title: Remedial operation for primary hyperparathyroidism.
abstract: BACKGROUND
  Remedial surgery for patients with persistent or recurrent primary hyperparathyroidism (1 degrees HPT) remains a significant challenge. Cervical reexploration is technically difficult; reoperative neck anatomy is distorted by fibrosis and, as a result, remedial 1 degrees HPT patients carry an increased risk of injury to the recurrent (RLN) and superior laryngeal nerve(s) as well as to normal residual parathyroid tissue. Causative hyperfunctioning parathyroid tissue is also more frequently ectopic in the remedial setting and can thus be difficult to localize.
  
  
  METHODS
  This report assimilates the current data underlying preoperative, intraoperative and postoperative remedial 1 degrees HPT management and presents an evidence-based algorithm for the management of remedial parathyroid disease. Recommendations are graded according to the quality of supporting data using the system initially developed by Sackett (Chest 95:2S-4S, 1989) and subsequently modified by Heinrich et al. (Ann Surg 243:154-168, 2006).
  
  
  RESULTS
  Recent advances in preoperative localization and intraoperative adjuncts have lead to substantial improvements in outcomes after remedial surgery. Preoperative localization techniques, including sestamibi scintigraphy (MIBI), high resolution ultrasound (US), US-guided fine needle aspiration (FNA) and selective venous sampling (SVS), coupled with intraoperative adjuncts such as the rapid parathyroid hormone (PTH) assay have lead to reoperative cure rates as high as 96 percent. Nonetheless, management of remedial 1 degrees HPT varies significantly between surgeons and no formal recommendations standardizing the care of these patients have been published.
  
  
  CONCLUSIONS
  Despite the significant challenges associated with remedial surgery for 1 degrees HPT, excellent outcomes can be reproducibly achieved when proper pre-, intra-, and postoperative management is employed.
authors.affiliation: Department of Surgery, Yale University School of Medicine, 330 Cedar Street, New Haven, CT 06520, USA.
authors.forename: Jason D
authors.initials: JD
authors.lastname: Prescott
authors.forename: Robert
authors.initials: R
authors.lastname: Udelsman
mesh_terms: D000465:Algorithms; D006801:Humans; D049950:Hyperparathyroidism, Primary / Q000175:diagnosis* / Q000601:surgery*; D009333:Neck / Q000601:surgery*; D016105:Parathyroidectomy / Q000009:adverse effects / Q000379:methods*; D012008:Recurrence