Surgical management of persistence or recurrence after subtotal parathyroidectomy for primary hyperparathyroidism

Abstract (1) In an experience with 44 patients requiring subtotal parathyroidectomy for primary hyperparathyroidism due to multiple gland involvement, persistence was identified in 3 patients and recurrence in 3, resulting in a failure rate of 14 per cent. (2) The development of chronic renal insufficiency secondary to hyperparathyroidism appears to be an aggravating factor in the failure of subtotal parathyroidectomy to control hypercalcemia in such cases. An associated MEN-1 syndrome may possibly also be a predisposing factor. (3) Overlooked supernumerary hyperfunctioning parathyroid glands may be the cause of persistent hypercalcemia. (4) If reoperation is performed, ultrasonography of the neck and computerized tomography of the mediastinum are justified preoperatively for localization studies. (5) If hyperplasia of the preserved remnant of parathyroid is the only explanation for failure of subtotal parathyroidectomy, its removal is justified with autotransplantation of parathyroid tissue and freezing of additional tissue for possible future use. (6) The presence of moderate or severe chronic renal insufficiency, related to primary hyperparathyroidism, appears to justify total parathyroidectomy with autotransplantation for primary hyperparathyroidism due to multiple gland involvement. (7) Periodic reevaluation is indicated for all patients after operation, especially subtotal parathyroidectomy, for primary hyperparathyroidism due to multiple gland involvement. If mild or borderline hypercalcemia persists or recurs, close follow-up study is indicated.