Langenbeck's Archives of Surgery

, Volume 398, Issue 1, pp 99–106 | Cite as

Reoperations for primary hyperparathyroidism—improvement of outcome over two decades

  • Elias Karakas
  • Hans-Helge Müller
  • Torsten Schlosshauer
  • Matthias Rothmund
  • Detlef K. Bartsch
Original Article

Abstract

Purpose

Reoperations (R-PTX) for primary hyperparathyroidism (pHPT) are challenging, since they are associated with increased failure and morbidity rates. The aim was to evaluate the results of reoperations over two decades, the latter considering the implementation of Tc99msestamibi-SPECT (Mibi/SPECT), intraoperative parathormone (IOPTH) measurement, and intraoperative neuromonitoring (IONM).

Patients and methods

Data of 1,363 patients who underwent surgery for pHPT were retrospectively analyzed regarding reoperations. Causes of persistent (p) pHPT or recurrent (r) pHPT, preoperative imaging studies, surgical findings, and outcome were analyzed. Data of patients who underwent surgery between 1987 and 1997 (group 1; G1) and between 1998 and 2008 (group 2; G2) with the use of Mibi/SPECT, IOPTH, and IONM were evaluated.

Results

One hundred twenty-five patients with benign ppHPT (n = 108) or rpHPT (n = 17) underwent reoperations (R-PTX). Group 1 included 54, group 2 71 patients. Main cause of ppHPT (G1 = 65 % vs. G2 = 53 %) and rpHPT (G1 = 80 % vs. G2 = 60 %) was the failed detection of a solitary adenoma (p = 0.2). Group 1 patients had significantly less unilateral/focused neck re-explorations (G1 = 23 % vs. G2 = 57 %, p = 0.0001), and more sternotomies (G1 = 35 vs. G2 = 14 %, p = 0.01). After a median follow-up of 4 (range 0.9–23.4) years, reversal of hypercalcemia was achieved in 91 % (G1) and in 98.6 % in group 2 (p = 0.08, OR 7.14 [0.809–63.1]). The rates of permanent recurrent laryngeal nerve palsy (G1 = G2 = 9 %, p = 1) and of postoperative permanent hypoparathyroidism (G1 = 9 % vs. G2 = 6 %, p = 0.5) were not significantly different. Other complications such as wound infection, postoperative bleeding, and pneumonia were significantly lower in group 2 (p < 0.001).

Conclusion

Nowadays, cure rates of R-PTX are nearly the same as in primary operations for pHPT. These results can be achieved in high-volume centers by routine use of well-established preoperative Mibi/SPECT and US in combination with IOPTH. However, morbidity is still considerably high.

Keywords

Primary hyperparathyroidism Reoperation Imaging 

Notes

Conflicts of interest

None.

