Approach to the patient with persistent or recurrent primary hyperparathyroidism

Reoperative parathyroid surgery may be required in patients who have persistent primary hyperparathyroidism after an unsuccessful operation and in patients who had an initially successful exploration but develop recurrent disease at an interval greater than 6 months postoperatively. Additionally, patients who have had significant surgery in the cervical region, particularly total thyroidectomy, should be considered in this group because they pose identical technical challenges that in the past have resulted in suboptimal cure and complication rates. These patients require a meticulous review of their historical, biochemical, imaging, and operative data to confirm the diagnosis, to evaluate the possibility of familial forms of hyperparathyroidism, and to confirm the indications for surgery. Once a patient is deemed an appropriate surgical candidate, sequential imaging is required to yield a roadmap to guide surgical intervention. These reoperative procedures require an experienced parathyroid surgeon armed with intraoperative adjuncts to locate the offending parathyroid gland(s) and remove them while minimizing collateral injury, particularly to the recurrent laryngeal nerves. These patients are also at increased risk of postoperative hypocalcemia that can be life-threatening. Despite these concerns, an experienced endocrine team can diagnose persistent or recurrent hyperparathyroidism, localize residual abnormal parathyroid glands, and perform surgical intervention with success and complication profiles that approximate those achieved in the unexplored patient.