The evolution of parathyroidectomy failures

Background. Reported operative failure rates for primary hyperparathyroidis m range from 5% to 10%. Failure has been due to multiglandular disease, ect opic parathyroid glands, errors in frozen section, and missed diagnoses. Re cently, our operative approach has changed from bilateral cervical explorat ion to direction by preoperative localization and intraoperative quick para thyroid hormone assay. The purpose of this study is to examine the causes a nd rates of failure in this evolving approach to parathyroidectomy. Methods. Among 447 consecutive cases of primary hyperparathyroidectomy, 20 operative failures were examined. Three different operative approaches were compared with respect to causes and rates of failure. Results, From 1969 to 1989, with bilateral neck exploration, failure was du e to missed diagnoses, ectopic glands, multiglandular disease, and unknown causes, with a failure rate of 5%. From 1990 to 1993, with bilateral neck e xploration and quick parathyroid hormone assay, failure was due to ectopic mediastinal glands, misinterpretation of frozen section, and operative judg ment, with a failure rate of 10%. From 1993 to 1998, with preoperative loca lization and quick parathyroid hormone assay, the two operative failures (1 .5 %) were due to operative judgment and misinterpretation of the quick par athyroid hormone assay. Conclusions. The new surgical approach combining preoperative localization studies and intraoperative parathyroid hormone monitoring has eliminated th e most common causes of parathyroidectomy failure and has significantly dec reased the operative failure rate.