High Success Rate of Parathyroid Reoperation may be Achieved with Improved Localization Diagnosis Ola Hessman Æ Peter Sta ˚lberg Æ Anders Sundin Æ Ulrike Garske Æ Claes Rudberg Æ Lars-Gunnar Eriksson Æ Per Hellman Æ Go ¨ran A ˚ kerstro ¨m Published online: 12 March 2008 Ó Socie ´te ´ Internationale de Chirurgie 2008 Abstract Introduction Because of the difficulty of reoperative parathyroid surgery, preoperative imaging studies have been increasingly adopted. We report the use of consis- tently applied localization diagnosis to yield high success rates in parathyroid reoperations. Methods Parathyroid reoperation was performed after previous parathyroid surgery in 144 patients with nonma- lignant hyperparathyroidism (HPT) between 1962 and 2007. From the year 2000, 46 patients who underwent parathyroid reoperation and 14 patients who were subjected to thyroid surgery before primary parathyroid operation were investigated with sestamibi scintigraphy (MIBI), 11 C- methionine PET/CT (met-PET), surgeon-performed ultra- sound (US), US-guided fine-needle aspiration biopsy (US- FNA), and selective venous sampling (SVS) with rapid PTH (Q-PTH) analyses. When imaging was considered adequate, additional studies were generally not obtained. Results Reversal of hypercalcemia was achieved by reoperation in 134 of 144 (93%) of all patients with previous parathyroid surgery. In patients operated from year 2000, MIBI had 90% sensitivity and 88% predictive value, met-PET 79% sensitivity and 87% predictive value, and US 72% sensitivity and 93% predictive value. SVS with Q-PTH analyses provided accurate localization or regionalization in 11 of 11 recently selected patients. Q-PTH analyses in fine-needle aspirations verified para- thyroid origin of excised specimens, and intraoperative Q-PTH helped decide when operations could be termi- nated. In patients subjected to the algorithm of imaging procedures, reversal of hypercalcemia and apparent cure was obtained after the reoperation in 45 of 46 patients with previous parathyroid surgery, implying a success rate of 98%, and in all patients with previous thyroid surgery. Conclusions Reoperative parathyroid surgery is chal- lenging. Results can be improved by consistently applied sensitive methods of preoperative imaging, and reoperative procedures may then achieve nearly the same success rates as primary operations. Introduction Many of the early patients diagnosed with hyperparathy- roidism (HPT) in the beginning of the 20th century had to undergo several operations to be cured; therefore, the his- tory of parathyroid surgery is to a great extent the history of parathyroid reoperation. Reoperations for HPT generally have been associated with more frequent failures and higher complication rates than primary surgery [1–3]. Due to scarring and obliterated tissue planes, considerable dif- ficulties in finding the parathyroid glands and avoiding injury to especially recurrent nerves may be encountered, both after previous parathyroid and thyroid surgery [4]. O. Hessman (&) Á P. Sta ˚lberg Á P. Hellman Á G. A ˚ kerstro ¨m Department of Surgery, University Hospital, 751 85 Uppsala, Sweden e-mail: ola.hessman@surgsci.uu.se A. Sundin Á L.-G. Eriksson Department of Radiology, University Hospital, 751 85 Uppsala, Sweden U. Garske Department of Nuclear Medicine, University Hospital, 751 85 Uppsala, Sweden C. Rudberg Department of Surgery, Centrallasarettet, 721 89 Va ¨stera ˚s, Sweden 123 World J Surg (2008) 32:774–781 DOI 10.1007/s00268-008-9537-5