Review articleParathyroid re-exploration
Section snippets
Parathyroid re-exploration
Interest in parathyroid surgery seems to be increasing with a paradigm shift in the management of primary hyperparathyroidism [1], [2], [3], [4]. This shift arises mainly from the current interest in minimally invasive parathyroid surgery, with special attention to sestamibi scanning and intraoperative parathyroid hormone (PTH) assay. Several recent nuances, such as sestamibi scan with excellent accuracy in localization, intraoperative PTH assay, and an understanding of the limitations of
Location of the parathyroid glands
Approximately 80% of parathyroid glands are adjacent to the thyroid. Rarely, they may be in the crypt of the thyroid, under the capsule, or intrathyroidal. Ten percent to 15% of parathyroid glands are within the thymus, whereas 3% to 5% may be in the posterior mediastinal area or in the carotid sheath. The superior thyroid gland is undescended in less than 0.5% of patients and may be recognized as parapharyngeous; and the superior parathyroid gland may be located near the hyoid bone [24], [25],
Failed first operation
Reoperation surgery includes surgery for persistent hyperparathyroidism when the previous operation has failed and recurrent hyperparathyroidism following initially successful surgery. It is extremely important to evaluate the patient completely and to confirm the initial diagnosis of hyperparathyroidism with appropriate diagnostic tests, including 24-hour urinary calcium. It is extremely important in reoperation surgery to rule out benign familial hypocalciuric hypercalcemia. It is also
Localization studies
Before any surgical consideration, it is extremely important to review in detail the previous medical records including previous localization studies, blood tests, and the operative notes, including the pathology report. The new localization studies are extremely important, and generally the sestamibi scan will be quite helpful. If the sestamibi scan does not localize the enlarged parathyroid gland, other tests such as ultrasound and MRI are important. If the ultrasound shows an abnormality, an
Reoperation strategy
The best strategy is to prevent reoperation surgery. The surgeon should do his or her best the first time with a correct diagnosis and appropriate localization studies before initial surgical exploration. Use of the intraoperative PTH will confirm the success of the initial surgical procedure. The use of bipolar cautery and loops will be of great help during the surgical procedure. After the diagnosis is confirmed, and if the parathyroid gland is localized with appropriate localization studies,
Reoperation pearls
- 1.
Reconfirm the diagnosis of hyperparathyroidism.
- 2.
Rule out benign familial hypocalciuric hypercalcemia.
- 3.
Review prior operative notes.
- 4.
Discuss the case with the previous operative surgeon, if possible.
- 5.
Assess patient's risk factors.
- 6.
Review prior pathology slides.
- 7.
Remember that the missed gland is usually in the neck.
- 8.
Use cost-effective parathyroid localization techniques judiciously.
- 9.
Invasive localization studies are rarely necessary.
- 10.
Consider the lateral cervical approach.
- 11.
For a missing inferior gland,
Parathyroid carcinoma
Parathyroid carcinoma is a rare condition. Approximately 1000 patients with parathyroid carcinoma are described in the world literature. The diagnosis of parathyroid carcinoma is generally based on the histopathologic evaluation, presence of nodal metastasis, recurrent disease, or distant metastasis [39], [40], [41]. The clinical suspicion of parathyroid carcinoma is confirmed by high calcium level or high parathormone assay, boney disease, or palpable mass in the neck. At the time of surgery,
Summary
Reoperation parathyroid surgery is always a challenge for the endocrine surgeon. The surgeon must confirm the diagnosis of primary hyperparathyroidism, use appropriate localization studies, exercise critical intraoperative decision making as to the location of the parathyroid glands, and understand their abnormalities. The general consensus is to proceed with appropriate localization studies, to document the location of the parathyroid gland, and to conduct surgical exploration with special
References (41)
- et al.
Primary hyperparathyroidism in the 1990s: choice of surgical procedures for this disease
Ann Surg
(1992) - et al.
Parathyroid reoperations
Localization studies for hyperparathyroidism: implications for surgery
Acta Otorhinolaryngol
(2001)Diagnosis and management of asymptomatic primary hyperparathyroidism: Consensus Development Conference statement
Ann Intern Med
(1991)- et al.
Minimally invasive radio-guided parathyroidectomy in the reoperative neck
Surgery
(1998) The technique of intraoperative nuclear mapping to facilitate minimally invasive parathyroidectomy
Cancer Control
(1997)- et al.
Clinical usefulness of an intraoperative “quick parathyroid hormone” assay
Surgery
(1993) - et al.
Parathyroid localization prior to primary exploration
Am J Surg
(1993) - et al.
One hundred consecutive minimally invasive parathyroid explorations
Ann Surg
(2000) - et al.
Localization studies in patients with persistent or recurrent hyperparathyroidism
Surgery
(1985)
Technetium-99m-sestamibi imaging before reoperation for primary hyperparathyroidism
J Nucl Med
Surgery for persistent or recurrent hyperparathyroidism
Curr Pract Surg
Re-operative parathyroidectomy in the era of localization technology
Head Neck
Technetium Tc-99m sestamibi scan for localization of abnormal parathyroid glands after previous neck: preliminary experience in re-operative cases
South Med J
Value of technetium-99m sestamibi iodine-123 imaging in re-operative parathyroid surgery
Surgery
Locally recurrent parathyroid neoplasms as a cause for recurrent and persistent primary hyperparathyroidism
Ann Surg
Persistent and recurrent sporadic primary hyperparathyroidism: histopathology, complications and results of reoperation
Surgery
Reoperation for missed parathyroid adenoma
Adv Surg
The reasons for failure in parathyroid operations
Arch Surg
Causes of failure in operations for hyperparathyroidism
Surgery
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