AHNS Series: Do you know your guidelines? Optimizing outcomes in reoperative parathyroid surgery: Definitive multidisciplinary joint consensus guidelines of the American Head and Neck Society and the British Association of Endocrine and Thyroid Surgeons

Abstract

Background Revision parathyroid is challenging due to possible diagnostic uncertainty as well as the technical challenges it can present. Methods A multidisciplinary panel of distinguished experts from the American Head and Neck Society (AHNS) Endocrine Section, the British Association of Endocrine and Thyroid Surgeons (BAETS), and other invited experts have reviewed this topic with the purpose of making recommendations based on current best evidence. The literature was also reviewed on May 12, 2017. PubMed (1946‐2017), Cochrane SR (2005‐2017), CT databases (1997‐2017), and Web of Science (1945‐2017) were searched with the following strategy: revision and reoperative parathyroidectomy to ensure completeness. Results Guideline recommendations were made in 3 domains: preoperative evaluation, surgical management, and alternatives to surgery. Eleven guideline recommendations are proposed. Conclusion Reoperative parathyroid surgery is best avoided if possible. Our literature search and subsequent recommendations found that these cases are best managed by experienced surgeons using precision preoperative localization, intraoperative parathyroid hormone (PTH), and the team approach.

Surgical Management of Primary Hyperparathyroidism—Clinicopathologic Study of 1019 Cases from a Single Institution

“…The investigation of this patient also shows that there is still a possibility that parathyroid adenomas can be missed even with previous use of advanced imaging methods if they occur in various anatomical positions [9]. Moreover, ectopic parathyroid glands can be so small that they may be invisible, or a single removed gland is one when all function abnormally [5,7]. In our opinion, the best surgical solution for the latter is a removal of three and a half of the parathyroid glands.…”

“…Surgical failures may result from an incomplete excision or parathyromatosis. Reoperative parathyroid surgery can be required in approximately 10% of patients [5]. Out of the 1019 patients, 19 (1.9%) received a surgery that failed.…”

Single gland excision for MEN1‐associated primary hyperparathyroidism

“…Nowadays, neck reoperations are less challenging due to the higher chance of preoperative localization of the hyperplastic gland(s) by improved modern imaging such as contrast‐enhanced ultrasonography, 99mTc‐MiBI SPECT scintigraphy, 3 Tesla magnetic resonance imaging, 4D‐computed tomography, and methionine or fluorcholin PET/CT 33. The use of an intraoperative quick parathormone test allows success control after a focused removal of enlarged parathyroid glands and the use of continuous intraoperative neuromonitoring might prevent lesions of the RLN by traction in the scar tissue 32,34,35. Moreover, the risk of RLNP can be further minimized, if the reoperation is performed by experienced surgeons in specialized centers 36…”

Vocal cord paralysis due to ectopic parathyroid adenoma and function recovery: a case report and review of the literature

“…Previous reports in the literature describe an algorithm for the management of PHPT [20,21]. Similarly, at our institution, the general approach to minimally invasive parathyroidectomy involves imaging techniques in conjunction with IOPTH and frozen section, which could help rule out multiple-gland disease and predict cure intraoperatively.…”