Bruno Carnaille

Electrophysiologic recurrent laryngeal nerve monitoring during thyroid and parathyroid surgery: International standards guideline statement

Intraoperative neural monitoring (IONM) during thyroid and parathyroid surgery has gained widespread acceptance as an adjunct to the gold standard of visual nerve identification. Despite the increasing use of IONM, review of the literature and clinical experience confirms there is little uniformity in application of and results from nerve monitoring across different centers. We provide a review of the literature and cumulative experience of the multidisciplinary International Neural Monitoring Study Group with IONM spanning nearly 15 years. The study group focused its initial work on formulation of standards in IONM as it relates to important areas: 1) standards of equipment setup/endotracheal tube placement and 2) standards of loss of signal evaluation/intraoperative problem‐solving algorithm. The use of standardized methods and reporting will provide greater uniformity in application of IONM. In addition, this report clarifies the limitations of IONM and helps identify areas where additional research is necessary. This guideline is, at its forefront, quality driven; it is intended to improve the quality of neural monitoring, to translate the best available evidence into clinical practice to promote best practices. We hope this work will minimize inappropriate variations in monitoring rather than to dictate practice options. Laryngoscope, 121:S1–S16, 2011

Adrenocortical carcinomas: surgical trends and results of a 253-patient series from the French Association of Endocrine Surgeons study group

