Safety and effectiveness of reoperation for persistent or recurrent drug refractory secondary hyperparathyroidism

Abstract

Background: Drug-refractory secondary hyperparathyroidism (SHPT) is the most common complication in patients with chronic renal failure (CRF). Although surgery is the most effective and safe method for drug-refractory SHPT, the condition may persist or recur after the primary surgery, and reoperation is often required in these patients. The purpose of our current study was to evaluate the safety and effectiveness of reoperation for drug-refractory SHPT. Methods:The clinical data of 15 patients requiring reoperation after a surgery for drug-refractory SHPT in our hospital from 2010 to 2019 were retrospectively analyzed. Changes in biochemical markers including intact parathyroid hormone (iPTH), blood calcium (Ca), blood phosphorus (P), alkaline phosphatase (ALP), and blood calcium phosphorus product (Ca*P) were compared before and after the surgery, and the effectiveness and complications of the reoperation were summarized. Results:The reoperation was successful in all the 15 patients after a single attempt. Routine pathological examinations identified a total of 25 parathyroid glands, of which 10 were in the neck in situ, 5 were ectopic in the neck, and 10 were in the forearm. The ectopic parathyroid glands were located inside the thyroid gland (n=1), anterior superior mediastinum (n=1), or thymus (n=3). Surgical treatment significantly improved clinical symptoms such as skin pruritus and bone pain. Blood iPTH, Ca, P, ALP, and Ca*P were significantly reduced (P<0.05 or P<0.01) after surgery. Hypothyroidism occurred in 1 patient; 4 patients undergoing orthotopic neck surgery developed transient hoarseness, which were alleviated within 6 months; no severe complications such as bleeding or death were noted. No recurrence occurred during the 6-month follow-up.Conclusions: Reoperation is safe and effective for drug-refractory SHPT. Preoperative imaging should be performed to achieve accurate positioning, and the recurrent laryngeal nerve should be closely monitored during surgery. The purpose of the reoperation is to remove all possible parathyroid tissues to avoid recurrence.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism

“…No studies have been performed to compare the utility of the various criteria to reoperate. However, all patients being considered for reoperation should have disease that is refractory to medical therapy 284,428,432,435 Recommendation 9-1: Reoperation should be considered for patients with medically refractory persistent or recurrent HPT.…”

“…The neck can be approached through the same incision428 or a lateral approach; if a gland has been identified in the mediastinum, sternotomy may be indicated 427. Once the central neck has been entered, a bilateral exploration should be performed in order to identify all remaining parathyroid tissue, including the remnant gland as well as any ectopic or supernumerary glands 428. The goal of the operation is to remove as much parathyroid tissue as possible without rendering the patient hypoparathyroid.…”

Application of nanocarbon negative imaging technology in surgery for secondary hyperparathyroidism

“…Secondly, the objective of fully removing all tissue at first operation renders the identification of the anatomical boundaries for surgery more precise, increasing the likelihood of its success and also reduces the need for further procedures. Reoccurrence is more likely following partial removal as residual tissue may be missed, and a second operation significantly increases the incidence of damage to nerves, blood vessels, and the thoracic duct (16). To sum up, minimizing the recurrence rate and avoiding the need for subsequent surgery offers the best outcome for uremic patients with SHPT.…”

Surgical Management of Secondary Hyperparathyroidism

“…Some surgeons defer to the same indications used for the original procedure and will consider re-exploration of patients with PTH >800 pg/ml and hypercalcemia and/or hyperphosphatemia unresponsive to drug therapy. 81 KDOQI guidelines recommend imaging with ultrasound, sestamibi, and CT or magnetic resonance imaging to aid in localization of lingering parathyroid tissue before re-exploration. 16 Preoperative localization, if possible, is particularly important in this scenario as the search can be complicated by significant adhesions and scar tissue from the previous operation.…”

“…Some centers have reported significantly greater drops in ioPTH during successful reoperations compared with the initial operation, which may help guide re-exploration. 81 , 82 …”