Parathyroidectomy failures and causes evaluation
DOI:
https://doi.org/10.65540/jar.v29i2.1260Keywords:
Persistent hyperparathyroidism, reoperative parathyroid surgery, adenoma, Sestamibi scan, hormone (PTH)Abstract
Background: Persistent primary hyperparathyroidism (PHPT) after surgery is often due to missed ectopic or supernumerary glands. Reoperation is challenging and requires precise imaging, anatomical understanding, and surgical expertise.
Methods: A 34-year-old woman with classic PHPT symptoms and biochemical evidence (Ca: 12.75 mg/dL, PTH: 891 pg/mL) underwent two failed parathyroidectomies. Imaging was inconclusive; histology showed nodular hyperplasia in the first and absence of parathyroid tissue in the second. A third surgery, guided by high-resolution ultrasound and intraoperative endoscopy, located an ectopic retroesophageal adenoma, which was excised.
Results: Immediate postoperative laboratory confirmed cure (Ca: 7.2 mg/dL, PTH: <1.2). The patient developed transient hungry bone syndrome. No complications were noted.
Conclusion: Persistent PHPT requires high suspicion for ectopic or supernumerary glands. Third-time parathyroidectomy, when planned with expert imaging and surgical collaboration, can be safe and curative.
References
. Sandström I. On a new gland in man and several mammals (glandulae parathyroideae). Ups Läk Förh 1880; 15:441.
. Mandl F. Therapeutischer versuch bein einem falle von ostitis fibrosa generalisata mittels exstirpation eines epithelk orperchen tumors. Zentrabl Chir 1926; 5:260.
. Bliss RD, Gauger PG, Delbridge LW. Surgeon's approach to the thyroid gland: surgical anatomy and the importance of technique. World J Surg 2000; 24:891. DOI: https://doi.org/10.1007/s002680010173
. Akerström G, Malmaeus J, Bergström R. Surgical anatomy of human parathyroid glands. Surgery 1984; 95:14.
. Wang C. The anatomic basis of parathyroid surgery. Ann Surg 1976; 183:271. DOI: https://doi.org/10.1097/00000658-197603000-00010
. Shen W, Düren M, Morita E, et al. Reoperation for persistent or recurrent primary hyperparathyroidism. Arch Surg 1996; 131:861. DOI: https://doi.org/10.1001/archsurg.1996.01430200071013
. Richards ML, Thompson GB, Farley DR, Grant CS. Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring. Am J Surg 2008; 196:937. DOI: https://doi.org/10.1016/j.amjsurg.2008.07.022
. Carter WB, Carter DL, Cohn HE. Cause and current management of reoperative hyperparathyroidism. Am Surg 1993; 59:120.
. Arveschoug AK, Brøchner-Mortensen J, Bertelsen H, Vammen B. Supernumerary parathyroid glands in recurrent secondary hyperparathyroidism. Clin Nucl Med 2002; 27:599. DOI: https://doi.org/10.1097/00003072-200208000-00014
. Edis AJ, Levitt MD. Supernumerary parathyroid glands: implications for the surgical treatment of secondary hyperparathyroidism. World J Surg 1987; 11:398. DOI: https://doi.org/10.1007/BF01658128
. Flament JB, Delattre JF, Pluot M . Arterial blood supply to the parathyroid glands: Implications for thyroid surgery. Surgical and Radiologic Anatomy 1982; 3:279. DOI: https://doi.org/10.1007/BF01799024
. Jaskowiak N, Norton JA, Alexander HR, et al. A prospective trial evaluating a standard approach to reoperation for missed parathyroid adenoma. Ann Surg 1996; 224:308.Shah KN, Racine J, Jones LC, Aaron RK. Pathophysiology andrisk factors for osteonecrosis. Curr Rev Musculoskelet Med.2015;8(3):201–9.5. DOI: https://doi.org/10.1097/00000658-199609000-00007
. Bilezikian JP, Silverberg SJ. Clinical practice. Asymptomatic primary hyperparathyroidism. N Engl J Med 2004; 350:1746. DOI: https://doi.org/10.1056/NEJMcp032200
. Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism. JAMA Surg 2016; 151:959. DOI: https://doi.org/10.1001/jamasurg.2016.2310
. Perrier ND. Asymptomatic hyperparathyroidism: a medical misnomer? Surgery 2005; 137:127. DOI: https://doi.org/10.1016/j.surg.2004.06.037
. Udelsman R, Pasieka JL, Sturgeon C, et al. Surgery for asymptomatic primary hyperparathyroidism: proceedings of the third international workshop. J Clin Endocrinol Metab 2009; 94:366. DOI: https://doi.org/10.1210/jc.2008-1761
. Yu N, Leese GP, Donnan PT. What predicts adverse outcomes in untreated primary hyperparathyroidism? The Parathyroid Epidemiology and Audit Research Study (PEARS). Clin Endocrinol (Oxf) 2013; 79:27. DOI: https://doi.org/10.1111/cen.12206