Because of the rarity of adrenocortical carcinoma, survival rates and the prognosis for patients who have undergone operation are not well known. The purpose of the French Association of Endocrine Surgery was to evaluate these factors over an 18-year period. A trend study was associated to assess changes in the clinical and biochemical presentations as well as the surgical evolution. A total of 253 patients (158 women, 95 men) with a mean age of 47 years were included. Cushing syndrome was the main clinical presentation (30%), and hormonal studies revealed secreting tumors in 66% of the cases. Altogether, 72% (n=182) of patients underwent resection for cure, and 41.5% (n=105) of them had an extensive resection because of metastatic cancer. A lymphadenectomy was performed in 32.5% (n=89) of the cases. The operative mortality was 5.5% (n=14). Patients were given mitotane as adjuvant therapy in 53.8% of the cases (n=135). The results of staging were stage I in 16 patients (6.3%), stage II (local disease) in 126 patients (49.8%), stage III (locoregional disease) in 57 patients (22.5%), and stage IV (metastases) in 54 patients (21.3%). Neither tumor staging nor the rate of curative surgery changed during the study period. More subcostal incisions were performed, and the use of mitotane increased significantly. The 5-year actuarial survival rates were 38% overall, 50% in the curative group, 66% for stage I, 58% for stage II, 24% for stage III, and 0% for stage IV. Multivariate analysis showed that mitotane benefited only the group of patients not operated on for cure. A better prognosis was found in patients operated on after 1988 (p=0.04), in those with precursor-secreting tumors (p=0.005), and in those at local stages of the disease (p=0.0003). Thus mitotane benefited only patients not operated on for cure. Curative resection, precursor secretion, recent diagnosis, and local stage were favorably associated with survival.RésuméIntroduction: La survie et le pronostic des patients opérés d’un corticosurrénalome restent mal connus car il s’agit d’une tumeur rare. L’Association Française de Chirurgie Endocrinienne s’est fix pour but d’évaluer ces facteurs pendant une période de 18 ans. Les changements de présentation clinique, biochimique et l’évolution de la prise en charge chirurgicale ont également fait l’objet d’une analyse. Méthode: Deux cent cinquante trois patients (158 femmes, 95 hommes), d’une moyenne d’âge de 47 ans. ont été étudiés. Un syndrome de Cushing a été la situation clinique la plus fréquente (30%), et les études hormonales ont montré une tumeur sécrétante dans 66% des cas. Soixante-douze pour cent (n=182) des patients ont bénéficié d’une chirurgie à visée curative et 41,5% (n=105) ont eu une résection étendue en raison des métastases. Un curage ganglionnaire a été réalisé dans 32,5% (n=89) des cas. La mortalité post-opératoire a été de 5,5% (n=14). Du mitotane a été utilisé dans 53,8% des cas (n=135). La classification tumorale a montré : 16 stades I (6,3%): 126 stades II (maladie locale) (49,8%), 57 stades III (maladie loco-régionale) (22,5%); et 54 stades IV (métastases) (21.3%). Résultats: Le stade des tumeurs et le pourcentage de chirurgie à visée curative n’ont pas évolué. II a été réalisé plus d’incisions sous-costales et l’utilisation du mitotane n’a cessé de croître de façon significative. La survie actuarielle à 5 ans a été de 38% : 50% dans le groupe opéré à visée curative, 66% dans les stades I, 58% dans les stades II, 24% dans les stades III, et 0% dans les stades IV. L’analyse multivariée a montré que le mitotane a apporté un bénéfice de survie au groupe de patients opérés à visée palliative. Une amélioration du pronostic a été notée après 1988 (p=0.04), chez les patients sécrétant des précurseurs (p=0,005) et dans les stades locaux (p=0,0003). Conclusion: Le mitotane n’a été profitable qu’aux patients opérés à visée palliative. Le caractère curatif de la chirurgie, le type de sécrétion hormonale, la période récente de diagnostic et le stade local ont été des facteurs favorables de survie.ResumenIntroducción: Dada la poca frecuencia del cáncer adreno-cortical el pronóstico y la supervivencia de los pacientes intervenidos no es bien conocido. La Asociación Francesa de Cirugía Endocrina se ha marcado como objetivo valorar estos factores durante un periodo de tiempo de 18 años. Además, pretendemos analizar los cambios clínicos y bioquímicos, así como la evolución del tratamiento quirúrgico. Método: Se estudiaron 253 pacientes (158 hembras y 95 varones) cuya edad media fue de 47 años. El cuadro clínico más frecuente fue el del síndrome de Cushing (30%) y los análisis hormonales demostraron la existencia de un tumor secretor en el 66% de los casos. El 72% (n=182) de los pacientes fueron intervenidos quirúrgicamente con fines curativos y en el 41.5% (n=105) hubieron de efectuarse resecciones ampliadas por metástasis. Una linfadenectomia se realizó en el 32.5% (n=89) de los casos. La mortalidad operatoria fue del 5.5% (n=14). El 53.8% (n=135) de los pacientes recibieron como terapia adyuvante Mitotane. La clasificación tumoral registra: 16 estadios I (6.3%); 126 estadios II (enfermedad local) (49.8%). 57 estadios III (enfermedad loco-regional) (22.5%) y 54 estadios IV (con metástasis) (21.3%). Resultados: El porcentaje de tumores en los diferentes estadios no se ha modificado, ni tampoco la cirugía con fines curativos. La vía de abordaje más frecuente ha sido la subcostal y el empleo, como terapia adyuvante, de Mitotane no ha cesado de aumentar significativamente. La supervivencia actuarial global a 5 años fue del 38%; 50% en el grupo operado con fines curativos: 66% en pacientes en estadio I, 58% en los del estadio II, 24% en los del estadio III y 0% en los del estadio IV. Un análisis multivariante ha demostrado los beneficiosos efectos del Mitotane, por lo que a la supervivencia se refiere, en el grupo de pacientes intervenidos con fines paliativos. El pronóstico ha mejorado desde 1988 (p=0.04), en los pacientes secretores de precursores (p=0.005) y en los pacientes con enfermedad local (p=0.0003). Conclusiones: El Mitotane sólo es útil en casos de cirugía paliativa. La cirugía radical, el tipo de secreción hormonal, el diagnóstico precoz y el estadio de enfermedad local, son los factores más favorables en cuanto a la supervivencia se refiere.

Hypocalcemia following Thyroid Surgery: Incidence and Prediction of Outcome

Abstract. Postoperative hypocalcemia is a common and most often transient event after extensive thyroid surgery. It may reveal iatrogenic injury to the parathyroid glands and permanent hypoparathyroidism. We prospectively evaluated the incidence of hypocalcemia and permanent hypoparathyroidism following total or subtotal thyroidectomy in 1071 consecutive patients operated during 1990–1991. We then determined in a cross-sectional study which early clinical and biochemical characteristics of patients experiencing postoperative hypocalcemia correlated with the long-term outcome. Postoperative calcemia under 2 mmol/l was observed in 58 patients (5.4%). In 40 patients hypocalcemia was considered severe (confirmed for more than 2 days, symptomatic or both). At 1 year after surgery five patients (0.5%) had persistent hypocalcemia. We found that patients carried a high risk for permanent hypoparathyroidism if fewer than three parathyroid glands were preserved in situ during surgery or the early serum parathyroid hormone level was ≤ 12 pg/ml, the delayed serum calcium levels ≤ 8 mg/dl, or the delayed serum phosphorus level ≥ 4 mg/dl under oral calcium therapy. When one or more of these criteria are present, long-term follow-up should be enforced to check for chronic hypocalcemia and to avoid its severe complications by appropriate supplement therapy.

