Reoperation For Primary Hyperparathyroidism Research Articles

4:42 PM Abstract No. 135 - The added value of parathyroid venous sampling for preoperative parathyroid adenoma localization by dynamic 4DCT in patients with recurrent primary hyperparathyroidism

Reoperation for primary hyperparathyroidism (pHPT) carries higher morbidity and lower cure rates especially in the context of negative sestaMIBI and ultrasound exams. Dynamic four-dimensional CT (4DCT) and parathyroid hormone venous sampling (PVS) help localize parathyroid adenomas. We hypothesize that PVS improves 4DCT presurgical localization of parathyroid adenomas in this patient population.

Long‐Term Outcome in Patients with Primary Hyperparathyroidism who Underwent Minimally Invasive Parathyroidectomy

Minimally invasive parathyroidectomy (MIP) has become a well-accepted treatment for selected patients with primary hyperparathyroidism (PHPT). However, few studies have evaluated long-term outcomes for this operative approach. We therefore chose to examine both the long-term symptom resolution and biochemical cure following MIP for PHPT. A total of 460 PHPT patients who underwent a MIP between 2004 and 2009 were successfully mailed a questionnaire that assessed preoperative and postoperative Parathyroidectomy Assessment of Symptoms (PAS) scores, most recent calcium and parathyroid hormone (PTH) levels, and information about any reoperation for PHPT. Long-term evaluation of symptomatic and biochemical cure was performed. A total of 200 patients (43.5%) responded to our correspondence. The mean age of the patients was 58.7 ± 11.9 years, 74.5% were female, and 78.5% were Caucasian. The mean follow-up was 37 ± 19 months. The mean PAS scores fell by 117 ± 14 at long-term follow-up after MIP (P < 0.0001). All 13 symptoms comprising the PAS score diminished, of which ten did so significantly (P < 0.01). There was a significant drop in the mean serum calcium (preop. 11.1 mg/dl, postop. 9.6 mg/dl; P < 0.0001) and PTH (preop. 130.9 pg/ml, postop. 45.7 pg/ml; P < 0.0001) at long-term follow-up. Five patients (2.5%) developed recurrent disease (calcium > 10.5 mg/dl), and one (0.5%) underwent a reoperation for persistent disease and was subsequently cured. This study demonstrates that MIP has long-term benefits in terms of excellent symptom resolution and a high biochemical cure rate (97%) in selected patients who have PHPT, preoperative localization with sestamibi scans, and assessment of intraoperative PTH level.

Reoperation for primary hyperparathyroidism: tips and tricks

Reoperation for primary hyperparathyroidism (PHPT) remains a major challenge for both the patient and surgeons. Before considering reoperation, the surgeon must confirm the diagnosis of PHPT and assess patient risk factors. The goal of reoperative surgery is to excise the abnormal parathyroid gland(s) and limit exploration to help minimize the potential complications. At least two positive and concordant localizing studies should be available before reoperation, but the surgeon must keep in mind that the operative and histology reports from previous operation are the first localization techniques. A thorough knowledge of the anatomy and an understanding of the embryonic development of the parathyroid glands are also the keys to successful localization. According to the case history and the results of localization studies, the surgeon must clearly establish whether or not there is a suspicion of multiglandular disease (MGD). If the lesion sought is a solitary adenoma, an open-focused approach can be proposed. Conversely, if there is a confirmation or strong suspicion of MGD, revision of the transverse cervicotomy is recommended. In case of suspicion of local recurrence, an extensive local resection or en bloc resection may be indicated. Intraoperative QPTH assay is recommended to rule out MGD. In some cases, cryopreservation of parathyroid tissue and judicious use of parathyroid transplantation can be useful. With experienced parathyroid surgeons, the success rate of reoperations can be as high as 95%. It has been estimated that about 5% to 10% of initial operations for PHPT result in recurrent or persistent disease. It is too early to evaluate the real risk of persistent or recurrent disease following minimally invasive techniques, but any attempt to limit the extent of the primary procedure will be insignificant if the risk of persistent or recurrent disease is increased.

Chirurgische Therapie des primären Hyperparathyreoidismus und dessen Komplikationen: Erfahrungen an 453 Patienten

453 patients underwent surgery for primary hyperparathyreoidism between 1994 and 2003. In all patients, biochemical parameters were monitored and X-ray with USG of the neck was done. Struma nodosa was concommitantly present in 48 % of treated patients with primary hyperparathyroidism. In such cases, MRI offers better resolution of soft tissues. 98.6 % of treated patients had postoperative decrease of blood calcium to normal level. 5.4 % of cases were reoperations for primary hyperparathyroidism. In 12 % of cases, pathologically changed parathyroid glands in dystopic localization were found. In these dystopic localizations, pathologic parathyroid glands were found: in 3 % intrathyroid, in 7 % mediastinal and in 2 % of all 453 cases in other localization. In 4 % of patients, sternotomy was necessary. Persistent hypocalcemia was not registered in any patient. Transient hypocalcemia with necessity of infusion therapy was observed in 3.5 % of patients. Postoperative hypercalcemia persisted in 1.2 % of patients. Recurrent hypercalcemia was present in 0.2 % of cases. In three cases (0.7 %), unilateral injury of recurrent laryngeal nerve was observed.

