Department of General and Endocrine Surgery, Hopital La Timone, 264, rue Saint Pierre, 13385 Marseille Cedex 5, France.
Langenbecks Arch Surg. 2010 Feb;395(2):103-9. doi: 10.1007/s00423-009-0560-2.
Reoperation for primary hyperparathyroidism (PHPT) remains a major challenge for both the patient and surgeons. Before considering reoperation, the surgeon must confirm the diagnosis of PHPT and assess patient risk factors. The goal of reoperative surgery is to excise the abnormal parathyroid gland(s) and limit exploration to help minimize the potential complications. At least two positive and concordant localizing studies should be available before reoperation, but the surgeon must keep in mind that the operative and histology reports from previous operation are the first localization techniques. A thorough knowledge of the anatomy and an understanding of the embryonic development of the parathyroid glands are also the keys to successful localization. According to the case history and the results of localization studies, the surgeon must clearly establish whether or not there is a suspicion of multiglandular disease (MGD). If the lesion sought is a solitary adenoma, an open-focused approach can be proposed. Conversely, if there is a confirmation or strong suspicion of MGD, revision of the transverse cervicotomy is recommended. In case of suspicion of local recurrence, an extensive local resection or en bloc resection may be indicated. Intraoperative QPTH assay is recommended to rule out MGD. In some cases, cryopreservation of parathyroid tissue and judicious use of parathyroid transplantation can be useful. With experienced parathyroid surgeons, the success rate of reoperations can be as high as 95%. It has been estimated that about 5% to 10% of initial operations for PHPT result in recurrent or persistent disease. It is too early to evaluate the real risk of persistent or recurrent disease following minimally invasive techniques, but any attempt to limit the extent of the primary procedure will be insignificant if the risk of persistent or recurrent disease is increased.
原发性甲状旁腺功能亢进症（PHPT）的再次手术仍然是患者和外科医生面临的主要挑战。在考虑再次手术之前，外科医生必须确认 PHPT 的诊断并评估患者的风险因素。再次手术的目标是切除异常甲状旁腺（s）并限制探查范围，以最大程度地减少潜在并发症。在再次手术之前，至少应提供两项阳性且一致的定位研究，但外科医生必须记住，之前手术的手术和组织学报告是最初的定位技术。对解剖结构有透彻的了解，并了解甲状旁腺的胚胎发育也是成功定位的关键。根据病史和定位研究的结果，外科医生必须明确是否存在多腺体疾病（MGD）的怀疑。如果要寻找的病变是单个腺瘤，可以提出开放性聚焦方法。相反，如果存在 MGD 的确认或强烈怀疑，则建议对横向颈切开术进行修订。如果怀疑局部复发，可能需要进行广泛的局部切除或整块切除。建议进行术中 QPTH 测定以排除 MGD。在某些情况下，甲状旁腺组织的冷冻保存和甲状旁腺移植的合理使用可能会有所帮助。有经验的甲状旁腺外科医生可以将再次手术的成功率提高到 95%。据估计，大约 5%至 10%的初始 PHPT 手术结果为复发性或持续性疾病。评估微创技术后持续性或复发性疾病的真实风险还为时过早，但是如果持续性或复发性疾病的风险增加，任何限制初次手术范围的尝试都将无足轻重。
