REEXPLORATION AND ANGIOGRAPHIC ABLATION FOR HYPERPARATHYROIDISM

Objective: Persistent and recurrent hyperparathyroidism remains a chal lenging clinical problem. The purposes of this study were to determine the causes of initial failure, the accuracy of preoperative localizat ion tests, the role of angiographic parathyroid ablation, and the safe ty and efficacy of reexploration for hyperparathyroidism. Design: A re trospective review of 42 patients undergoing reexploration or angiogra phic ablation for hyperparathyroidism was done, with a mean follow-up of 3 years, 7 months (range, 1 month to 13 years). Setting: This study was carried out in a university medical center and a Veterans Affairs hospital. Patients: All patients who underwent reexploration or angio graphic ablation for hyperparathyroidism were included. Intervention: 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 us ed for deeper mediastinal glands not resectable through a cervical app roach. Angiographic ablation of mediastinal glands was performed using contrast administration after a catheter was wedged into the selectiv e feeding artery. Main Outcome Measures: End points included causes of initial treatment failure, accuracy of preoperative localization stud ies, long-term correction of hypercalcemia with repeated treatment, ne ed for subsequent intervention for hypercalcemia, and complications of therapy. Results: The most common reasons for initial failure were me diastinal glands (18 patients), surgeon's inexperience (12 patients), supernumerary glands (six patients), and other anatomic anomalies. Hyp erplasia accounted for hyperparathyroidism in 1 1 patients (26%) and a denomas in 31 patients (74%). Preoperative localization studies includ ed technetium-Tc-99m-sestamibi scanning (sensitivity, 86%), technetium -thallium scanning (67%), arteriography (63%), venous sampling (52%), computed tomography (42%), magnetic resonance imaging (33%), and ultra sonography (27%). Thirty-three (89%) of 37 patients who underwent reex ploration had resolution of hypercalcemia Localization study results w ere negative in all four patients who experienced failure. Angiographi c ablation was successful in four (67%) of six patients. One of the pa tients with a failed ablation had successful mediastinal exploration. Hypoparathyroidism occurred in six patients (14.3%) and there was no i nstance of recurrent nerve injury. Conclusions: The most common causes of initial failure were ectopic mediastinal glands and incomplete sur gical exploration; the most sensitive preoperative localization study is the technetium-Tc-99m-sestamibi scan; angiographic ablation of para thyroid tissue is most useful for poor-risk surgical patients or to av oid median sternotomy; and reexploration and angiographic ablation yie ld a high success rate with acceptable morbidity and mortality.