Localization Studies in Persistent or Recurrent Hyperparathyroidism

The surgical management of patients with hyperparathyroidism (HPT) is successful in more than 90% of cases.13 Furthermore, in specialized centers, the morbidity rate of parathyroidectomy is lower than 1%.4"8

Patients with persistent HPT (hypercalcemia persists or recurs within 6 months after surgery) or, less commonly, recurrent HPT (hypercalcemia recurs after >6 months of normocalcemia) necessitate reoperation. In these cases, the morbidity rate increases up to 10% for permanent recurrent laryngeal nerve injury and to 35% for hypoparathyroidism.913

A successful neck exploration for HPT is primarily dependent on the experience of the surgeon, the anatomic location of the parathyroid glands (normal or ectopic sites), and the presence of a single adenoma as opposed to multiglandular disease or carcinoma.14 The most common causes of recurrent or persistent disease are unlocated parathyroid adenoma (80%),15'16 undiagnosed second adenoma (<9% of cases),17 misdiagnosis of parathyroid hyperplasia as adenomatous disease, and parathyroid carcinoma.18 Supernumerary glands account for 15% to 25% of failed cases.19"21 We found ectopic parathyroid tumors in 5% to 11% of failures (thymus, intrathyroid, undescended, in the retroesophageal space and in the carotid sheath).1015 22'23 In these cases of persistent or recurrent HPT, surgical intervention is most difficult because of the loss of normal tissue planes (as also occurs after extensive thyroid surgery) and the possibility that the missed parathyroid gland is situated in an ectopic position. Localization studies in these patients reduce operating time, avoid unnecessary dissection, reduce operative morbidity, and improve the success rate.1,24

In cases of persistent or recurrent HPT, one must first confirm the diagnosis of HPT and review previous surgical and pathology reports. With this information, we can usually determine whether the patient has a single adenoma, a double adenoma, parathyroid hyperplasia or, rarely, a carcinoma.

Localization studies can be selected according to availability, cost, and experience.25 Surgery for persistent or recurrent HPT should be performed only after positive localization studies. Various localization techniques that are no longer used include esophageal fluoroscopy,26 cineradiography,27 and thermography.28 Currently, we classify localization methods as preoperative (invasive or noninvasive) and intraoperative (Table 46-1).

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