Re-operation for hyperparathyroidism

Re-operation for hyperparathyroidism (HPT) represents a challenge for experienced endocrine surgeons. The present study reviews the technical and pathological factors for failure of initial surgery and identifies strategies to approach re-operative parathyroidectomy.

Clinical details, operation notes, pathology, localization studies and complications for re-operative cases performed by three surgeons were reviewed.

Over a 10-year period there were 40 re-operative cases with a 98% success rate. There were 31 patients with primary HPT, 21 with persistent primary (PP) and 10 with recurrent primary (RP). Multigland disease (MGD) was present in 19 of the 31 (61%) primary HPT cases. The culprit gland was ectopic in 14 cases, at a normal location in 10 and there was regrowth at previously excised sites or remnant disease in 10. There were nine patients with secondary HPT, four with persistent secondary (PS) and five with recurrent secondary (RS). The culprit gland was ectopic in five, at a normal location in four and regrowth at a previously excised site in two. Pre-operative investigations were employed in all cases and the most helpful were sestamibi scan (S) and selective venous sampling (SVS) for parathyroid hormone (PTH) concentration. True positive localizations for S was in 20 of 34 cases (59%), SVS in seven of nine (78%), computed tomography (CT) in seven of 17 (41%) and ultrasound scan (USS) in 10 of 28 (36%).

Re-operative parathyroidectomy can be performed by experienced surgeons with a very high success rate and minimal complications.