Re-explorative Parathyroid Surgery for Persistent and Recurrent Primary Hyperparathyroidism

Abstract

Primary hyperparathyroidism (HPT) is treated by parathyroidectomy. Excision of abnormal parathyroid tissue is curative in the majority of cases. Postoperative persistent or recurrent HPT has been reported up to 30%. The purpose of this study was to evaluate the role of imaging techniques and determine the efficacy of reexplorative surgery. A total of 306 patients underwent parathyroidectomy between 2000 and 2009. Twelve patients (3.9%) were not cured. Two patients declined further treatment, the other 10 patients underwent further investigation and surgery. Imaging and results of redo surgery together with associated complications were evaluated. All 10 patients were investigated with sestamibi, which accurately localized aberrant parathyroid tissue in three cases and ultrasound scans which also localized three cases. CT was useful in one of the three cases for which it was used. PET and MRI were not helpful. Twelve glands were resected, six adenomas, five hyperplastic and one normal gland. Nine of the 10 reoperated patients became normocalcemic. Complications included a bilateral recurrent laryngeal paresis. In total, 317 operations were performed and 303 of 306 (99%) patients were cured. Redo surgery for HPT is challenging and carries higher risks than primary surgery. Sestamibi and ultrasound scans are the most helpful imaging modalities. When there is concordance a targeted approach may be considered, otherwise a more extensive dissection is required. Redo parathyroid surgery should be considered, even if scans are unhelpful, for patients who are symptomatic or young or have a persistently high calcium level.

Primary Hyperparathyroidism

“…The first line of investigation is to use noninvasive preoperative localization studies, like neck US, sestamibi scan, MRI or 4-D CT scan. If noninvasive studies failed to localize the diseased gland(s), invasive techniques such as venous sampling for PTH levels may be used (48). Intraoperative adjuncts like US, ioPTH monitoring, and radioguided parathyroidectomy are recommended in reoperative parathyroidectomy.…”

“…Intraoperative adjuncts like US, ioPTH monitoring, and radioguided parathyroidectomy are recommended in reoperative parathyroidectomy. The cure rate for reoperative parathyroidectomy for PHPT ranges from 76% to 94% (48). However, the complication rate of reoperative parathyroidectomy is higher, in which up to 13% of patients may develop permanent hypoparathyroidism, and up to 4% may suffer from recurrent laryngeal nerve injury (49).…”

Primary Hyperparathyroidism

“…Approximately 2-5% of PHPT patients who undergo parathyroidectomy will need further surgical intervention for either persistent or recurrent disease (26,47). Persistent PHPT is defined as hypercalcemia within 6 months of parathyroidectomy and it occurs in about 3.9% (48). It is likely due to failure to identify and remove all hyperfunctioning glands.…”