title: Reoperations for primary hyperparathyroidism--improvement of outcome over two decades.
abstract: OBJECTIVE
  Reoperations (R-PTX) for primary hyperparathyroidism (pHPT) are challenging, since they are associated with increased failure and morbidity rates. The aim was to evaluate the results of reoperations over two decades, the latter considering the implementation of Tc(99m)sestamibi-SPECT (Mibi/SPECT), intraoperative parathormone (IOPTH) measurement, and intraoperative neuromonitoring (IONM).
  
  
  METHODS
  Data of 1,363 patients who underwent surgery for pHPT were retrospectively analyzed regarding reoperations. Causes of persistent (p) pHPT or recurrent (r) pHPT, preoperative imaging studies, surgical findings, and outcome were analyzed. Data of patients who underwent surgery between 1987 and 1997 (group 1; G1) and between 1998 and 2008 (group 2; G2) with the use of Mibi/SPECT, IOPTH, and IONM were evaluated.
  
  
  RESULTS
  One hundred twenty-five patients with benign ppHPT (n = 108) or rpHPT (n = 17) underwent reoperations (R-PTX). Group 1 included 54, group 2 71 patients. Main cause of ppHPT (G1 = 65 % vs. G2 = 53 %) and rpHPT (G1 = 80 % vs. G2 = 60 %) was the failed detection of a solitary adenoma (p = 0.2). Group 1 patients had significantly less unilateral/focused neck re-explorations (G1 = 23 % vs. G2 = 57 %, p = 0.0001), and more sternotomies (G1 = 35 vs. G2 = 14 %, p = 0.01). After a median follow-up of 4 (range 0.9-23.4) years, reversal of hypercalcemia was achieved in 91 % (G1) and in 98.6 % in group 2 (p = 0.08, OR 7.14 [0.809-63.1]). The rates of permanent recurrent laryngeal nerve palsy (G1 = G2 = 9 %, p = 1) and of postoperative permanent hypoparathyroidism (G1 = 9 % vs. G2 = 6 %, p = 0.5) were not significantly different. Other complications such as wound infection, postoperative bleeding, and pneumonia were significantly lower in group 2 (p < 0.001).
  
  
  CONCLUSIONS
  Nowadays, cure rates of R-PTX are nearly the same as in primary operations for pHPT. These results can be achieved in high-volume centers by routine use of well-established preoperative Mibi/SPECT and US in combination with IOPTH. However, morbidity is still considerably high.
authors.affiliation: Department of Visceral-, Thoracic and Vascular Surgery, Philipps-University Marburg, Baldingerstraße, 35043 Marburg, Germany. karakas@med.uni-marburg.de
authors.forename: Elias
authors.initials: E
authors.lastname: Karakas
authors.forename: Hans-Helge
authors.initials: HH
authors.lastname: Müller
authors.forename: Torsten
authors.initials: T
authors.lastname: Schlosshauer
authors.forename: Matthias
authors.initials: M
authors.lastname: Rothmund
authors.forename: Detlef K
authors.initials: DK
authors.lastname: Bartsch
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002828:Choristoma / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D006801:Humans; D006934:Hypercalcemia / Q000000981:diagnostic imaging* / Q000601:surgery*; D049950:Hyperparathyroidism, Primary / Q000000981:diagnostic imaging / Q000601:surgery*; D007011:Hypoparathyroidism / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods*; D010280:Parathyroid Glands / Q000000981:diagnostic imaging; D010281:Parathyroid Hormone / Q000097:blood*; D010282:Parathyroid Neoplasms / Q000000981:diagnostic imaging* / Q000601:surgery*; D016105:Parathyroidectomy / Q000379:methods* / Q000639:trends*; D011183:Postoperative Complications / Q000517:prevention & control*; D061226:Recurrent Laryngeal Nerve Injuries / Q000517:prevention & control*; D012086:Reoperation / Q000379:methods* / Q000639:trends*; D012189:Retrospective Studies; D056346:Sternotomy / Q000379:methods / Q000639:trends; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods* / Q000639:trends*; D016896:Treatment Outcome; D014826:Vocal Cord Paralysis / Q000517:prevention & control*
chemical_list: D010281:Parathyroid Hormone; D017256:Technetium Tc 99m Sestamibi