options for treatment of persistent or recurrent hyperparathyroidism
Although preoperative localization is optional prior to an initial surgery for HPT, it is essential in cases of persistent or recurrent disease because the success rate of the surgery is much higher when the abnormal gland has been accurately localized. Multiple modalities are often utilized with 99m technetium sestamibi scanning, neck ultrasonography, and CT being the most common. Having correlation of the location of the abnormal gland on two different imaging modalities is very reassuring and is used by some surgeons as a criterion for reoperation in persistent HPT. Repeat cervical exploration is successful in normalizing PTH levels in about 85% of patients, and may be aided by intraoperative ultrasonography and ioPTH assay. Mediastinal parathyroid tissue is most often removed via the transcervical approach, but thoracoscopy or median sternotomy may be required 1% to 2% of the time. Angiographic ablation of mediastinal parathyroid tissue using high doses of ionic contrast may be successful in selected patients and prevent sternotomy.