Réinterventions pour hyperparathyroïdisme primaire persistant ou récidivant. Soixante-dix-sept cas sur 1888 opérés

Aims. – To analyse the results of re-operations for persistent ( p) or recurrent ( r) primary hyperparathyroidism (PHPT). Patients and methods. – From 1965 throughout 2001, 1888 patients were operated on for PHPT. The cure rate after initial surgery was 97.6%. Seventy-seven (4.1%) were reoperated for p PHPT ( n = 54) or r PHPT ( n = 23). Thirty-two out of 77 (41%) had been primarily operated elsewhere. In 15 cases (20%) PHPT was genetically determined. The re-operation was undertaken on average 40.7 months after initial surgery (1 day–190 months). Results. – Two out of 77 were cases of familial hypocalciuric hypercalcaemia. Among the 75 patients reoperated for true PHPT, 23 (31%) had uniglandular disease (UGD) and 52 (69%) had multiglandular disease (MGD). There were two cases of recurrent parathyroid carcinoma. Overall 97 pathological glands were resected, 37% being orthotopic and 63% heterotopic. The re-operation was performed by a cervical approach in 80%, by a mediastinal approach in 15%, whereas 5% involved excision of antebrachial implants. In 96% of cases the parathyroid glands were in the cervical position. Among the preoperative localisations studies the sensitivity of scintigraphy utilising 2-methoxyisobutyl-isonitril (MIBI) was 61%. Utilising both MIBI and cervical ultrasound the sensitivity was 64%. Sixty-eight out of 75 (91%) were cured of their hypercalcaemia, but at the cost of permanent hypoparathyroidism in 9% of cases. No sporadic adenoma appears to have been missed. The seven failures after re-operation (9%) involved five cases of MGD, of which four were sporadic, two cases of carcinoma and one case of parathyreomatosis. 39 patients (51%) had more than four parathyroid glands and in 22/39 cases at least one supernumerary gland was pathological. Conclusion. – The re-operations for PHPT were essentially due to MGD that was either sporadic or genetically determined. Often the offending supernumerary gland was not detected by imaging studies. Avoiding failures entails an initial bilateral cervicotomy with thymic exploration after MIBI scintigraphy to exclude a mediastinal focus.

Prospective evaluation of selective venous sampling for parathyroid hormone concentration in patients undergoing reoperations for primary hyperparathyroidism.

The utility of standard radiologic imaging studies in guiding reoperative parathyroid surgery for primary hyperparathyroidism is widely known and accepted. The additional information gained by selective venous sampling in that patient population has not been well defined. We report the results of our experience with this method. Between 1982 and 1992, 223 consecutive patients underwent reoperations for persistent or recurrent primary hyperparathyroidism after a prospectively determined series of imaging studies. Patients underwent noninvasive testing consisting of ultrasonography, computed tomography, technetium thallium scanning, and magnetic resonance imaging. Patients with negative, equivocal, or discordant results on the noninvasive studies proceeded to angiography. If angiography was negative, selective venous sampling was performed. Eighty-six patients (39%) with negative or equivocal noninvasive test and angiogram results underwent selective venous sampling. Seventy-six patients (88%) had a significant gradient in levels of parathyroid hormone from veins draining the left side of the neck (n = 25), the right side of the neck (n = 33), both sides of the neck (n = 7), and the thymus (n = 11). Correlation of these findings with operative findings revealed a sensitivity of 88% and a specificity of 86%. In the subgroup of patients who underwent venous sampling and had completely negative results of standard radiologic studies (35 of 86; 40%), 28 patients (80%) had venous gradients and seven patients (20%) had no gradient. Of those 28 patients in whom the venous sampling gradients were the only positive localization study, the venous samplings were helpful in 23 patients (true positive gradients), and the operative success rate was 93%. In the seven patients with no positive preoperative localizing studies including venous sampling, there were two operative failures (operative success, 71%). Our results show that selective venous sampling is a highly sensitive and specific method to regionally localize abnormal parathyroid glands not imaged by standard noninvasive and invasive radiologic techniques. Venous sampling is the study of choice in guiding reoperative procedures for occult abnormal parathyroid glands that are undetected despite the use of all available imaging studies.

Causes of failed primary exploration and technical aspects of re-operation in primary hyperparathyroidism.

Hypercalcemia was corrected in 62 (90%) of 69 patients after re-operation for primary hyperparathyroidism during a mean follow-up of 6.3 years. Failed primary exploration was mainly due to inadequate visualization of the pathological parathyroid glands, often in association with misleading or absent peroperative histology. Other causes included seeding of parathyroid adenoma tissue, truly recurrent adenomas, and recurrent hyperplasia, especially in patients with multiple endocrine neoplasia type 1. A considerable number of parathyroid glands missed at the primary operations were subsequently found in essentially normal positions. Ectopic superior glands were most frequently positioned para-esophageally or retro-esophageally, while abnormally placed inferior glands were generally situated within or close to the thymus. Glands in 3 patients were dissected from around the large vessels in the mediastinum. Concomitant thyroid procedures during the primary operation yielded few abnormal parathyroids and made the re-exploration considerably more difficult. We suggest a semilateral approach and caudal identification of the recurrent laryngeal nerve to reduce the hazards of difficult parathyroid re-operations. Mediastinal exploration may require total removal of the thymus and careful dissection of the middle mediastinum.