References

  1. 1.
    Grant CS, Herden JA, Charboneau JW, James EM, Reading CC (1986) Clinical management of persistent and/or recurrent primary hyperparathyroidism. World J Surg 10:555–565PubMedCrossRefGoogle Scholar
  2. 2.
    Akerström G, Rudberg C, Grimelius L, Johannsson H, Lundström B, Rastad J (1992) Causes of failed primary exploration and technical aspects of re-operation in primary hyperparathyroidism. World J Surg 16:562–568PubMedCrossRefGoogle Scholar
  3. 3.
    Jaskowiak N, Norton JA, Alexander HR, Doppman JL, Shawker T, Skarulis M, Marx S, Spiegel A, Fraker DL (1986) A prospective trial evaluating a standard approach to reoperation for missed parathyroid adenoma. Ann Surg 224(3):308–320CrossRefGoogle Scholar
  4. 4.
    Karakas E, Zielke A, Dietz C, Rothmund M (2005) Reoperations for primary hyperparathyroidism. Chirurg 76:207–216PubMedCrossRefGoogle Scholar
  5. 5.
    Richards ML, Thompson GB, Farley DR, Grant CS (2008) Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring. Am J Surg 196:937–943PubMedCrossRefGoogle Scholar
  6. 6.
    Hessman O, Stalberg P, Sundin A, Garske U, Rudberg C, Eriksson L-G, Hellman P, Akerström G (2008) High success rate of parathyroid reoperation may be achieved with improved localization diagnosis. World J Surg 32:774–781PubMedCrossRefGoogle Scholar
  7. 7.
    Henry JF, Sebag F, Cherenko M, Ippolito G, Taieb D, Vaillant J (2008) Endoscopic parathyroidectomy: why and when? World J Surg 32:2509–2515PubMedCrossRefGoogle Scholar
  8. 8.
    Bergenfelz A, Kanngiesser V, Zielke A, Nies C, Rothmund M (2005) Conventional bilateral cervical exploration versus open minimally invasive parathyroidectomy under local anaesthesia for primary hyperparathyroidism. Br J Surg 92(2):190–197PubMedCrossRefGoogle Scholar
  9. 9.
    Udelsman R, Lin Z, Donovan P (2011) The superiority of minimally invasive parathyroidectomy based on 1650 consecutive patients with primary hyperparathyroidism. Ann Surg 253:585–591PubMedCrossRefGoogle Scholar
  10. 10.
    Miura D, Wada N, Arici C, Morita E, Duh Q-Y, Clark OH (2002) Does intraoperative parathyroid hormone assay improve the results of parathyroidectomy? World J Surg 26:926–930PubMedCrossRefGoogle Scholar
  11. 11.
    Siperstein A, Berber E, Mackey R, Alghoul M, Wagner K, Milas M (2004) Prospective evaluation of sestamibi scan, ultrasonography, and rapid PTH to predict the success of limited exploration for sporadic primary hyperparathyroidism. Surgery 136:872–880PubMedCrossRefGoogle Scholar
  12. 12.
    Udelsman R, Aruny JE, Donovan P, Sokoll LJ, Santos F, Donabedian R, Venbrux AC (2002) Rapid parathyroid hormone analysis during venous localization. Ann Surg 237(5):714–721Google Scholar
  13. 13.
    Reidel MA, Schilling T, Graf S, Hinz U, Nawroth P, Büchler MW, Weber T (2006) Localization of hyperfunctioning parathyroid glands by selective venous sampling in reoperation for primary or secondary hyperparathyroidism. Surgery 140:907–913PubMedCrossRefGoogle Scholar
  14. 14.
    Gotthardt M, Lohmann B, Behr TM, Bauhofer A, Franzius C, Schipper ML, Wagner M, Höffken H, Sitter H, Rothmund M, Joseph K, Nies C (2004) Clinical value of parathyroid scintigraphy with technetium-99m methoxybutylisnitrile: discrepancies in clinical data and a systematic metaanalysis of the literature. World J Surg 28:100–107PubMedCrossRefGoogle Scholar
  15. 15.
    Grant C, Thompson G, Farley D, Heerden JV (2005) Primary hyperparathyroidism surgical management since the introduction of minimally invasive parathyroidectomy. Arch Surg 140:472–479PubMedCrossRefGoogle Scholar
  16. 16.
    Jaskowiak N, Norton JA, Alexander HR, Doppman JL, Shawker T, Skarulis M, Marx S, Spiegel A, Fraker DL (1996) A prospective trial evaluating a standard approach to reoperation for missed parathyroid adenoma. Ann Surg 224(3):308–320PubMedCrossRefGoogle Scholar
  17. 17.
    Brennan MF, Norton JA (1985) Reoperation for persistent and recurrent hyperparathyroidism. Ann Surg 201(1):40–44PubMedGoogle Scholar
  18. 18.
    Cheung PS, Borgstrom A, Thompson NW (1989) Strategy in reoperative surgery for hyperparathyroidism. Arch Surg 124(6):676–680PubMedCrossRefGoogle Scholar
  19. 19.
    Shen W, Duren M, Morita E, Higgins C, Duh QY, Siperstein A, Clark OH (1996) Reoperation for persistent or recurrent primary hyperparathyroidism. Arch Surg 131(8):861–867PubMedCrossRefGoogle Scholar
  20. 20.
    Akerström G, Malmaeus J, Bergström R (1984) Surgical anatomy of human parathyroid glands. Surgery 95:14–21PubMedGoogle Scholar
  21. 21.
    Van Heerden JA, Grant CS (1991) Surgical treatment of primary hyperparathyroidism: an institutional perspective. World J Surg 15(6):688–692PubMedCrossRefGoogle Scholar
  22. 22.
    Mitchell J, Milas M, Barbosa G, Sutton J, Berber E, Siperstein A (2008) Avoidable reoperations for thyroid and parathyroid surgery: effect of hospital volume. Surgery 144(5):899–906PubMedCrossRefGoogle Scholar
  23. 23.
    Henry JF (2010) Reoperation for primary hyperparathyroidism: tips and tricks. Langenbecks Arch Surg 395:103–109PubMedCrossRefGoogle Scholar
  24. 24.
    Sebag F, Shen W, Brunaud L, Kebebew E, Duh QY, Clark OH (2003) Intraoperative parathyroid hormone assay and parathyroid reoperations. Surgery 134:1049–1056PubMedCrossRefGoogle Scholar
  25. 25.
    Fayet P, Hoeffel C, Fulla Y, Legmann P, Hazebroucq V, Luton JP, Chapuis Y, Richard B, Bonnin A (1997) Technetium-99m sestamibi scintigraphy, magnetic resonance imaging and venous blood sampling in persistent and recurrent hyperparathyroidism. Brit J Radiol 70:459–464PubMedGoogle Scholar
  26. 26.
    Jones JJ, Bruneaud L, Dowd CF, Duh QY, Morita E, Clark OH (2002) Accuracy of selective venous sampling for intact parathyroid hormone in difficult patients with recurrent or persistent hyperparathyroidism. Surgery 132:944–951PubMedCrossRefGoogle Scholar
  27. 27.
    Irvin GL III, Molinari AS, Figueroa C, Carneiro DM (1999) Improved success rate in reoperative parathyroidectomy with intraoperative PTH assay. Ann Surg 229:874–879PubMedCrossRefGoogle Scholar
  28. 28.
    Powell AC, Alexander HR, Chang R, Marx SJ, Skarulis M, Pingpank JF, Bartlett DL, Hughes M, Weinstein LS, Simonds WF, Collins MF, Shawker T, Chen CC, Reynolds J, Cochran C, Steinberg SM, Libutti SK (2009) Reoperation for parathyroid adenoma: a contemporary experience. Surgery 146:1144–1155PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Elias Karakas
    • 1
  • Hans-Helge Müller
    • 2
  • Torsten Schlosshauer
    • 1
  • Matthias Rothmund
    • 1
  • Detlef K. Bartsch
    • 1
  1. 1.Department of Visceral-, Thoracic and Vascular SurgeryPhilipps-University MarburgMarburgGermany
  2. 2.Institute of Medical Informatics, Biometry and EpidemiologyUniversity of MunichMunichGermany

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