American Association of Endocrine Surgeons- Annual Meeting Abstract Papers

PARATHYROIDECTOMY IN SECONDARY HYPERPARATHYROIDISM: IS THERE AN OPTIMAL SURGICAL MANAGEMENT?
Melanie Richards, Jennifer Wormuth, Juliane Bingener, Kenneth Sirinek
University of Texas Health Science Center, San Antonio, Texas

Background: Subtotal parathyroidectomy (PTx) and total PTx with autotransplantion (autotx) are both accepted operations for secondary hyperparathyroidism (2HPT). Studies have shown the two procedures to have similar rates of recurrent and/or persistent HPT (0-10%). The majority of these reports consist of small case series and despite apparently similar outcomes; the optimal surgical management for 2HPT continues to be debated. The purpose of this study was to determine whether subtotal PTx and total PTx with autotx are truly equivalent options for patients with 2HPT.
Methods: A meta-analysis of 54 publications between 1983-2004 that reported on reoperative surgery for 2HPT identified 514 patients who underwent an operation for recurrent or persistent 2HPT. These patients were evaluated for the type of primary operation, the need for reoperative surgery as it relates to the type of primary operation and the findings at reoperation.
Results: Reoperative surgery was for persistent 2HPT in 82/485 (17%) and for recurrent 2HPT in 403/485 (83%) patients. The primary operation was a subtotal PTx in 44% and a total PTx with autotx in 56%. Imaging prior to the initial operation was obtained in 19/50 (38%). There were 4 or more glands identified in 63%, 3 glands in 24% and 2 glands in 13% of patients at the primary operation. Findings at reoperation included: autograft hyperplasia (46%), supernumerary glands (24%), remnant hyperplasia (18%), and a missed insitu gland (7%) (n=486). Negative explorations occurred in 26% (126/486). Significantly more pts had an autograft recurrence than a remnant recurrence (p < 0.001).
Conclusions: More recurrences occur in autografts than in insitu remnants. However, negative explorations or supernumerary glands occur in 50% of reoperations. Primary operations, therefore, should include attempts to localize supernumerary glands both pre- and intra-operatively. The failures may occur NOT because of the type of primary procedure but as a result of limitations in localization and the natural history of hyperplastic parathyroid tissue.