Re-operative surgery for recurrent or persistent primary hyperparathyroidism.

Abstract

While initial surgery for primary hyperparathyroidism, in experienced hands, will result in a cure in 98% of cases, re-operative surgery remains a significant challenge. Because attitudes as to who should perform initial exploration for hyperparathyroidism are significantly different around the world, the approach to re-operative surgery may also vary. The aim of the present study was to examine a local experience of re-operative surgery for recurrent or persistent primary hyperparathyroidism. Information on indications for surgery, the procedure performed, pathology and complications of all re-operative procedures for primary hyperparathyroidism in the period January 1962 to December 1996 were obtained from a prospective database. Sixteen patients with persistent (n = 12) or recurrent (n = 4) primary hyperparathyroidism were treated in the unit over the study period. Eight patients had their initial operation within the unit at Royal North Shore Hospital and eight were referred from elsewhere for re-operation. Nine of the 12 patients with persistent hyperparathyroidism were cured by re-operation with failures due to spillage at first operation (n = 1) or failure to find any additional pathology (n = 2). All four patients with recurrent hyperparathyroidism were cured. All the failures occurred early in the learning phase of the unit, with a 100% cure rate for re-operative procedures performed in the last 15 years. The most common finding in patients referred from elsewhere with a failed initial operation was a missed inferior adenoma in association with the thymus. Localization studies had a variable sensitivity, with sestamibi scintigraphy, selective venous sampling and ultrasonography providing the most reliable information. Re-operative surgery for persistent or recurrent hyperparathyroidism is an uncommon procedure in Australia when compared to major centres in the USA. Successful surgery depends upon experience and an accurate knowledge of the embryology and anatomy of the parathyroid glands.