. Bilezikian JP, Khan AA, Potts JT Jr, Third International Workshop on the Management of Asymptomatic Primary Hyperthyroidism. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the third international workshop. J Clin Endocrinol Metab 2009; 94:335. DOI: https://doi.org/10.1210/jc.2008-1763
. Carty SE, Norton JA. Management of patients with persistent or recurrent primary hyperparathyroidism. World J Surg 1991; 15:716. DOI: https://doi.org/10.1007/BF01665305
. Karakas E, Müller HH, Schlosshauer T, et al. Reoperations for primary hyperparathyroidism--improvement of outcome over two decades. Langenbecks Arch Surg 2013; 398:99. DOI: https://doi.org/10.1007/s00423-012-1004-y
. Li W, Zhu Q, Lai X, et al. Value of preoperative ultrasound-guided fine-needle aspiration for localization in Tc-99m MIBI-negative primary hyperparathyroidism patients. Medicine (Baltimore) 2017; 96:e9051. DOI: https://doi.org/10.1097/MD.0000000000009051
. Owens CL, Rekhtman N, Sokoll L, Ali SZ. Parathyroid hormone assay in fine-needle aspirate is useful in differentiating inadvertently sampled parathyroid tissue from thyroid lesions. Diagn Cytopathol 2008; 36:227. DOI: https://doi.org/10.1002/dc.20783
. Bilezikian JP, Silverberg SJ. Normocalcemic primary hyperparathyroidism. Arq Bras Endocrinol Metabol 2010; 54:106. DOI: https://doi.org/10.1590/S0004-27302010000200004
. Bilezikian JP, Potts JT Jr, Fuleihan Gel-H, et al. Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st century. J Bone Miner Res 2002; 17 Suppl 2:N2.
. Lundgren E, Hagström EG, Lundin J, et al. Primary hyperparathyroidism revisited in menopausal women with serum calcium in the upper normal range at population-based screening 8 years ago. World J Surg 2002; 26:931. DOI: https://doi.org/10.1007/s00268-002-6621-0
. Pinney SP, Daly PA. Parathyroid cyst: an uncommon cause of a palpable neck mass and hypercalcemia. West J Med 1999; 170:118.
. McCoy KL, Yim JH, Zuckerbraun BS, et al. Cystic parathyroid lesions: functional and nonfunctional parathyroid cysts. Arch Surg 2009; 144:52. DOI: https://doi.org/10.1001/archsurg.2008.531
. Lew JI, Solorzano CC, Irvin GL 3rd. Long-term results of parathyroidectomy for hypercalcemic crisis. Arch Surg 2006; 141:696. DOI: https://doi.org/10.1001/archsurg.141.7.696
. Khalid AN, Hollenbeak CS, Higginbotham BW, Stack BC Jr. Accuracy and definitive interpretation of preoperative technetium 99m sestamibi imaging based on the discipline of the reader. Head Neck 2009; 31:576. DOI: https://doi.org/10.1002/hed.20982
. Weiser TG, Haynes AB, Dziekan G, et al. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg 2010; 251:976. DOI: https://doi.org/10.1097/SLA.0b013e3181d970e3
. Fujiwara S, Sposto R, Ezaki H, et al. Hyperparathyroidism among atomic bomb survivors in Hiroshima. Radiat Res 1992; 130:372. DOI: https://doi.org/10.2307/3578384
. Stratton JR. Chronic left ventricular thrombi. G Ital Cardiol 1994; 24:269.
. Albert U, De Cori D, Aguglia A, et al. Lithium-associated hyperparathyroidism and hypercalcaemia: a case-control cross-sectional study. J Affect Disord 2013; 151:786. DOI: https://doi.org/10.1016/j.jad.2013.06.046
. Awad SS, Miskulin J, Thompson N. Parathyroid adenomas versus four-gland hyperplasia as the cause of primary hyperparathyroidism in patients with prolonged lithium therapy. World J Surg 2003; 27:486. DOI: https://doi.org/10.1007/s00268-002-6824-4
. Yip L, Ogilvie JB, Challinor SM, et al. Identification of multiple endocrine neoplasia type 1 in patients with apparent sporadic primary hyperparathyroidism. Surgery 2008; 144:1002. DOI: https://doi.org/10.1016/j.surg.2008.07.030
. Stang MT, Yim JH, Challinor SM, et al. Hyperthyroidism after parathyroid exploration. Surgery 2005; 138:1058. DOI: https://doi.org/10.1016/j.surg.2005.09.011
. Silverberg SJ, Clarke BL, Peacock M, et al. Current issues in the presentation of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop. J Clin Endocrinol Metab 2014; 99:3580. DOI: https://doi.org/10.1210/jc.2014-1415
. Solorzano CC, Carneiro-Pla D. Minimizing cost and maximizing success in the preoperative localization strategy for primary hyperparathyroidism. Surg Clin North Am 2014; 94:587. DOI: https://doi.org/10.1016/j.suc.2014.02.006
. Alonso S, Ferrero E, Donat M, et al. The usefulness of high pre-operative levels of serum type I collagen bone markers for the prediction of changes in bone mineral density after parathyroidectomy. J Endocrinol Invest 2012; 35:640.
