Reexploration and angiographic ablation for hyperparathyroidism.
OBJECTIVE
Persistent and recurrent hyperparathyroidism remains a challenging clinical problem. The purposes of this study were to determine the causes of initial failure, the accuracy of preoperative localization tests, the role of angiographic parathyroid ablation, and the safety and efficacy of reexploration for hyperparathyroidism.


METHODS
A retrospective review of 42 patients undergoing reexploration or angiographic ablation for hyperparathyroidism was done, with a mean follow-up of 3 years, 7 months (range, 1 month to 13 years).


METHODS
This study was carried out in a university medical center and a Veterans Affairs hospital.


METHODS
All patients who underwent reexploration or angiographic ablation for hyperparathyroidism were included.


METHODS
All patients underwent preoperative localization studies. The cervical approach was used when the abnormal gland was suspected to be in the neck or the mediastinum superior to the aortic arch; sternotomy was used for deeper mediastinal glands not resectable through a cervical approach. Angiographic ablation of mediastinal glands was performed using contrast administration after a catheter was wedged into the selective feeding artery.


METHODS
End points included causes of initial treatment failure, accuracy of preoperative localization studies, long-term correction of hypercalcemia with repeated treatment, need for subsequent intervention for hypercalcemia, and complications of therapy.


RESULTS
The most common reasons for initial failure were mediastinal glands (18 patients), surgeon's inexperience (12 patients), supernumerary glands (six patients), and other anatomic anomalies. Hyperplasia accounted for hyperparathyroidism in 11 patients (26%) and adenomas in 31 patients (74%). Preoperative localization studies included technetium-Tc-99m-sestamibi scanning (sensitivity, 86%), technetium-thallium scanning (67%), arteriography (63%), venous sampling (52%), computed tomography (42%), magnetic resonance imaging (33%), and ultrasonography (27%). Thirty-three (89%) of 37 patients who underwent reexploration had resolution of hypercalcemia. Localization study results were negative in all four patients who experienced failure. Angiographic ablation was successful in four (67%) of six patients. One of the patients with a failed ablation had successful mediastinal exploration. Hypoparathyroidism occurred in six patients (14.3%) and there was no instance of recurrent nerve injury.


CONCLUSIONS
The most common causes of initial failure were ectopic mediastinal glands and incomplete surgical exploration; the most sensitive preoperative localization study is the technetium-Tc-99m-sestamibi scan; angiographic ablation of parathyroid tissue is most useful for poor-risk surgical patients or to avoid median sternotomy; and reexploration and angiographic ablation yield a high success rate with acceptable morbidity and mortality.
McIntyre
R C
RC
Department of Surgery, University of Colorado Health Sciences Center, Denver.
Kumpe
D A
DA
Liechty
R D
RD
D000236:Adenoma / Q000175:diagnosis / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000465:Algorithms; D017115:Catheter Ablation; D002908:Chronic Disease; D005188:False Negative Reactions; D005189:False Positive Reactions; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006961:Hyperparathyroidism / Q000175:diagnosis / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D008297:Male; D008479:Mediastinal Neoplasms / Q000175:diagnosis / Q000601:surgery*; D008875:Middle Aged; D011183:Postoperative Complications; D012008:Recurrence; D012086:Reoperation; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D017256:Technetium Tc 99m Sestamibi; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure
D017256:Technetium Tc 99m Sestamibi