyromatosis. It arises from iatrogenically caused parathyroid cell seeding in the cervical connective tissue, based on PTG cell displacement during PTGA capsule opening, which can occur in both pHPT and renal HPT.
Wound Infection < 1 %