Weiss system revisited: a clinicopathologic and immunohistochemical study of 49 adrenocortical tumors.

The definitive diagnostic criteria for malignant adrenocortical tumors are distant metastasis and/or local invasion. The Weiss histopathologic system is the most commonly used method for assessing malignancy because of its simplicity and reliability. Unfortunately, its application remains subjective. This current retrospective study evaluated the Weiss system and assessed the value of MIB-1 labeling in the diagnosis of adrenocortical malignancy. Twenty-four malignant tumors with distant metastasis, gross local invasion, or recurrence were selected and matched on their functioning status to 25 benign tumors. Two independent observers delineated the Weiss criteria. An MIB-1 labeling index was determined. Presence of three or more Weiss microscopic criteria was related to malignancy (specificity 96%, sensitivity 100%), thus confirming the value of the Weiss system. Interobserver agreement for the Weiss system (total score) was excellent (r = 0.94). The lack of reliability for some Weiss criteria led us to propose a statistically modified system, based on the most reliable criteria (2.mitotic rate × 2.cytoplasm × abnormal mitoses × necrosis × capsular invasion) with a significant correlation with the Weiss system (r = 0.98). The MIB-1 labeling index was significantly higher in malignant tumors (p <0.0001). MIB1 could also help to differentiate malignant from benign adrenocortical tumors.

Reference range of serum calcitonin levels in humans: influence of calcitonin assays, sex, age, and cigarette smoking

OBJECTIVE The objective of this study was to re-evaluate the adult C(T) reference values determined by five different immunoassays and by introducing criteria for selecting control subjects. DESIGN A prospective multicenter study. PATIENTS Three hundred and seventy-five clinically euthyroid subjects. METHODS We used five different C(T) immunoassays. Sera were assayed for the concentration of TSH, gastrin, procalcitonin, urea, calcium, and anti-thyroperoxidase antibodies. RESULTS Screening for the various potential causes of hypercalcitoninemia led to the exclusion of 23% of the sera. Our reference value analysis dealt with 287 subjects (142 men and 145 women). The proportion of samples in which no C(T) was detected varied from 56% (for assay D) to 88% (for assay C). We observed significant correlations (whose magnitude depended on the assay used) between C(T) levels and age or body mass index (BMI) (primarily in men). The distribution of C(T) levels showed that 4.7, 9.8, 2.5, 6.5, and 8.0% of the values were over 10 pg/ml respectively. These values corresponded essentially to samples from 11 male subjects (median age: 55 years), most of whom were smokers. The highest C(T) values were around twice as high in men than women, and were higher in smokers than non-smokers. Conclusion In clinical practice (and after having excluded the usual causes of raised C(T) levels), the interpretation of C(T) assay results must take into account i) the method used; ii) the patients gender, age, and weight; and iii) the potential influence of cigarette smoking.

Micrometastases in thyroid cancer. An important finding

Differentiated thyroid cancer is a cancer with a good prognosis but the presence of lymph node metastases is associated with increased rates of loco-regional recurrence and in some reports decreased survival. This has led to an increased interest in the lymph node status with guidelines calling for routine central node dissection and increased interest in lateral compartment node sampling and sentinel node biopsy. We know from studies in regions where routine central and ipsilateral node dissection is the preferred surgical management of differentiated thyroid cancer that lymph node metastases are present in the majority of cases and that many of these are micrometastatic deposits. However, where routine node dissection is not performed recurrence rates are relatively low suggesting that not all micrometastatic disease progresses to a loco-regional recurrence or that the majority of disease is mopped up by adjuvant radioactive iodine. This review examines the available evidence for the significance of micrometastatic disease in differentiated thyroid cancer and suggests that it is probably of little clinical significance and does not warrant further aggressive surgical intervention. We would expect a conservative surgical approach combined with adjuvant radioactive iodine to lead to durable disease control.

