The multidisciplinary approach for re-operative parathyroidectomy
Sznerch N1, Pollitt MJK1, Rees J2, Rees A3, Davies JS3, Scott-Coombes DM1.
Departments of Endocrine Surgery1, Radiology2 and Endocrinology3,
University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK.
Aim: To review pre-operative investigations and outcomes in patients undergoing re-operative parathyroid surgery for hyperparathyroidism (HPT). Specific outcomes include accuracy of pre-operative localization, anatomy, rates of normocalcaemia and recurrent laryngeal nerve injury.
Method: A prospective study of re-operative parathyroidectomy. Data was obtained from a personal database and the electronic clinical portal.
Results: Between March 2003 and June 2010; 31 patients underwent 31 parathyroid explorations. The majority (n=21, 68%) had persistent HPT. The pathology was sporadic primary HPT (n=20, 66%), MEN-1 HPT (n=5, 16%) and secondary HPT (n=6, 19%). Patients with sporadic persistent disease were subjected to repeat biochemical tests to confirm the diagnosis. All patients underwent pre-operative localisation with a combination of ultrasound (US) and MIBI and in selected cases CT scan (n=6), selective venous sampling (SVS)(n=3); MRI (n=2) and PET scan (n=1). Half of CT scans and both MRI scans were negative and none of the SVS or PET were helpful. However US and MIBI, alone or in combination, were helpful in 23 (74%) patients. Only 6 (19%) patients had single gland disease. The abnormal gland was eutopic on 17 (55%) occasions, whereas the gland was ectopic on 10 (32%) occasions. In two operations no parathyroid gland was identified (6%). Three month post operative serum calcium levels reveal that 5 (16%) of patients remain hypercalcaemic; two patients have recurrent renal HPT, one patient has persistent disease due to parathyromatosis requiring medical therapy. Two patients had persistent disease following removal of an adenoma and one has undergone subsequent (3rd) exploration for a double adenoma and is now normocalcaemic. One patient (3%) has a permanent recurrent laryngeal nerve injury.
Conclusion: Re-operative parathyroid surgery is mainly for patients with multiple gland disease. Pre-operative localisation is mandatory. Re-operative surgery is more challenging owing to the increased rate of ectopia and a scarred operative field. Outcomes are less successful and associated with a higher complication rate compared with first-time surgery.