Impact of localization studies and clinical scenario in patients with hyperparathyroidism being evaluated for reoperative neck surgery

Background: Previous studies have focused on the success of localization studies (LSs) in patients undergoing reoperative parathyroid surgery; however, patients who did not undergo reexploration surgery have been excluded from analysis. In addition, the concept of whether clinical scenario (CS) suggests single- vs multiple-gland disease in reoperative strategy is often underemphasized. Objective: To evaluate how LSs and CS direct operative strategy in patients being considered for reexploration. Design: Retrospective review of a prospective database. Setting: Tertiary referral center. Patients: Two hundred three patients with hyperparathyroidism who underwent previous neck surgery. The CS stratified patients as candidates for single- or multiplesite exploration (or unknown). Main Outcome Measure: Ability of CS and LSs to direct successful reexploration. Results: Of 203 patients, 27 were not explored owing to nonlocalizing studies. Of the remaining 176 patients, LSs accurately guided reexploration in 85%. However, when including the 27 nonexplored patients, the success of LSs decreased to 73%. The cure rate in reoperated patients was 96% but was reduced to 83% when including nonexplored patients. Of the reoperated patients, 83% had single-site disease and 17% had multiple-site disease. The positive predictive value of LSs in predicting single- or multiple-site disease was 92% and 73%, respectively. However, when stratified by CS, the positive predictive value increased to 95% for single-site disease and to 100% for multiple-site disease. Conclusions: Failure to cure patients was 4 times more likely to be due to nonlocalizing studies than to a failed reexploration. Stratification by CS was useful in the interpretation of LSs and in determining the most accurate reoperative approach.