Recurrent secondary hyperparathyroidism - An argument for total parathyroidectomy

Objective: To define better the incidence and causes of recurrent secondary hyperparathyroidism. Design: Review of total parathyroidectomy with auto-transplantation in uremic patients and literature review. Setting: Two teaching hospitals. Patients: Nine patients treated for secondary hyper-parathyroidism between 1982 and 1993 by a single surgeon. Interventions: Total parathyroidectomy with auto-transplantation into the sternocleidomastoid muscle. Recurrence was treated, if necessary, with a graft reduction procedure. Main Outcome Measures: The symptomatic and biochemical response to initial therapy, morbidity, and mortality, as well as the development of recurrent hypercalcemia. Results: All patients were normocalcemic after their initial surgery. One patient died postoperatively (mortality, 11%). Three (38%) of the remaining patients developed recurrent hypercalcemia, 2 (25%) requiring reoperation. Of the 2 patients who underwent surgery for recurrence, 1 had an adenoma in the implant and the other had graft hyperplasia. Conclusions: Recurrence rates after total parathyroidectomy with autotransplantation are substantial and, given the pathophysiology of secondary hyperparathyroidism, unavoidable in patients with uncorrected renal failure. An argument is made for performing total parathyroidectomy alone in patients with secondary hyperparathyroidism who will not undergo renal transplantation in the near future.