Primary Hyperparathyroidism: An Analysis of Failure of Parathyroidectomy

Abstract

Dear Editor, We read the article by Bagul et al. [1] with interest and would like to congratulate the authors for highlighting an untold story. Series on primary hyperparathyroidism are available from almost all centers, but the authors have done a commendable job by highlighting this issue. However, there are certain observations in the article that need further clarification and comment. The collection of data seems to be heterogeneous, with large differences observed between center 1 and center 2. At center 1, four surgeons operated on 318 patients (mean 79.5 patients per surgeon), whereas at center 2, one surgeon operated on 223 patients (mean 223 patients per surgeon). Hence, there is a large difference between the expertise of surgeons at both centers. Surgeons at center 2 had operated on 2.8 times the cases per surgeon as compared with surgeons at center 1. Did this really have any influence on the study? The data also suggest, similarly, that there were more failures in center 1. Another difference between both centers is the difference in imaging policies: 79 % or more patients at center 1 received at least one imaging compared with 43–44 % of patients at center 2, making the study population inhomogeneous between the two centers. This was found to be highly significant and also caused skewing of data. It also resulted in more targeted approaches at center 1. Was it necessary to include data from both centers? It seems it has caused heterogeneity in the results. What are authors’ views regarding this? The authors defined success of surgery as normalization of serum calcium levels after surgery. However, they did not mention how many patients suffered from normocalcemic hyperparathyroidism before surgery [2]. How did they define successful surgery in these normocalcemic patients? The authors described that 40 % of failures were due to large adenomas. What was their definition of large adenoma and what was their policy if they found a large adenoma? Overall, how many large adenomas were present in the study population and what was the failure rate among this subgroup? In patients 16, 17, 18, 19, and 24, who had large adenomas, it seems that the imaging findings before surgery were misinterpreted and inadequate surgery performed in the first instance only. In patient number 6, whose disease was localized in the mediastinum, sternotomy should have been planned in the first instance when the authors were not sure of the nature of the excised lesion [3]. In patients 7 and 8, bilateral neck exploration was negative in the first surgery and curative in the second without differences in imaging before the first and second surgery. Similarly, in patients 13 and 15, what were the reasons for the inadequate first surgery? Were these possibly attributable to surgeon’s experience? What did the authors infer for this difference? One comment we would like to make is that the patients’ safety and curative intent is more important than the cost factor. We agree cost is an important factor, but considering the possibility of failure simply to cut costs seems inappropriate. R. Agrawal (&) Department of General Surgery, Aarupadai Veedu Medical College, Kirumampakkam, Puducherry 607402, India e-mail: drriteshagrawal@rediffmail.com