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Reoperative Parathyroidectomy: Recognizing Unique Risk Profiles
Tessa Gruen1, Tim Kravchenko2, Theodore Hu2
1University of Michigan Medical School, Ann Arbor, Michigan.
Introduction:
Reoperative parathyroidectomy following prior parathyroidectomy, thyroidectomy, or nonendocrine anterior cervical procedures is more complex than initial parathyroidectomy. Limited data exist on how the index cervical operation affects reoperative outcomes. This study aimed to characterize reoperative parathyroidectomy outcomes by index procedure.
Methods:
We retrospectively reviewed adult patients who underwent reoperative parathyroidectomy for primary hyperparathyroidism at a tertiary center from 2016 to 2024. Patients were stratified by index procedure: subtotal (≥3 gland removal) parathyroidectomy, focused (single gland removal) parathyroidectomy, total thyroidectomy, hemithyroidectomy, and nonendocrine anterior cervical procedures. Immediate biochemical cure was defined as postexcision intraoperative parathyroid hormone (PTH) <65 pg/mL and surgical failure as final intraoperative PTH >65 pg/mL. Permanent postoperative hypoparathyroidism (POHP) was defined as PTH <6 pg/mL beyond 6 mo. Operative and clinical notes were reviewed for recurrent laryngeal nerve injury, postoperative neck hematoma, and parathyroid autotransplantation.
Results:
Among 242 reoperative parathyroidectomy patients, 128 (60%) had prior focused parathyroidectomy, 16 (7.5%) subtotal parathyroidectomy, 33 (16%) total thyroidectomy, 26 (12%) hemithyroidectomy, and 10 (4.1%) nonendocrine anterior cervical procedures. Prior subtotal parathyroidectomy was associated with higher rates of autotransplantation (P < 0.001) and surgical failure (P = 0.03). Time to reoperation was shortest in focused parathyroidectomy patients (P < 0.001). The rate of recurrent laryngeal nerve injury in the overall cohort was 1.9%, and the rate of permanent POHP was 14%.
Conclusions:
Reoperative parathyroidectomy has an increased risk profile for POHP regardless of the index procedure. Those with prior subtotal parathyroidectomy are at higher risk of surgical failure and require autotransplantation more often. Reoperative parathyroidectomy should be performed at high-volume centers with thorough preoperative risk discussion and a low threshold for autotransplantation.
