Reoperative Parathyroidectomy

Introduction

Parathyroidectomy for primary hyperparathyroidism has a success rate of 90% to 95% among experienced surgeons. However, management of persistent hyperparathyroidism following surgery can be challenging. Careful preoperative analysis of factors that lead to the failure of the initial surgery must be performed prior to reoperative parathyroidectomy. After confirmation of the diagnosis of persistent hyperparathyroidism, all prior operative reports, pathology reports, and imaging studies should be reviewed in detail. Planning for reoperation should include obtaining new imaging, when indicated, and formulating a methodical operative plan. Surgery can be complicated by tissue fibrosis, edema, inflammation, and loss of surgical landmarks. Reoperative parathyroidectomy is still associated with lower success rates and increased postoperative hypocalcemia and recurrent laryngeal nerve injury.

Key Operative Learning Points

1.
Careful confirmation of the diagnosis of primary hyperparathyroidism is essential before planning the operation.
2.
Localizing imaging, including a parathyroid nuclear scan with single photon emission comptuted tomograph (SPECT), and when negative, four-dimensional (4D) computed tomography (CT) and/or selective venous angiography and parathyroid hormone (PTH) sampling, are important potential adjuncts to preoperative identification of single gland disease in the reoperative scenario.
3.
A detailed discussion with the patient regarding the risks of reoperative surgery is necessary.

Preoperative Period

History

1.
History of present illness
- a.
  Signs or symptoms of hypercalcemia
  - 1)
    Nephrolithiasis
  - 2)
    Severe osteoporosis
  - 3)
    Pancreatitis
  - 4)
    Abdominal pain
  - 5)
    Extremity (bone and muscle) pain
  - 6)
    Depression, anxiety, fatigue
- b.
  How are symptoms now different from symptoms prior to the initial surgery?
2.
Prior surgical treatment
- a.
  Surgical approach (unilateral vs. bilateral)
- b.
  Specimens removed (assessment of size, weight and number of glands removed or biopsied, thyroid removal). This helps to avoid unnecessary exploration in regions devoid of parathyroid tissue.
- c.
  Complications encountered: The presence of pre-existing vocal fold paralysis would greatly influence the random exploration of the paratracheal region on the ipsilateral side of the functioning vocal fold to prevent tracheostomy.
3.
Past medical history
- a.
  Obtain preoperative and postoperative calcium and PTH levels. The diagnosis of primary hyperparathyroidism should be independently reconfirmed.
- b.
  Obtain detailed operative and pathology reports from all prior surgeries.
- c.
  Personal history
  - 1)
    Endocrinopathies, including thyroid disorders or carcinoma, pheochromocytoma
  - 2)
    Renal disease (increased chance that subtotal parathyroidectomy is necessary for cure)
  - 3)
    Hypothalamus-pituitary axis disease
- d.
  Family history of endocrinopathies (multiple endocrine neoplasia syndromes, familial hyperparathyroidism)
- e.
  Medications
  - 1)
    Exogenous calcium/vitamin D supplementation
  - 2)
    Anticoagulants
  - 3)
    Diuretics (especially thiazides)
  - 4)
    Use of lithium
  - 5)
    Allergies

Physical Examination

1.
Neck
- a.
  Palpation of any midline or lateral neck masses (unlikely, but if present raise the concern of coexistent thyroid pathology or parathyroid carcinoma)
- b.
  Palpation of thyroid
- c.
  Examination of prior surgical incision
2.
Flexible laryngoscopy
- a.
  Assess recurrent laryngeal nerve function (fiberoptic laryngoscopy is preferable)

Imaging

1.
Ultrasound of the neck: identifies concomitant thyroid disease and potentially abnormal parathyroid glands
2.
Parathyroid uptake scan [technetium 99 metastable (Tc99m) Sestamibi SPECT preferred]: greater than 80% success in localizing side of overactive parathyroid
3.
Dexa bone density scan: Patients with severe osteoporosis, especially with pathologic fractures, must strongly be considered for reoperation, even if persistently nonlocalizing.
4.
Possible 4D CT scan of neck and chest in patients that are not localizing by ultrasound or nuclear medicine scans
5.
Selective venous angiography and PTH sampling

Indications

1.
Persistent symptomatic hypercalcemia within 6 months following prior parathyroidectomy
2.
Recurrent primary hyperparathyroidism greater than 6 months following parathyroidectomy
3.
Recurrent parathyroid carcinoma
4.
Parathyromatosis (seeding from prior surgery/spillage)
5.
Bone mineral density greater than 2 standard deviations below gender- and age-matched group (z score <−2.0)
6.
Recurrent nephrolithiasis

Contraindications

1.
Asymptomatic disease with borderline hyperparathyroidism
2.
Recurrent laryngeal nerve injury contralateral to parathyroid adenomas (relative)
3.
Significant medical comorbidities increasing risk of anesthesia
4.
Cause other than hyperparathyroidism for hypercalcemia is confirmed
5.
Diagnostic uncertainty (should be resolved prior to repeat surgery)

Preoperative Preparation

1.
Detailed explanation of risks and benefits to reoperation
2.
Obtain baseline PTH.
3.
Review imaging and have relevant imaging available.

Operative Period

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