The experience of parathyroidectomy when treating primary parathyroid hyperplasia

Total parathyroidectomy with forearm autograft (TP) and subtotal parathyroidectomy (SP) are the two widely-accepted surgical procedures for treating primary parathyroid hyperplasia. Although TP carries an increased risk of permanent hypoparathyroidism and implantation site recurrence, it is still the preferred option of some surgeons. This retrospective study's aim is to confirm the superiority of initial TP when treating primary multiple gland hyperplasia.

All patients who had received parathyroidectomy for primary multiple gland hyperplasia from 1987 to 2007 were reviewed. Two modalities of parathyroidectomy were used; these were subtotal parathyroidectomy (3 (1/2), SP) as the standard initial treatment strategy and TP for disease recurrence or synchronous thyroid abnormality.

A total of 14 patients were treated and these had a median follow-up period of 98 months (range, 51~216). Among these patients, 11 received SP and 3 underwent TP. Seven out of the 11 SP patients (63%) developed postoperative disease recurrence. Of the seven patients who received neck re-exploration, six (85%) demonstrated temporary postoperative hypocalcemia compared with the first operation (14%) (p = 0.003). Four of these patients (57%) experienced recurrent laryngeal nerve palsy, which was significantly higher than the rate after the first operation (0%) (p = 0.006). Therefore, cervical reexploration carried a significantly elevated overall complication rate compared to initial neck exploration (p = 0.002). Of the three initial TP patients, one showed recurrence at the implantation site. All eight recurrence cases underwent re-operations that significantly reduced their serum calcium concentrations (12.55 to 8.7 mg/dL, p = 0.008) and parathyroid hormone levels (135 to 70 pg/mL, p = 0.008) compared with their respective levels just before re-exploration; this group had a 10-year recurrence-free rate of 45%.

Re-operations for recurrent disease are common regardless of the type of primary surgery. Compared with initial TP, re-operation for post-SP disease recurrence was associated with a significantly higher complication rate. TP would seem to be recommended as the choice of initial surgical procedure.