Clinical Study: Novel Approach to Reoperative Neck Surgery for Hyperparathyroidism Results in 96% Cure Rate

Clinical history plays an important role in success

By Joyce Shin, MD

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Cleveland Clinic’s Department of Endocrine Surgery within the Endocrinology & Metabolism Institute (EMI) is one of the largest in the country and is a national leader in surgical care for endocrine disorders. We performed 1,071 endocrine surgeries in 2014, and total patient visits numbered more than 6,000. A large number of complex cases are referred to our five full-time endocrine surgeons, including about 25 percent that are reoperative and require special expertise for optimal surgical strategy.

Reexploration for persistent or recurrent hyperparathyroidism is a common procedure performed by our team. Reoperative neck surgery for hyperparathyroidism in patients with previous cervical explorations can pose diagnostic and technical difficulties. With the higher risk of morbidity, surgeons need to rely heavily on the patient’s clinical history and localization studies to perform curative reexploration. When sufficient data can be obtained from both clinical information and imaging studies, reoperative parathyroid surgery can have success rates that are comparable with those of initial parathyroidectomy.

Clinical approach guides reoperative strategy

We conducted a study within EMI that analyzed our Endocrine Surgery group’s clinical strategies in the management of patients with hyperparathyroidism requiring reoperative neck surgery. The study, published in JAMA Surgery (formerly Archives of Surgery), found that our overall cure rate in reoperated patients was 96 percent. This success is driven in large part by applying clinical information that allows our surgeons to categorize patients according to their disease status; aids in the interpretation of localization studies; and helps correctly direct the reoperative approach.

Information provided by localization studies and clinical history was applied in the stratification of patients by disease status (single diseased gland or multiple diseased glands remaining in the neck and/or mediastinum) and reoperative approach (single-site exploration or multiple-site exploration). The 203 patients with hyperparathyroidism who were evaluated for reoperative neck surgery over a 10-year period were stratified into different disease categories based on their clinical scenario, which was determined by the type of hyperparathyroidism and findings at previous exploration(s) obtained from referring notes, operative notes and surgical pathology reports (Table 1).

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All 203 patients underwent localization studies, such as surgeon-performed ultrasound and sestamibi-iodine subtraction scan. Our endocrine surgeons have considerable expertise in performing parathyroid ultrasound in these challenging reoperative cases. When indicated, we also can perform fine needle aspiration biopsy of the suspected parathyroid gland during the initial evaluation. In addition, our Department of Nuclear Medicine department has particular imaging protocols for performing sestamibi-iodine subtraction scan with CT coregistration in these difficult cases. In this study, 173 were candidates for reexploration due to concordance on two localization studies.

One of the aims of the study was to emphasize the importance of clinical history in this patient population. By applying clinical scenario to the stratification of disease status, the likelihood of actually having either a single or multiple remaining abnormal glands was improved. Furthermore, the positive predictive value of the disease status based on localization studies also increased when a patient was stratified as having either a single or multiple abnormal glands.

Comprehensive care leads to successful outcomes

The results of the study support the strategy used by the endocrine surgeons at Cleveland Clinic. Our group expends a great amount of time and effort reviewing every patient’s medical records, from routine cases to the very complex. Our endocrine surgeons also have considerable expertise in performing appropriate localization studies that help guide curative reexploration. This comprehensive approach has been the key to surgical cure, patient satisfaction and the overall success of our team.

Express Care Service Streamlines Endocrine Surgery Referrals

Patients who are referred to Cleveland Clinic’s Endocrine Surgery group do not need an extensive diagnostic workup by the referring physician. Instead, our team obtains all necessary medical records, which are reviewed by the endocrine surgeon prior to the patient’s initial consultation.

Diagnostic testing, including in-office ultrasound and fine needle aspiration biopsy when needed, can be done the same day. If warranted, surgery will be discussed and coordinated at the initial appointment and often can be scheduled within a few days, especially for out-of town patients.

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This express care service allows the patient to experience a comprehensive consultation in one seamless visit, which is particularly important when a patient is referred for reoperative surgery.

Our endocrine surgeons also frequently refer patients for postsurgical care that may involve other specialists for long-term treatment and surveillance.

Dr. Shin is an endocrine surgeon and Surgical Director of Cleveland Clinic’s Thyroid Center. She is fellowship-trained in endocrine surgery. Her specialty interests include thyroid and parathyroid surgery, thyroid/parathyroid ultrasound, advanced laparoscopic surgery, laparoscopic adrenalectomy, intra-abdominal ultrasound and neuroendocrine tumors.