Primary Hyperparathyroidism in Multiple Endocrine Neoplasia Type IIa: Retrospective French Multicentric Study

Abstract. Primary hyperparathyroidism (PHPT) in multiple endocrine neoplasia (MEN) type IIa is rare, occurring in 20% to 30% of the patients. The aim of this study was to evaluate clinical findings, surgical therapy, and outcome for 56 patients affected by PHPT among 249 MEN-IIa patients collected from 84 families assembled by the Groupe d’Etude des Tumeurs á Calcitonine (GETC, French Calcitonin Tumors Study Group). This retrospective study was based on cases registered by the GETC (20 participating centers) from 1969 to 1994. Characteristics of PHPT in 56 patients (31 women, 25 men) with MEN-IIa were reviewed. All but two underwent cervicotomy. The median age at diagnosis was 37.6 years. PHPT was found concomitantly with medullary thyroid carcinoma (MTC) or pheochromocytoma in 43 patients (77%). PHPT was asymptomatic in 68% of the patients. Serum calcium levels ranged from 2.20 to 3.70 mmol/L (median 2.82 mmol/L; normal 2.10–2.60 mmol/L). The number of parathyroid glands removed at surgery was 0 (n = 2), 1 (n = 24), 2 (n = 5), > 2 (n = 12), 4 (n = 11). Pathology (initial surgery) consisted of 24 adenomas, 4 double adenomas, and 25 hyperplasia. Cure after initial surgery was obtained in 89%, including a 22% incidence of hypoparathyroidism. There were 6 cases (11%) with persistent PHPT. With a mean follow-up of 6.4 years, five patients (9%) had recurrent PHPT. The results indicate that MEN-IIa-related PHPT is generally associated with mild, often asymptomatic hypercalcemia. Despite recurrences encountered 5 to 15 years after the first cervicotomy, resection of only macroscopically enlarged glands generally appears sufficient. Subtotal or total parathyroidectomy with autotransplantation is associated with a high rate of hypoparathyroidism.

Hyperparathyroidism in multiple endocrine neoplasia type I: Surgical trends and results of a 256-patient series from groupe d’Etude des Néoplasies endocriniennes multiples study group

