Revision surgery for hyperparathyroidism can best be summarized by three questions: Is the diagnosis correct? Can the abnormal glands be found? and How can they be removed surgically with minimal morbidity?

Patient Evaluation

Is the Diagnosis Correct?

Whenever a surgeon is referred a patient with suspected recurrence of hyperparathyroidism, the basic principle of making a diagnosis applies. Is this truly a recurrence of hyperparathyroidism, or is this a different disease? Was the original diagnosis correct? What were the patient’s symptoms before the first operation, and have they recurred? Symptoms such as renal colic, abdominal pain, fatigue, and bone pain are commonly seen in parathyroid disease; however, they may also be seen with other syndromes. Signs may include nephrolithiasis, weakness of the proximal muscles of the lower extremities, mental changes, peptic ulcer disease, and chondrocalcinosis in some joints, commonly the knee and pseudogout. Patients can also have nephrolithiasis and hypertension and not have parathyroid disease. Laboratory studies should show elevations of serum calcium, intact parathyroid hormone (PTH), and elevated urinary calcium excretion, the latter requiring the 24-hour creatinine clearance be within the normal range. Supplementary studies may include bone density studies and plain radiographs. Patients with primary PTH may have pain in their long bones, clavicles, hands, and dentition; however, this is more commonly seen with secondary hyperparathyroidism. The physician should inquire if there is any family history or significant endocrine history. Entities that need to be considered include familial hyperparathyroidism, both the autosomal dominant pattern (four-gland hyperplasia) and the recessive (adenoma), and the multiple endocrine neoplasia syndromes, both type 1 (> 90%) and type 2 and their subtypes. One usually sees four-gland hyperplasia in these disease states. Familial hypocalciuric hypercalcemia is another entity that may at times lead the best of clinicians astray. Of paramount importance in diagnosing this disease is the evaluation of renal function and calcium excretion.

What Was Done Previously?

One of the most important aspects in evaluating the patient is obtaining old records. These should include old operative reports, pathology reports, slides, and old localization studies. Direct communication with the prior surgeon can be invaluable in performing an operation with minimal morbidity. Were any markers left in the patient to identify residual parathyroid tissue, such as a suture or clip? To what were these markers attached? Patients can also be very helpful by their recollection of prior surgery. What were they told after the surgery? How many glands were left? Were the glands in an ectopic location, and were their symptoms and signs improved after surgery? It can be extremely helpful to know if there were any complications after prior surgeries, including hoarseness and hypocalcemia. Did the patient need to take calcium or vitamin D after prior parathyroid exploration? Was the thyroid gland removed as well? How long was the patient symptom free?

What Needs to Be Done Now?