James, E M

AbstractPersistent or recurrent hypercalcemia following operation for benign hyperparathyroidism (HPT) remains a surgical challenge. From 1978 to 1984 at the Mayo Clinic, 157 patients underwent reexploration. This included 110 cervical, 38 combined cervical and mediastinal, and 9 mediastinal explorations. A total of 197 previous operations (range 1–5) had been performed, including 136 patients for sporadic disease, 14 for multiple endocrine neoplasia, and 7 for familial HPT. Preoperative localizing studies were employed in 137 patients (87%), Cervical ultrasonography had an accuracy of 76% (sensitivity, 82%; positive predictive value, 81%), while mediastinal computed tomography was accurate in 76% (sensitivity, 57%; positive predictive value, 80%). Arteriography, venography, and venous sampling were not used. Guided by high‐resolution, small parts ultrasonography, fine‐needle aspiration biopsy confirmed localization of parathyroid tissue in 3 patients. Successful resolution of hypercalcemia occurred in 139 patients (89%) with a mean follow‐up of 22 months. There were no operative deaths; 12 patients (8%) had temporary neuropraxia of the recurrent laryngeal nerve, 6 patients (4%) suffered permanent unilateral paralysis, and 20 (13%) became permanently hypoparathyroid. Two of 4 hypoparathyroid patients who were autotransplanted with cryopreserved parathyroid tissue have become eucalcemic. The results indicate that the disease site is usually in the neck, that noninvasive localizing techniques have superseded arteriography and venous sampling, and that reoperative parathyroid surgery can be performed with rare mortality and acceptable morbidity. Although these refinements have led to improved success, reoperative parathyroid surgery should not be performed by the occasional parathyroid surgeon.

AbstractUltrasound and computed tomography have had an enormous impact on the imaging procedures used in the detection of tumors of the parathyroids, pancreas, and adrenals. Ultrasound is now the examination of choice in localizing parathyroid adenomas in the neck prior to cervical exploration or after unsuccessful exploration. Its role as a screening test in patients without biochemical confirmation of hyperparathyroidism awaits further study. Computed tomography is useful in identifying mediastinal parathyroid adenomas in patients who have had unsuccessful neck explorations and islet‐cell tumors of the pancreas if they are sufficiently large (greater than 2 cm). Angiography remains the most accurate method of localizing insulinomas prior to surgery. Computed tomography scanning has become the procedure of choice in localizing adrenal tumors and has sufficient sensitivity to be used as a screening test in patients without biochemical confirmation of an adrenal abnormality.