Reexploration and angiographic ablation for hyperparathyroidism
R. C. McIntyre Jr, D. A. Kumpe and R. D. Liechty
Department of Surgery, University of Colorado Health Sciences Center, Denver.
OBJECTIVE: Persistent and recurrent hyperparathyroidism remains a
challenging clinical problem. The purposes of this study were to determine
the causes of initial failure, the accuracy of preoperative localization
tests, the role of angiographic parathyroid ablation, and the safety and
efficacy of reexploration for hyperparathyroidism. DESIGN: A retrospective
review of 42 patients undergoing reexploration or angiographic 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 angiographic 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 used for deeper mediastinal glands not
resectable through a cervical approach. Angiographic ablation of
mediastinal glands was performed using contrast administration after a
catheter was wedged into the selective feeding artery. MAIN OUTCOME
MEASURES: End points included causes of initial treatment failure, accuracy
of preoperative localization studies, long-term correction of hypercalcemia
with repeated treatment, need for subsequent intervention for
hypercalcemia, and complications of therapy. RESULTS: The most common
reasons for initial failure were mediastinal glands (18 patients),
surgeon's inexperience (12 patients), supernumerary glands (six patients),
and other anatomic anomalies. Hyperplasia accounted for hyperparathyroidism
in 11 patients (26%) and adenomas in 31 patients (74%). Preoperative
localization studies included technetium-Tc-99m-sestamibi scanning
(sensitivity, 86%), technetium-thallium scanning (67%), arteriography
(63%), venous sampling (52%), computed tomography (42%), magnetic resonance
imaging (33%), and ultrasonography (27%). Thirty-three (89%) of 37 patients
who underwent reexploration had resolution of hypercalcemia. Localization
study results were negative in all four patients who experienced failure.
Angiographic ablation was successful in four (67%) of six patients. One of
the patients with a failed ablation had successful mediastinal exploration.
Hypoparathyroidism occurred in six patients (14.3%) and there was no
instance of recurrent nerve injury. CONCLUSIONS: The most common causes of
initial failure were ectopic mediastinal glands and incomplete surgical
exploration; the most sensitive preoperative localization study is the
technetium-Tc-99m-sestamibi scan; angiographic ablation of parathyroid
tissue is most useful for poor-risk surgical patients or to avoid median
sternotomy; and reexploration and angiographic ablation yield a high
success rate with acceptable morbidity and mortality.
