The Southwestern Surgical Congress Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring Melanie L. Richards, M.D., M.H.P.E.*, Geoff B. Thompson, M.D., David R. Farley, M.D., Clive S. Grant, M.D. Mayo Clinic, Department of Surgery, Rochester, MN, USA Abstract BACKGROUND: Reoperative parathyroidectomy (R-PTX) in primary hyperparathyroidism (1HPT) has increased failure rates and morbidity. This study evaluated R-PTX during the era of minimal-access PTX with intraoperative parathyroid hormone (IOPTH) monitoring. METHODS: Two thousand sixty-five patients with 1HPT who underwent PTX were assessed for R-PTX. Preoperative studies, operative findings, and outcomes were evaluated. RESULTS: Two hundred twenty-eight patients underwent 236 R-PTX procedures. Imaging per- formed included sestamibi (89%), ultrasound (US; 56%), computed axial tomography/magnetic reso- nance imaging (5%), and selective venous sampling (1%). Sestamibi was more sensitive than US (84% vs 68%). Curative surgery was performed in 89% of patients. IOPTH was 99% sensitive. There was no relationship between cure and the following parameters: preoperative calcium or PTH levels, persistent or recurrent disease, or use of IOPTH. Solitary gland disease and a single previous operation were associated with increased likelihood of cure (P = .06). Hypoparathyroidism was decreased using IOPTH monitoring (2% vs 9%). One patient had recurrent laryngeal nerve palsy. CONCLUSIONS: R-PTX can be performed effectively with minimal complications. IOPTH is an accurate predictor of cure and may decrease the frequency of permanent hypoparathyroidism. © 2008 Elsevier Inc. All rights reserved. KEYWORDS: Primary hyperparathyroidism; Intraoperative parathyroid hormone; Parathyroidectomy Reoperative parathyroidectomy (R-PTX) in patients with primary hyperparathyroidism (1HPT) has historically been associated with increased failure rates and morbidity sec- ondary to permanent hypocalcemia or nerve injury. Recur- rent laryngeal nerve injury has been reported to increase 5-fold in the reoperative setting. 1 Previously, 10% of patients may have been expected to suffer permanent hypo- parathyroidism. 2 The decision to proceed with reoperation depends on a balance between these risks, the severity of disease and complications, and the likelihood of a curative operation. The fibrosis encountered in the reoperative setting and the risk of nerve injury suggest that directed surgery would have less morbidity. The success of a minimal approach in primary surgery for 1HPT has depended on accurate imag- ing modalities and the use of intraoperative parathyroid hormone (IOPTH) monitoring to predict biochemical cure. Although accurate localization has been the foundation of a curative reoperation with low morbidity in patients with confirmed 1HPT, the contributions of IOPTH monitoring in the reoperative setting have been controversial. Irvin et al * Corresponding author. Tel.: +1-507-284-8968; fax: +1-507-284- 5196. E-mail address: richards.melanie@mayo.edu Manuscript received May 2, 2008; revised manuscript July 3, 2008 0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.07.022 The American Journal of Surgery (2008) 196, 937–943