Median sternotomy in reoperations for primary hyperparathyroidism.

AbstractThirty‐three patients underwent median sternotomy at reoperation for persistent or recurrent hyperparathyroidism. Radiographic studies correctly localized abnormal tissue to the mediastinum in 21 patients and surgery was successful in 19 of them. In the 12 patients without preoperative localization, surgery was successful in 9. Twenty‐six of 29 patients with a diagnosis of parathyroid adenoma had successful surgery, while only 2 of 4 patients with hyperplasia had successful procedures. In 10 patients the median sternotomy proved unnecessary since the parathyroid abnormality was located at a site reachable through the cervical incision. Abnormal parathyroid glands were found in the thymus (21), posterior to the thymus along the arch (6), within the thyroid (4), and at other ectopic locations. Abnormal parathyroid glands found within the thymus were often smaller than 1 cm in diameter and were detected by the pathologist after dissecting the entire thymus, indicating the need for total thymectomy. The complication rate was 12%, and the mortality rate was 6%.

Reoperation for primary hyperparathyroidism

Reoperation for primary hyperparathyroidism

Reoperation for Primary Hyperparathyroidism

Between 1960 and April, 1980, 302 patients were explored for primary hyperparathyroidism at Emory University Hospital. Seventeen of these 302 patients had undergone initial surgical exploration elsewhere, and were referred for persistent hypercalcemia. Of the 285 patients who were operated on at our institution, 14 subsequently had persistent hypercalcemia, and two had recurrent hypercalcemia. Twenty-eight of these 33 patients had had re-exploration, and 23 (82%) are now normocalcemic. Twenty-eight abnormal glands were found; 22 (79%) were retrievable via the neck and six (21%) required sternotomy. Of those glands removed via the neck, nine were in a near normal location and 13 in a subnormal or abnormal location. The causes of initial surgical failures were abnormally located glands, in ten patients, insufficient explorations of the neck in eight patients, hyperfunctioning parathyroid remnants in three patients, inadequate plans for hyperplasia in two patients, and carcinoma in one patient. In 57% of our patients who underwent successful re-exploration, the glands were correctly localized before operation by angiographic examination or selective venous sampling for parathormone. Thorough exploration and obtainment of biopsy specimens of all parathyroid glands are recommended in order to keep initial failures to a minimum. If reoperation is required, localization using CT scan, angiography and selective venous sampling are recommended.

Reoperation for primary hyperparathyroidism

The reasons for failure of the initial exploration and the results of reoperation were analyzed in 53 patients with a diagnosis of primary hyperparathyroidism, 29 of whom were referred after initial operations elsewhere. Seventy-nine reoperations were performed. Sternotomy was used in 15 patients, and in retrospect was necessary in only 5. There was no operative mortality. The reasons for initial failure were incorrect diagnosis in 6 patients, true recurrence in 4 and persistent disease in 43. Persistence was caused by surgical failure in two thirds and pathology failure in one third. Of 47 patients reoperated on for hyperparathyroidism, 39 (83 percent) were cured, a rate warranting this type of surgery. Analysis of a long-term series of initial operations demonstrates a persistence rate of 5 percent (24 of 461) and a recurrence rate of 1 percent (4 of 461) in this disease. The need for reoperation was less than 1 percent over the recent 5 year period.

Reoperation for primary hyperparathyroidism.

Between 1960 and April, 1980, 302 patients were explored for primary hyperparathyroidism at Emory University Hospital. Seventeen of these 302 patients had undergone initial surgical exploration elsewhere, and were referred for persistent hypercalcemia. Of the 285 patients who were operated on at our institution, 14 subsequently had persistent hypercalcemia, and two had recurrent hypercalcemia. Twenty-eight of these 33 patients had had re-exploration, and 23 (82%) are now normocalcemic. Twenty-eight abnormal glands were found; 22 (79%) were retrievable via the neck and six (21%) required sternotomy. Of those glands removed via the neck, nine were in a near normal location and 13 in a subnormal or abnormal location. The causes of initial surgical failures were abnormally located glands, in ten patients, insufficient explorations of the neck in eight patients, hyperfunctioning parathyroid remnants in three patients, inadequate plans for hyperplasia in two patients, and carcinoma in one patient. In 57% of our patients who underwent successful re-exploration, the glands were correctly localized before operation by angiographic examination or selective venous sampling for parathormone. Thorough exploration and obtainment of biopsy specimens of all parathyroid glands are recommended in order to keep initial failures to a minimum. If reoperation is required, localization using CT scan, angiography and selective venous sampling are recommended.