Strategy and technique of reoperative parathyroid surgery

Reoperative parathyroid surgery requires strategies and techniques different from those employed in initial surgery for primary hyperparathyroidism. Differentiation between single- and multiple-gland disease and between sporadic and familial disease helps determine the extent of surgery. Identification and removal of only enlarged glands with biopsy, if possible, of normal parathyroid tissue, is indicated in patients with sporadic disease. Patients with multiple-gland or familial disease undergoing reoperation for recurrence or persistence should have all identifiable parathyroid tissue removed from the neck, and portions should be cryopreserved. Immediate autotransplantation is not recommended even for patients undergoing total parathyroidectomy at reoperation. Such patients may become normocalcemic or remain hypercalcemic because of inaccurate assessment of previous surgery, supernumerary glands, or because an underlying stimulus promotes hyperplasia of residual parathyroid fragments. Since hypercalcemia in patients with functional tissue in the arm is difficult to manage, it is wiser to perform autograft with cryopreserved tissue only in those patients who exhibit prolonged hypoparathyroidism. A surgical approach with emphasis on operative techniques that has evolved from recent experience with over 90 reoperations is presented.