Patterns of disease in patients at a tertiary referral centre requiring reoperative parathyroidectomy

Abstract

INTRODUCTIONReoperative parathyroidectomy is required when there is persistent or recurrent hyperparathyroidism following the initial surgery (at least 5% of parathyroidectomies nationally). By convention, 'persistent disease' is defined as the situation where the patient has not been cured by the first operation. The term 'recurrent hyperparathyroidism' is used when the patient was confirmed to be biochemically cured for six months from the first operation but has hyperparathyroidism after this date. Reoperative surgery is associated with higher rates of postoperative complications as well as a greater rate of failure to cure. The aim of our study was to review our departmental experience of reoperative parathyroidectomy, with a view to identify patterns of disease persistence and recurrence. METHODS Using a departmental database, patients were identified who had undergone reoperative parathyroidectomy between 2006 and 2014. All the pre, intra and postoperative information was documented including the operative note so as to record the location of the abnormal parathyroid gland found at reoperation. RESULTS Almost two-thirds (63%) of patients had negative, equivocal or discordant conventional imaging so secondary investigative tools were required frequently. The majority of abnormal glands were found in eutopic locations. The most common locations for ectopic glands were intrathyroidal, mediastinal and intrathymic. A third (33%) of the patients had multigland disease and over a quarter (28%) had coexisting thyroid disease. CONCLUSIONS Persistent hyperparathyroidism represents a challenging patient subgroup for which access to all radiological modalities and intraoperative parathyroid hormone monitoring are required. Patient selection for reintervention is a key determinant in the reoperation cure rate. Primary hyperparathyroidism (HPT) is caused by a single adenoma in approximately 90%, multigland disease including adenomas or hyperplasia in 10% and parathyroid carcinoma in under 1% of cases.1 Parathyroidectomy remains the definitive cure of primary HPT and the procedure of choice in refractory tertiary HPT in renal failure patients both before and after renal transplantation. Failure to cure HPT at the first operation (persistent HPT) is reported to occur in 5% of cases, both in the literature and in national registry data, but this is very probably underreported.2,3 In contrast, patients with recurrent HPT will have been biochemically cured (normal serum calcium and accommodated parathyroid hormone) for more than six months since the initial operation.Patients who have ongoing HPT despite a previous operation are candidates for a reoperative parathyroidectomy. This surgery is associated with higher rates of postoperative complications as well as a lower chance of being cured. 4,5 The aim of our study was to review our departmental experience of reoperative parathyroidectomy with a view to identifying patterns of disease persistence and recurrence.

Persistent and recurrent hyperparathyroidism

“…Obesity and ASA3 have also been reported as predictive factors of P-PHPT and R-PHPT [14]. Those predictive parameters have been confirmed by other studies [15,16]. These findings indicate that parathyroid surgery should be performed in high volume centers by experienced surgeons with adequate imaging modalities.…”

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

“…The true incidence of ectopic and supernumerary glands in the neck is on the order of 1% with autopsy series suggesting a higher frequency than encountered clinically. 16 Failure to identify glands in characteristic anatomic position(s) is a more common occurrence than the presence of a supernumerary gland. True intrathyroidal parathyroids are also rare; they are more commonly closely attached to nodular thyroid gland capsule than truly intrathyroidal.…”

Cervical re‐explorations and proxy survival following parathyroidectomy for primary hyperparathyroidism using Australian administrative data

“…This focus has enabled the introduction of more ambulant surgical pathways, minimally invasive procedures and the capacity to offer surgery to a greater proportion of patients . The published outcomes following parathyroidectomy are also frequently derived from specialized units or the accumulation of results collected by survey . Data such as that aggregated by the American College of Surgeons for the National Surgical Quality Improvement Program or The University of Sydney Endocrine Surgery Database provide such a perspective of surgical results .…”