Yale-New Haven Hospital, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut 06520, USA.
J Clin Endocrinol Metab. 2011 Oct;96(10):2950-8. doi: 10.1210/jc.2011-1010.
Reoperative parathyroid surgery may be required in patients who have persistent primary hyperparathyroidism after an unsuccessful operation and in patients who had an initially successful exploration but develop recurrent disease at an interval greater than 6 months postoperatively. Additionally, patients who have had significant surgery in the cervical region, particularly total thyroidectomy, should be considered in this group because they pose identical technical challenges that in the past have resulted in suboptimal cure and complication rates. These patients require a meticulous review of their historical, biochemical, imaging, and operative data to confirm the diagnosis, to evaluate the possibility of familial forms of hyperparathyroidism, and to confirm the indications for surgery. Once a patient is deemed an appropriate surgical candidate, sequential imaging is required to yield a roadmap to guide surgical intervention. These reoperative procedures require an experienced parathyroid surgeon armed with intraoperative adjuncts to locate the offending parathyroid gland(s) and remove them while minimizing collateral injury, particularly to the recurrent laryngeal nerves. These patients are also at increased risk of postoperative hypocalcemia that can be life-threatening. Despite these concerns, an experienced endocrine team can diagnose persistent or recurrent hyperparathyroidism, localize residual abnormal parathyroid glands, and perform surgical intervention with success and complication profiles that approximate those achieved in the unexplored patient.
对于初次手术不成功的持续性原发性甲状旁腺功能亢进症患者，以及初次手术成功但术后 6 个月以上复发的患者，可能需要再次甲状旁腺手术。此外，曾在颈部进行过重大手术的患者（尤其是甲状腺全切除术）也应考虑在此类患者中，因为他们存在相同的技术挑战，过去这些技术挑战导致治疗效果不佳和并发症发生率较高。这些患者需要仔细回顾其病史、生化、影像学和手术数据，以确认诊断，评估甲状旁腺功能亢进症的家族形式的可能性，并确认手术适应证。一旦患者被认为是合适的手术候选者，就需要进行连续影像学检查，以提供指导手术干预的路线图。这些再次手术需要有经验的甲状旁腺外科医生使用术中辅助手段来定位有问题的甲状旁腺（s）并将其切除，同时最大限度地减少对喉返神经的附带损伤。这些患者还存在术后低钙血症的风险增加，这可能危及生命。尽管存在这些担忧，但有经验的内分泌团队可以诊断持续性或复发性甲状旁腺功能亢进症，定位残留的异常甲状旁腺，并进行手术干预，其成功率和并发症发生率与未探查患者相似。
