Postoperative hypocalcemia is a common and most often transient event after extensive thyroid surgery. It may reveal iatrogenic injury to the parathyroid glands and permanent hypoparathyroidism. We prospectively evaluated the incidence of hypocalcemia and permanent hypoparathyroidism following total or subtotal thyroidectomy in 1071 consecutive patients operated during 1990-1991. We then determined in a cross-sectional study which early clinical and biochemical characteristics of patients experiencing postoperative hypocalcemia correlated with the long-term outcome. Postoperative calcemia under 2 mmol/l was observed in 58 patients (5. 4%). In 40 patients hypocalcemia was considered severe (confirmed for more than 2 days, symptomatic or both). At 1 year after surgery five patients (0.5%) had persistent hypocalcemia. We found that patients carried a high risk for permanent hypoparathyroidism if fewer than three parathyroid glands were preserved in situ during surgery or the early serum parathyroid hormone level was /= 4 mg/dl under oral calcium therapy. When one or more of these criteria are present, long-term follow-up should be enforced to check for chronic hypocalcemia and to avoid its severe complications by appropriate supplement therapy.

Background: Pancreatitis is associated with primary hyperparathyroidism (PHPT) in 1.5-7% of cases. The relationship of cause and effect between the two diseases has been debated. Methods: To evaluate this relationship, the clinical, biochemical and pathological data on 1435 patients operated on for hyperparathyroidism (HPT) over the past 30 years were retrospectively reviewed. A total of 1224 of these patients had biologically proven and cured PHPT and 21 1 patients had renal HPT (RHPT). The diagnosis of pancreatitis (PTS) was based on a high serum amylase level andor abnormalities on ultrasound or computed tomography (CT) scan explorations. Only patients without biliary stones were included in the PTS group associated with HPT. Results: A total of 3.2% (n = 40) of patients with PHPT had PTS, which was acute in 18 cases, subacute in 8 cases and chronic in 14 cases. This rate of PTS is higher than in a random hospital population. Surgical cure of HPT was followed by the spontaneous healing of 17/18 acute PTS, whereas six of the 22 patients with subacute or chronic PTS developed complications due to the evolution of their disease (diabetes, pancreatic duct stenosis treated by surgery). A single diseased gland was found in 27 patients with PTS, which is in favour of primary parathyroid disease, being responsible for, and not a consequence of, PTS. Only the serum calcium (13.0 vs 12.1 g/dL) level was significantly increased in PHPT patients with PTS, when compared to those without PTS. The calcium level is probably of major importance in the development of PTS, which was never encountered in 21 I patients with RHPT, who had low calcium and high PTH levels. Conclusions: The data suggest that (i) the PTS-PHPT association is not incidental; (ii) PTS is the consequence and not the cause of PHPT; (iii) hypercalcaemia seems to be a major factor in the development of PTS in PHPT patients; and (iv) cure of PHPT leads to the healing of acute PTS, whereas it does not affect the evolution of subacute and chronic PTS.

Aim: To analyse the causes and outcome of reoperations for persistent or recurrent primary hyperparathyroidism (HPT). Materials and methods: We reviewed the medical records of 38 patients who underwent reoperation between December 1965 and April 1997 for persistent or recurrent primary HPT. During this period of time, 1448 patients underwent operation for primary HPT, 294 for renal HPT and 58 for questionable disease, i. e. a total of 1800. In the 1448 cases of HPT, 22 patients were reoperated after a first cervicotomy in the institution, i. e. a first reoperation rate of 1.5%. Sixteen patients were referred after unsuccessful parathyroid surgery. Six patients were reoperated on twice and one patient seven times for a graftdependent recurrence. Results: Reasons for failed parathyroid operations included tumour tissue in ectopic location (75%) or tumour tissue that had not been seen in normal position (19%), parathyreomatosis (2%), parathyroid cancer (2%) and graft-dependent hypercalcaemia (2%). Of the ectopic glands, 45% were intrathymic, 12.5% intrathyroidal, 7.5% retro-oesophageal, 7.5% in the carotid sheath, 5% interthyrotracheal, 5% in the mediastinum (extrathymic), 5% in the aorto-pulmonary window, 2.5% undescended, 2.5% overdescended and 2.5% intertracheooesophageal. Of the patients, 38% had uniglandular lesions, 60% multiglandular lesions, and 2% parathyroid cancer. The histologically confirmed cause of HPT was adenoma in 50% of cases, hyperplasia in 38% and "normal" but overweight glands in 9.5%. Of the 38 patients studied, 15 presented one or more supernumerary glands (fifth to eighth gland). Reoperation was performed through a cervical incision in 82% of cases and using a mediastinal approach in 18% (8 median sternotomies, 1 thoracoscopy). The success rate of the reoperations was 92%. A total of 8% of patients suffered permanent unilateral vocal cord paralysis; 5% are definitely hypocalcaemic. The sensitivities of preoperative localization studies ranged from 69% for sestamibi scan and 63% for selective venous catheterization to 16% for computed tomography. Conclusion: Repeated parathyroidectomy can be avoided in more than 98% of patients if an experienced surgeon performs bilateral cervical exploration during the initial parathyroid operation. For patients with persistent or recurrent primary HPT, preoperative localization studies and a focused surgical approach can result in a 92% success rate with a minimal complication rate.

The accuracy with which pheochromocytomas and paragangliomas can be visualized questions nowadays the routine use of abdominal approach. In selected cases of sporadic unilateral chromaffin tumours, a posterior, lateral, or even laparoscopic approach should be considered.

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