The French and Belgian GENEM study group’s multiple endocrine neoplasia type I (MEN-I) database was used to evaluate trends in clinical presentation, surgical treatment of primary hyperparathyroidism (pHPT) (n=245), and prognostic factors for hypercalcemia correction among 256 MEN-I cases. The patients were retrieved through the GENEM network from various Belgian and French instititutions with the help of genetics laboratories. Among the 245 pHPT patients (96%), 42% were men. The mean age at the time of diagnosis was 39.5 ± 13.3 years. Trends were studied for three periods: before 1986, from 1986 to 1990, and thereafter. After 1990 MEN-I patients were more often diagnosed with isolated pHPT (8%, 11%, 28%, for the three periods, respectively; p=0.002); it was seen more often in screened patients (31%, 28%, 53%; p=0.001), more often among those in already known MEN-I families (64%, 45%, 72%; p=0.005), and among those with lower preoperative calcemia (2.93, 2.87, 2.79 mmol/L; p=0.001). The age at pHPT diagnosis remained constant throughout the study. The percentage of cervical explorations dropped during the entire study (87%, 87%, 53%; p<0.0001). After 1985 the percentage of subtotal parathyroidectomies increased (25%, 59%, 51%; p=0.0004). Pathology disclosed more hyperplasias (59%, 85%, 74%; p=0.008). Postoperative hypercalcemia decreased (47%, 15%, 19%; p<0.0001); and postoperative hypocalcemia increased nonsignificantly (5%, 15%, 15%; p=0.1). Subtotal parathyroidectomy [odds ratio (OR) 13], no MEN-I family background (OR 3), and the most recent study period (>1985) (OR 3) were significant predictive factors of hypercalcemia correction according to the multivariate analysis. This is the first multicentric study on the management of MEN-I-related pHPT. Immediate postoperative hHPT cure increased, but only 80% of the operated patients were cured after 1990. Fifteen percent were hypocalcemic. Because MEN-I-related hHPT cure remains difficult to achieve, we advocate that subtotal parathyroidectomies be performed in specialized centers.RésuméIntroduction. A partir de 245 cas d’hyperparathyroïdie (pHPT) enregistrés au groupe d’étude franco-belge du GENEM (96%), (256 cas de NEM1), on a analysé l’évolution de la présentation clinique, le résultat après traitement chirurgical et de son effet sur la maladie pHPT. Population et méthodes. Les patients ont été retrouvés grâce au réseau multicentrique du GENEM et avec l’aide des laboratoires d’analyse génétique. Parmi les 245 cas de pHPT, 42% étaient des hommes. L’âge moyen au moment du diagnostic a été de 39,5 ± 13,3 ans. Trois périodes ont été étudiées: avant 1986, de 1986 à 1990, et après 1990. Résultats. Après 1990, il s’agissait plus souvent d’pHPT isolées (8%-11%-28%, 0; p=0,002), plus souvent dépistées (31%-28%-53%, p=0,001), plus souvent au sein de familles NEM1 connues (64%-45%-72%, respectivement: p=0,005), et avec une calcémie plus basse (2,93-2,87-2,79, respectivement; mmol/L, p=0,001). L’âge au moment du diagnostic de pHPT n’a pas changé au cours du temps. Le pourcentage de patients opérés pour exploration cervicale a diminué (87%-87%-53%, respectivement; p<0,0001). Après 1985, le pourcentage de parathyroïdectomies subtotales a augmenté (25%-59%-51%, respectivement: p=0,0004). L’anatomo-pathologie a mis en évidence plus d’hyperplasies (59%-85%-74%, respectivement; p=0,008). L’hypercalcémie post-opératoire a diminué (47%-15%-19%, respectivement; p<0,0001) et l’hypocalcémie a augmenté non significativement (5%-5% – 15%, respectivement; p=0,1). La parathyroïdectomie subtotale (Odds ratio=13), l’absence d’autre atteinte familiale (Odds ratio=3), et la prise en charge après 1985 (Odds ratio=3) ont été les facteurs indépendants prédictifs d’un contrôle de la pHPT en analyse multivariée. Conclusion. Il s’agit de la première analyse multicentrique de la prise en charge de la pHPT des NEM1. Après 1990, la correction de la pHPT a été plus efficace mais seulement dans 80% des cas. Quinze pourcent des patients étaient hypocalcémiques. Ces constatations poussent à opérer les pHPT des NEM1 en centres spécialisés pour réaliser une parathyroïdectomie subtotale.ResumenIntroducción: Se utilizó, para analizar los casos de hiperparatiroidismo (pHPT) (n=245) registrados como MEN L (n=256), el grupo de estudio franco-belga del GENEM. Se analizaron: La evolución clinica y el tratamiento quirúrgico y, sus efectos sobre la pHPT. Material y métodos: Los pacientes se descubrieron gracias a la red multicéntrica del GENEM y con la ayuda de laboratorios de análisis genético. Entre los 245 pHPT (96%), 42% eran varones. La edad media, en el momento del diagnóstico, fue de 39.5 ± 13.3 años. Su evolución se estudió en tres periodos de tiempo: antes de 1986, entre 1986 y 1990 y después de 1990. Resultados: Después de 1990 los casos de MEN 1 se diagnosticaron sobre todo por determinaciones aislada de pHPT (8%-11%-28%, p=0.002), se descubrieron con más frecuencia (31%-28%-53%, p=0.001), en especial en el seno de familias conocidas por padecer un MEN 1 (64%-45%-72%, p=0.005) y con calcemias más bajas (2.93-2.87-2.79 mmol/L, p=0.001). La edad, al efectuar el diagnóstico, no se ha modificado a lo largo del tiempo. El porcentaje de enfermos operados ha disminuido (87%-87%-53%, p<0.0001). A partir de 1985 el porcentaje de paratiroidectomias subtotales aumentó (25%-59%-51%, p=0.0004). Los estudios anatomopatológicos revelaron una mayor incidencia de hiperplasias (59%-85% -74%, p=0.008). La hipercalcemia postoperatoria ha disminuido (47%-15%-19%, p<0.0001) y la hipocalcemia aumentado, pero no significativamente (5%-5%-15%, p=0.1). En un análisis multivariante la paratiroidectomia subtotal (Odds ratio=13), la falta de antecedentes familiares de MEN 1 (Odds ratio=3) y la operación más precoz a partir de 1985 (Odds ratio=3), son los factores predictivos más significantes de la corrección de la hipercalcemia. Conclusión: Se trata del primer análisis multicéntrico del tratamiento del sÍndrome de MEN 1 referido a la pHPT. La curación del hHPT aumentó en el postoperatorio inmediato, pero sólo el 80% de los pacientes operados estaban curados después de 1990. 15% de los pacientes estaban hipocalcémicos. Dado que la curación de enfermos con síndrome de MEN 1 relacionado con hHPT es dificil, se aconseja realizar una paratiroidectomía subtotal en centros especializados.

Gabapentin attenuates late but not early postoperative pain after thyroidectomy with superficial cervical plexus block.

