PERSISTENT AND RECURRENT SPORADIC PRIMARY HYPERPARATHYROIDISM - HISTOPATHOLOGY, COMPLICATIONS, AND RESULTS OF REOPERATION

Background. Our purpose was to analyze the causes of persistent and re current sporadic primary hyperparathyroidism (PD and RD). Methods. The histopathology, complications, and results of reoperation were studie d. Five hundred sixty-eight patients with primary hyperparathyroidism were operated on initially by one surgeon and underwent follow-up exam ination for 3.7 +/- 3.8 years. During the operation, all parathyroids were sought and confirmed by biopsy. Enlarged glands were resected, an d subtotal parathyroidectomy was done for multiglandular disease (hype rplasia). Results. The cure rate after the initial surgical procedure was 96.4%, PD = 2.8% (16 of 568). At reoperation (10 of 16), nine of 1 0 were cured (90%) (two adenomas, six hyperplasias, one lung carcinoma ). RD was documented (at years 4, 4, 10, 15, 16) in five (0.9%) patien ts, one with parathyroid carcinoma and four with hyperplasia. Thirty-f ive patients with PD and two patients with RD were referred for reoper ation: 17 with adenomas (eight mediastinal) and 18 with hyperplasias ( one mediastinal gland). Preoperative calcium level was higher for PD ( 12.57 mg/dl) and RD (13.89 mg/dl) versus all cases (12.19 mg/dl) (p < 0.03 and p < 0.005, respectively). After reoperation, normocalcemia wa s achieved in 47 (92%) of 51 patients with PD or RD. Transient hypocal cemia occurred in 22% of patients (permanent, 2.0%) and transient hoar seness in 2.0% of patients (no permanent nerve damage). Permanent hypo calcemia and nerve damage after 568 initial operations were 0% and 0%, respectively. Two perioperative deaths occurred. Conclusions. We conc lude that inadequate neck exploration or resection of hyperplastic tis sue accounts for most cases of PD and RD. Optimal results necessitate intraoperative identification of all parathyroids whenever possible, w ith minimal morbidity.