Parathyroid re-exploration. A clinical and pathological study of 112 cases

In a series of 112 patients who underwent reoperation for primary hyperparathyroidism at the Massachusetts General Hospital between 1930 and 1975, all but 10 were treated successfully. Seventy-five initial explorations had been performed elsewhere, and 37 in our hospital. A total of 110 diseased parathyroids were uncovered-89 (81%) via re-exploration of the neck and 21 (19%) via mediastinotomy. In operation via the neck, the missing glands were most frequently found in the superior posterior mediastinum at the thoracic inlet (34, or 38%) and in mediastinal exploration, in the upper anterior mediastinum (14, or 67%). There were 66 patients with adenoma, 7 with carcinoma, and 29 with primary hyperplasia. Four had a hyperfunctioning fifth gland. One patient had an intrathyroidal and one, an ectopic gland. Reoperation was unsuccessful in 10 patients. Four died, and 6 are living. Unsuccessful exploration resulted from failure to understand the widespread distribution of normal parathyroids and the way they were displaced when diseased, error in diagnosing the pathologic entity of hyperparathyroidism at surgery, and technical incompetence. Reoperation of the neck was generally performed first. A mediastinotomy was undertaken only if the missing gland was clearly excluded from the neck or if localization studies had demonstrated its presence beyond doubt in the mediastinum. Reoperation was rarely performed simultaneously on the neck and the mediastinum, and it was seldom indicated in asymptomatic cases with a mild degree of the disease.