BACKGROUND: Preoperative oral gabapentin has been shown to reduce postoperative pain. However, the effects of gabapentin as an adjunct to regional anesthesia is unclear and its effects on chronic pain remains unknown. In patients undergoing thyroidectomy, we investigated the effects on early and late (at 6 mo) postoperative pain of preoperative oral gabapentin as an adjunct to superficial cervical plexus block (SCPB). METHOD: Fifty consecutive consenting patients were randomized to receive either 1200 mg of gabapentin (Group G) or placebo (Group P) 2 h preoperatively. Preoperative anxiety was assessed on a numeric scale from 0 to 6. A SCPB was performed after a standardized induction of anesthesia. The primary outcome, analgesic drug consumption, was assessed during the procedure and postoperatively in the postanesthesia care unit and after discharge to the ward. Over the first 24 h, pain levels at rest and during swallowing were measured on a numeric scale from 0 to 10. If the pain level was more than 4/10 at rest, patients received 1 g/6 h of IV paracetamol and/or 50 mg/6 h of IV tramadol as a rescue analgesic treatment in the interval. The day before operation and 6 mo after thyroidectomy, included patients were asked to answer a neuropathic pain diagnostic questionnaire. RESULTS: Population characteristics, preoperative anxiety, intraoperative drug consumption, procedure duration, and postoperative care unit stay were comparable in both groups. Analgesic consumption during the first 24 postoperative hours was similar in both groups (G: 3 [0–5] doses/24 h; P: 3 [1–5] doses/24 h; P = NS), as well as pain at rest (G: 2,2 [0.2–3.7]; P: 2 [0–6.3]; P = NS), and during swallowing (G: 2.8 [0.4–8.9]; P: 3 [1.4–6.3]; P = NS]). Eight patients had a diagnostic questionnaire score more than 3, 6 mo after operation versus 2 in preoperative period (P = 0.04). Such delayed neuropathic pain complaints were reported in seven patients receiving SCPB alone and only in one patient receiving both SCPB and preoperative adjunctive oral gabapentin. (P = 0.01). CONCLUSION: Oral preoperative administration of gabapentin did not modify immediate pain management in thyroidectomy patients receiving SCPB, but prevented delayed neuropathic pain at 6 mo.

Reoperation for persistent or recurrent primary hyperparathyroidism.

Aim: To analyse the causes and outcome of reoperations for persistent or recurrent primary hyperparathyroidism (HPT). Materials and methods: We reviewed the medical records of 38 patients who underwent reoperation between December 1965 and April 1997 for persistent or recurrent primary HPT. During this period of time, 1448 patients underwent operation for primary HPT, 294 for renal HPT and 58 for questionable disease, i. e. a total of 1800. In the 1448 cases of HPT, 22 patients were reoperated after a first cervicotomy in the institution, i. e. a first reoperation rate of 1.5%. Sixteen patients were referred after unsuccessful parathyroid surgery. Six patients were reoperated on twice and one patient seven times for a graft-dependent recurrence. Results: Reasons for failed parathyroid operations included tumour tissue in ectopic location (75%) or tumour tissue that had not been seen in normal position (19%), parathyreomatosis (2%), parathyroid cancer (2%) and graft-dependent hypercalcaemia (2%). Of the ectopic glands, 45% were intrathymic, 12.5% intrathyroidal, 7.5% retro-oesophageal, 7.5% in the carotid sheath, 5% interthyrotracheal, 5% in the mediastinum (extrathymic), 5% in the aorto-pulmonary window, 2.5% undescended, 2.5% overdescended and 2.5% intertracheo-oesophageal. Of the patients, 38% had uniglandular lesions, 60% multiglandular lesions, and 2% parathyroid cancer. The histologically confirmed cause of HPT was adenoma in 50% of cases, hyperplasia in 38% and “normal” but overweight glands in 9.5%. Of the 38 patients studied, 15 presented one or more supernumerary glands (fifth to eighth gland). Reoperation was performed through a cervical incision in 82% of cases and using a mediastinal approach in 18% (8 median sternotomies, 1 thoracoscopy). The success rate of the reoperations was 92%. A total of 8% of patients suffered permanent unilateral vocal cord paralysis; 5% are definitely hypocalcaemic. The sensitivities of preoperative localization studies ranged from 69% for sestamibi scan and 63% for selective venous catheterization to 16% for computed tomography. Conclusion: Repeated parathyroidectomy can be avoided in more than 98% of patients if an experienced surgeon performs bilateral cervical exploration during the initial parathyroid operation. For patients with persistent or recurrent primary HPT, preoperative localization studies and a focused surgical approach can result in a 92% success rate with a minimal complication rate.