Reoperative parathyroid surgery

Reoperation for persistent or recurrent primary hyperparathyroidism immediately connotes a complex clinical management problem. Successful cure of hypercalcemia is less frequent whereas complications are more common compared to initial explorations. Of 212 patients operated on at the Mayo Clinic from 1978 through 1986, 189 (89%) were cured. Sporadic disease, multiple endocrine neoplasia, and familial hyperparathyroidism were found in 183 (87%), 20 (9%), and 9 (4%) patients, respectively. Prior to the most recent reoperation, these patients had undergone from one to five operations. Preoperative localization examinations were performed in 192 patients (91%). Cervical high-resolution, real-time ultrasonography, computed tomography, and thallium-technetium scintigraphy had sensitivity rates of 87%, 56%, and 71%, respectively. When the tumor was localized preoperatively, the operative time and cost were significantly reduced compared to nonlocalized tumors. Cervical reexploration only was required in 154 (72%), combined cervical and mediastinal exploration occurred in 46 (22%), and mediastinal exploration only was performed in 12 (6%). There was no perioperative mortality; permanent hypoparathyroidism developed in 33 patients (16%), and six patients (2.9%) suffered permanent unilateral vocal cord paralysis. Anatomically, the most frequent site to find a missed parathyroid adenoma was in the normal location. The large majority of these glands were removed through a cervical incision although, on occasion, they were retracted from the anterior superior mediastinum or the low tracheoesophageal space. These data confirm that reoperative parathyroid surgery can be performed safely, with a rather high degree of success, but too-frequently results in a lifetime morbidity of hypoparathyroidism.