"Conservative" versus "liberal" approach to parathyroid neck exploration.

Is the recent trend toward more radical parathyroid surgery justified? Surgical outcomes in three groups of 50 patients undergoing operation for primary hyperparathyroidism at the Mayo Clinic between January, 1974, and May, 1976, were compared. One group of patients was operated on by Surgeon A who used a "conservative" approach (removal of grossly enlarged glands only, with or without biopsy of one normal-sized gland). A second group was operated on by a Surgeon B, who used a more "liberal" approach (almost routine removal of at least two glands, removal of three and one-half glands when more than one gland was enlarged, and liberal use of biopsy identification). Symptomatic hypocalcemia requiring treatment occurred in 24% of patients after liberal neck exploration, as compared with 4% in the conservatively treated group. The liberal approach did not yield any higher cure rate. A third group of 50 patients was operated on by Surgeon B using the conservative approach. The incidence of postoperative hypocalcemia was reduced to 2%; one patient remained hypercalcemic. Symptomatic hypocalcemia, even if temporary, represents significant morbidity. A conservative approach to neck exploration in patients with primary hyperparathyroidism is recommended because it is associated with a very low incidence of temporary postoperative hypoparathyroidism (2 to 4%) and a high cure rate (99% in this series).