Re-operative (re-do) parathyroid surgery
Reoperative Parathyroid Surgery
After parathyroidectomy, follow up laboratory tests are done to determine if surgery was successful. This will most commonly entail simple blood tests for serum calcium levels and parathyroid hormone (PTH). Surgical cure is defined as a normal serum calcium level, and the PTH level usually returns to normal as well. These lab tests should be repeated in 6 months. In the hands of experienced surgeons the cure rate is 95-98%. However, even in the best of hands, some patients will not be cured after the first operation. Of this 2 to 5% of patients with a failed initial parathyroidectomy, up to 98% may be cured with a second operation. Reoperative parathyroid surgery is extremely specialized. It involves more risk than the initial parathyroid operation, and the preoperative evaluation is also more involved and complex. This operation truly requires a surgeon and operative center that is: 1) very experienced in parathyroid surgery, 2) has access to advanced preoperative testing methods to localize difficult to find parathyroid glands, and 3) has access to additional intraoperative tools such as intraoperative PTH monitoring and cryopreservationCryopreservation - When a piece of parathyroid tissue is frozen and stored for future use.. However, the most important predictor of success in re-operative cases is an experienced surgeon.
Prior to your operation, you will likely need additional localizing testsLocalizing tests - Any test that is used to find or "localize" abnormal parathyroid gland(s). The most common are sestamibi scan and ultrasound.. Your surgeon will decide which test or combination of tests you will need. Most experts will ask for a combination of tests to help confirm the location of the abnormal gland(s). One other procedure you may have done prior to surgery is direct laryngoscopy, a test to look at how well your vocal cords are moving. A known risk of parathyroid surgery is injury to the laryngeal nerves. It is important to determine if any injury occurred during your first operation. Most patients who have a nerve injury will have hoarseness as a symptom of nerve injury, but some may not.
Persistent and Recurrent Primary Hyperparathyroidism
There are two categories of disease that may require re-operative parathyroid surgery:
- Persistent primary hyperparathyroidismPersistent primary hyperparathyroidism - When calcium levels do not return to normal within 6 months of a parathyroid operation. is when the calcium and PTH levels do not return to normal levels after the operation or became abnormal again within 6 months of the operation. Persistent primary hyperparathyroidism usually happens because not all of the abnormal parathyroid tissue was removed at the first operation. This can happen if an inexperienced surgeon "misses" the diseased gland or if there is an ectopic gland located in a difficult to find location that would not be seen even by an experienced surgeon, or if the patient has multiple abnormal glands.
- Recurrent primary hyperparathyroidismRecurrent primary hyperparathyroidism - When calcium levels are initially normal after parathyroid surgery, but after 6 months become abnormal again. is when the calcium and PTH levels initially are normal but after 6 months again become abnormal. Recurrent hyperparathyroidism usually happens when one or more of the remaining glands becomes hyperactive. This is a new problem and does not reflect a "missed gland" at the first operation.
Parathyroid cancer can cause either persistent or recurrent primary hyperparathyroidism. Less than 1% of patients with primary hyperparathyroidism will be diagnosed with parathyroid cancer. (see Parathyroid Cancer) However, in this select group of patients, parathyroid cancer cells can spread just like any other cancer to other parts of the body (metastasis) or come back in the area from which it was originally removed (local recurrence). This is a rare problem that can be difficult to treat. Parathyromatosis is another very rare cause of persistent or recurrent parathyroid disease and happens when abnormal parathyroid cells spill into the neck. Under the right conditions, those spilled cells can survive and start growing again into multiple islands of parathyroid tissue that can become hyperactive. Parathyromatosis can be difficult to treat.
What should I bring to my appointment?
- Operative report In order to determine what was done at your first operation, your surgeon will first need copies of your operative report (this outlines what was done during your surgery and serves as a roadmap to determine which parathyroid glands were identified or removed during your first operation).
- Pathology report This report outlines which of the parathyroid gland(s) were removed and also confirms that what was actually removed at the time of surgery was indeed parathyroid tissue. There are other structures in the neck that can resemble parathyroid glands such as thyroid nodules and lymph nodes. The pathology report will exclude these other structures from the diagnosis.
- Laboratory reports/Radiology images Your surgeon may request any old tests that were done before your first operation to compare to your current tests. For example, if you had a sestamibi scanSestamibi scan - Nuclear medicine test where a small amount of radioactive material is injected into a vein and an X-ray is taken. before your first operation that showed a hyperactive gland, your surgeon may want to compare it to a new scan to see if a new parathyroid gland has become overactive in a different location. It is very helpful to your surgeon if you bring the pictures of your localizing tests to the visit. (see Localization)