Persistent Hyperparathyroidism: How Many Cases Can Be Prevented

Abstract

The need for surgery for persistent or recurrent hyperparathyroidism results from incomplete resection of abnormal parathyroid glands or adenoma of the remaining gland 6 months after successful surgery. Secondary surgeries can cause major problems, such as healthcare costs and surgical complications, some of which can be disastrous. Preventive medicine is one of the most effective ways to avoid these problems. In this study, our aim is to determine the main causes of persistent hyperparathyroidism and recurrent hyperparathyroidism and prevent these secondary surgeries. We reviewed data of patients who had been reoperated on for persistent hyperparathyroidism and recurrent hyperparathyroidism between July 2015 and November 2018 in our clinic. Patients who underwent reoperation for other reasons, patients under 18 years of age, and patients with missing follow-up information were excluded from the study. Thirty-six patients (7 man and 29 women) were included in the study, and the mean age was 56 SD15.2 years. Thirty of them suffered from persistent hyperparathyroidism, and six (16.7%) of them suffered from recurrent hyperparathyroidism. Ultrasonography was used for localization, which was performed by the department of endocrinology, or, alternatively, radiology, technetium 99m-sestamibi scintigraphy, computer tomography, and magnetic resonance imaging were used. Single imaging modality was used for 19 (52.7%) patients, while more than one imaging modality was used for 17 (47.2%) patients. In the first surgery, 21 (58.3%) patients underwent focus parathyroidectomy, while 15 (41.7%) patients underwent conventional bilateral neck exploration parathyroidectomy. In 29 persistent hyperparathyroidism patients, the causes of persistent hyperparathyroidism were pre-op imaging in 18 (62.0%) patients, inexperience of surgeon in 6 (20.6%) patients, and ectopic localization of parathyroid adenoma in 5 (17.4%) patients. Success was achieved in 35 (97.2%) patients after a second surgery, while 1 (2.8%) persistent hyperparathyroidism patient was followed up with medical treatment because no pathological parathyroid adenoma was detected in the imaging studies or in the second exploration. Hyperparathyroidism can persist after a first surgery due to localization discordance in pre-op imaging modalities, inadequate surgical experience, and sometimes because parathyroid adenoma cannot be found despite all efforts. In more than 80% of cases, persistent hyperparathyroidism can be prevented with careful pre-op image studies and surgeries performed by experienced surgeons.