. Rajeev P, Movseysan A, Baharani A. Changes in bone turnover markers in primary hyperparathyroidism and response to surgery. Ann R Coll Surg Engl 2017; 99:559. DOI: https://doi.org/10.1308/rcsann.2017.0092
. Bilezikian JP, Potts JT Jr, Fuleihan Gel-H, et al. Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st century. J Clin Endocrinol Metab 2002; 87:5353. DOI: https://doi.org/10.1210/jc.2002-021370
. Udelsman R. Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg 2002; 235:665. DOI: https://doi.org/10.1097/00000658-200205000-00008
. Kiernan CM, Wang T, Perrier ND, et al. Bilateral Neck Exploration for Sporadic Primary Hyperparathyroidism: Use Patterns in 5,597 Patients Undergoing Parathyroidectomy in the Collaborative Endocrine Surgery Quality Improvement Program. J Am Coll Surg 2019; 228:652. DOI: https://doi.org/10.1016/j.jamcollsurg.2018.12.034
. Järhult J, Ander S, Asking B, et al. Long-term results of surgery for lithium-associated hyperparathyroidism. Br J Surg 2010; 97:1680. DOI: https://doi.org/10.1002/bjs.7199
. Carchman E, Ogilvie J, Holst J, et al. Appropriate surgical treatment of lithium-associated hyperparathyroidism. World J Surg 2008; 32:2195. DOI: https://doi.org/10.1007/s00268-008-9616-7
. Delbridge LW, Dolan SJ, Hop TT, et al. Minimally invasive parathyroidectomy: 50 consecutive cases. Med J Aust 2000; 172:418. DOI: https://doi.org/10.5694/j.1326-5377.2000.tb124036.x
. Smit PC, Borel Rinkes IH, van Dalen A, van Vroonhoven TJ. Direct, minimally invasive adenomectomy for primary hyperparathyroidism: An alternative to conventional neck exploration? Ann Surg 2000; 231:559. DOI: https://doi.org/10.1097/00000658-200004000-00016
. Sackett WR, Barraclough B, Reeve TS, Delbridge LW. Worldwide trends in the surgical treatment of primary hyperparathyroidism in the era of minimally invasive parathyroidectomy. Arch Surg 2002; 137:1055. DOI: https://doi.org/10.1001/archsurg.137.9.1055
. Irvin GL 3rd, Solorzano CC, Carneiro DM. Quick intraoperative parathyroid hormone assay: surgical adjunct to allow limited parathyroidectomy, improve success rate, and predict outcome. World J Surg 2004; 28:1287. DOI: https://doi.org/10.1007/s00268-004-7708-6
. Bergenfelz A, Lindblom P, Tibblin S, Westerdahl J. Unilateral versus bilateral neck exploration for primary hyperparathyroidism: a prospective randomized controlled trial. Ann Surg 2002; 236:543. DOI: https://doi.org/10.1097/00000658-200211000-00001
. Day KM, Elsayed M, Monchik JM. No Need to Abandon Focused Unilateral Exploration for Primary Hyperparathyroidism with Intraoperative Monitoring of Intact Parathyroid Hormone. J Am Coll Surg 2015; 221:518. DOI: https://doi.org/10.1016/j.jamcollsurg.2015.04.013
. Westerdahl J, Bergenfelz A. Unilateral versus bilateral neck exploration for primary hyperparathyroidism: five-year follow-up of a randomized controlled trial. Ann Surg 2007; 246:976. DOI: https://doi.org/10.1097/SLA.0b013e31815c3ffd
. Russell CF, Dolan SJ, Laird JD. Randomized clinical trial comparing scan-directed unilateral versus bilateral cervical exploration for primary hyperparathyroidism due to solitary adenoma. Br J Surg 2006; 93:418. DOI: https://doi.org/10.1002/bjs.5250
. Miccoli P, Bendinelli C, Berti P, et al. Video-assisted versus conventional parathyroidectomy in primary hyperparathyroidism: a prospective randomized study. Surgery 1999; 126:1117. DOI: https://doi.org/10.1067/msy.2099.102269
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Mohamed Baayou، Mohamed Bashagha، Mostafa Sgheir، Eltaher Elshagmani
This work is licensed under a Creative Commons Attribution 4.0 International License.
