Abstract
Reoperation for primary hyperparathyroidism (PHPT) remains a major challenge for both the patient and surgeons. Before considering reoperation, the surgeon must confirm the diagnosis of PHPT and assess patient risk factors. The goal of reoperative surgery is to excise the abnormal parathyroid gland(s) and limit exploration to help minimize the potential complications. At least two positive and concordant localizing studies should be available before reoperation, but the surgeon must keep in mind that the operative and histology reports from previous operation are the first localization techniques. A thorough knowledge of the anatomy and an understanding of the embryonic development of the parathyroid glands are also the keys to successful localization. According to the case history and the results of localization studies, the surgeon must clearly establish whether or not there is a suspicion of multiglandular disease (MGD). If the lesion sought is a solitary adenoma, an open-focused approach can be proposed. Conversely, if there is a confirmation or strong suspicion of MGD, revision of the transverse cervicotomy is recommended. In case of suspicion of local recurrence, an extensive local resection or en bloc resection may be indicated. Intraoperative QPTH assay is recommended to rule out MGD. In some cases, cryopreservation of parathyroid tissue and judicious use of parathyroid transplantation can be useful. With experienced parathyroid surgeons, the success rate of reoperations can be as high as 95%. It has been estimated that about 5% to 10% of initial operations for PHPT result in recurrent or persistent disease. It is too early to evaluate the real risk of persistent or recurrent disease following minimally invasive techniques, but any attempt to limit the extent of the primary procedure will be insignificant if the risk of persistent or recurrent disease is increased.
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References
Cope O (1960) Hyperparathyroidism: diagnosis ant treatment. Am J Surg 99:394–397
Lundgren E, Rastad J, Ridefelt P (1992) Long-term effects of parathyroid operation on serum calcium and parathyroid hormone values in sporadic primary hyperparathyroidism. Surgery 112:1123–1129
Nordenstrom E, Westerdahl J, Isaksson A (2003) Patients with elevated serum parathyroid hormone levels after parathyroidectomy showing signs of decreased peripheral parathyroid hormone sensitivity. World J Surg 27:212–215
Marx SI, Stock JL, Attie MF, Downs RW, Gardner DG, Brown EM et al (1980) Familial hypocalciuric hypercalcemia: recognition among patients referred after unsuccessful parathyroid exploration. Ann Int Med 92:351–356
Stremler GH, Budayr AA, Clark OH, Nissenson RA (1993) Production of parathyroid hormone by a malignant nonparathyroid tumor in a hypercalcemic patient. J Clin Endocrinol Metab 76:1373–1376
Wang CA (1977) Parathyroid re-exploration, a clinical and pathological study of 112 cases. Ann Surg 186:140–145
Ippolito G, Palazzo FF, Sebag F, Henry JF (2007) Long-term follow-up after parathyroidectomy for radiation-induced hyperparathyroidism. Surgery 142:819–822
Edis AJ, Sheedy PF, Beahrs OH, Van Heerden JA (1978) Results of reoperation for hyperparathyroidism with evaluation of preoperative localization studies. Surgery 84:384–393
Shen W, Duren M, Morita E, Higgins C, Duh QY, Siperstein AE et al (1996) Reoperation for persistent or recurrent hyperparathyroidism. Arch Surg 131:861–869
Jaskowiak N, Norton JA, Doppman AHT, JL ST, Skarulis M et al (1996) A prospective trial evaluating a standard approach to reoperation for missed parathyroid adenoma. Ann Surg 224:308–322
Thompson GB, Grant CS, Perrier ND, Harman R, Hodgson SF, Ilstrup D et al (1999) Reoperative parathyroid surgery in the era of sestamibi scanning and intraoperative parathyroid hormone monitoring. Arch Surg 134:699–704
Mariette C, Pellissier L, Combemale F, Quiervieux JL, Carnaille B, Proye C (1998) Reoperation for persistent or recurrent primary hyperparathyroidism. Langenbeck’s Arch Surg 383:174–179
Yen YWF, Wang TS, Doffek KM, Krzywda EA, Wilson SD (2008) Reoperative parathyroidectomy: an algorithm for imaging and monitoring of intraoperative parathyroid hormone levels that results in a successful focused approach. Surgery 144:611–621
Fraker DL, Doppman JL, Shawker TH, Marx SJ, Spiegel AM, Norton JA (1990) Undescended parathyroid adenoma: an important etiology for failed operations for primary hyperparathyroidism. World J Surg 14:342–348
Chan TJ, Libutti SK, McCart JA, Chen C, Khan A, Skarulis MK et al (2003) Persistent primary hyperparathyroidism caused by adenomas identified in pharyngeal or adjacent structures. World J Surg 27:675–679
Wheeler MH, Williams ED, Wade JSH (1987) The hyperfunctioning intrathyroid parathyroid gland: a potential pitfall in parathyroid surgery. World J Surg 11:110–114
Sarfati E, Billotey C, Halimi B, Fritsch S, Cattan P, Dubost C (1997) Early localization and reoperation for persistent primary hyperparathyroidism. Br J Surg 84:98–100
Casanova D, Sarfati E, Francisco D, Amado JA, Arias M, Dubost C (1991) Secondary hyperparathyoridism: diagnosis of site or recurrence. World J Surg 15:546–554
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Henry, JF. Reoperation for primary hyperparathyroidism: tips and tricks. Langenbecks Arch Surg 395, 103–109 (2010). https://doi.org/10.1007/s00423-009-0560-2
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DOI: https://doi.org/10.1007/s00423-009-0560-2