Background: Primary hyperparathyroidism (PHPT) is a common endocrine disease expected to be curable in 95% of patients undergoing surgical treatment. The aim of this study was to assess the postoperative course of patients with failed surgical treatment.
Methods: Prospective database recorded clinical, biochemical, radiological, operative and pathological details of patients operated in a large tertiary referral centre.
Results: Between Jan 2001 and January 2011 a total of 662 patients (520F:142M, age 1590 years old, median 62 years) with non familial PHPT were referred for parathyroidectomy. Patients with concordant localization studies with sestamibi and neck USS underwent scan-directed minimally invasive parathyroidectomy (MIP, n=387). Five patients with intrathoracic adenomas underwent mediastinal exploration. Patients with negative scans had a bilateral neck exploration (n=269). Persistent primary hyperparathyroidism was diagnosed in 28 patients (4%) of patients. There was no difference in the mean calcium in those who were cured after first operation (2.92±0.62 mmol/L) versus those with initial negative exploration (2.96±0.74 mmol/L). All patients with persistent disease underwent biochemical reevaluation and repeat scanning with CT-SPECT sestamibi and selective PTH venous sampling. Two patients had negative localization studies and they continue to be under regular review for persistent PHPT. Of the 26 patients who had at least one positive localization study and underwent reoperation after an initial failed MIP (n=6) or a negative bilateral neck exploration (n=20), 22 were cured and four have persistent disease.
Conclusion: After a first negative cervical exploration there is a reasonable chance for cure if subsequent imaging is positive. A small proportion of patients (<1%) might not be cured even after redo parathyroidectomy and they should be candidates for Cinacalcet therapy.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.