Brief Review of Results of Reoperative Parathyroid Surgery

A summary of results reported by referral centers with extensive experience in parathyroid reoperations is shown in Table 58-4. Some of these results included all patients with persistent or recurrent HPT, but others, such as at the National Institutes of Health, only included patients with sporadic disease and one abnormal gland. From 1989 to 1997 at the Mayo Clinic, 124 patients with benign persistent or recurrent primary HPT underwent 106 cervical explorations (86%), 9 mediastinal explorations alone (7%), and 9 (7%) combined cervical-mediastinal explorations.20 In this series, US had an accuracy of 65%, a sensitivity of 75%, and a positive predictive value of 78%. Sestamibi scanning was accurate in 67% with a sensitivity of 82% and a positive predictive value of 79%. CT scanning of the mediastinum was accurate in 53% and had a sensitivity of 40% and a positive predictive value of 80%. Cure of hypercalcemia was achieved in 88% of patients. Morbidity was incurred in 15% of patients, with permanent hypoparathyroidism accounting for most of the morbidity (89%). Immediate forearm autotransplantation was performed in 13 patients, and 4 (32%) patients remained hypoparathyroid. Delayed autotransplantation was carried out in 4 patients with a 25% graft success rate.

Neither cure rates nor operative morbidity have changed appreciably over the past 2 decades despite the application of sestamibi scanning and intraoperative PTH monitoring.20 Multiple-gland disease continues to represent the principal cause of failure in reoperative parathyroid surgery and most missed abnormal glands reside in normal anatomic locations. Of the 15 patients who remained hypercalcemic following their reoperative surgery, 11 (73%) had multiple-gland disease based on previous records, histologic examination, and preoperative localization tests. The overwhelming majority of glands removed were in normal anatomic positions (76%) in the neck. Of glands not in a normal position (n = 26), 8 were found in the mediastinum, 7 were intrathyroidal,

TABLE 58-4. Comparisons of Outcome of Parathyroid Reoperations

No. of

Vocal Cord

Permanent

Institutes

Author, Year, Reference No.

Patients

Palsy (%|

Hypocalcemia (%)

Cure Rate (%)

MGH

Wang, 19775

112

2.7

18

91

MSKCC

Brennan et al, 19353

175

6.3

35

90

Mayo Clinic

Grant et al, 19862,1

157

3.8

14

89

UCSF

Levin et al, 19896

81

91

University of Michigan

Cheung et al, 198926

83

1.2

9.6

86

NIH

Carty et al, 199126

206

6.6

8

95

Uppsala, Sweden

AkeTstrom et al, 199227

69

0

17

90

Eksjo, Sweden

Jarhult et al, 199328

93

10

16

82

Emory University

Weber et al, 199429

51

0

2

92

UCSF

Shen et al, 19967

102

1

1

95

Mayo Clinic

Thompson et al, 199920

124

0.8

13

88

NIH

Feingold et al, 200031

62

98

MGH = Massachusetts General Hospital; MSKCC = Mémorial Sloan-Kettering Cancer Center; UCSF = University of California at San Francisco; NIH = National Institutes of Health.

MGH = Massachusetts General Hospital; MSKCC = Mémorial Sloan-Kettering Cancer Center; UCSF = University of California at San Francisco; NIH = National Institutes of Health.

TABLE 58-5. Anatomic Site of Disease at Reoperations

Author, Year, Reference No., and No. (Percentage) of Patients

TABLE 58-5. Anatomic Site of Disease at Reoperations

Author, Year, Reference No., and No. (Percentage) of Patients

WANG,

GRANT

LEVIN

AKERSTKÖM

SHEN ET AL,

THOMPSON

FEINGOLD

TOTAL NO.

Site

19776

ET AL, 1986w

ET AL, 19896

ET AL, 199227

ET AL, 19967

ETAL, 199920

ET AL, 20Q031 (PERCENTAGE)

Cervical

Normal position

29

49

49

29

7

103

14

280 (44)

Thymic tongue

13

3

10

12

13

13

64 (10)

Parapharyngeal

15

1

16(3)

Retiotracheal or

5

10

5

3

—-

2

5

30(5)

retroesophageal

Intrathyroidal

1

8

7

5

6

7

2

36 (6)

Tracheoesophageal

15

-

16

31(5)

groove

Carotid sheath

3

7

5

6

5

26 (4)

Medial to upper

2

4

6(1)

pole

Under thyroid

4

4 (0.6)

capsule

Anterior to trachea

3

3 (0.4)

Undescended

1

1

2

1

5 (0.7)

Strap muscle

1

1(0.1)

Mediastinal

8

8(1)

Superoposterior

34

11

4

4

3

56 (9)

Anterior

21

18

5

7

9

1

61 (9)

Middle

—,

3

—.

3 (0.4)

Aorticopulmonary

—.

2

3

5 (0.7)

window

Total

104

124

89

67

61

129

61

635 (100)

6 were within the carotid sheath, 3 were anterior to the trachea, and 2 were retroesophageal.

The anatomic site of disease at reoperation is well documented in various large series and is shown in Table 58-5.

FIGURE 58-2. Ultrasonography of the neck showing a suspicious enlarged parathyroid gland posterior to the lower pole of the right lobe of the thyroid (see Case 1).

Although the success rate of reoperation in experienced hands ranges from 82% to 98%, the fact that more than 40% of missing glands were found in normal anatomic positions challenges all surgeons who operate on primary HPT to strive for cure in the primary operation rather than submitting a patient to the risk of a reoperation—or rendering the reoperative endocrine surgeon to chronic excessive catecholamine secretion.

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