1112 Consecutive bilateral neck explorations for primary hyperparathyroidism

Background: Bilateral neck exploration has been the standard approach for patients with primary hyperparathyroidism. Improved localization studies and the availability of intraoperative parathyroid hormone monitoring have challenged the necessity of four-gland exploration. In this series we report a single surgeon's experience with bilateral neck exploration for primary hyperparathyroidism in an effort to establish benchmark outcomes from which to evaluate minimally invasive protocols. Methods: The charts of 1112 consecutive patients who underwent neck exploration for primary hyperparathyroidism by a single surgeon over a 17-year period were reviewed. All patients underwent bilateral neck exploration under either general (n = 264) or local (n = 848) anesthesia. Results: The overall cure rate was 97.4% with a complication rate of 3.4%. Morbidity included recurrent laryngeal nerve injury (0.2%), postoperative bleeding (0.8%), and transient hypocalcemia (1.8%). There was no mortality. Overall mean operating time was 52.5 ± 30.2 minutes. A single gland was removed in 78.4% of patients, and 22.3% of patients underwent concomitant thyroidectomy. The cure rate was lower for patients undergoing reexploration (89.2% vs. 97.9%, p < 0.05). Choice of anesthetic approach did not affect the cure or complication rate. The overall conversion rate from local to general anesthesia was 1.5%. Patients undergoing general anesthesia were operated on earlier in the series and were less likely to be managed on an ambulatory basis (local 87.5% vs. general 38.4%, p < 0.05). During the last 5 years of the series, more than 90% of patients underwent exploration under local anesthesia. Conclusion: This large modern series of neck explorations for primary hyperparathyroidism confirms the safety, feasibility, and efficacy of the bilateral approach. It further demonstrates that individual surgeons can achieve outcomes equivalent to those with four-gland explorations under local anesthesia.