Challenges in the Perioperative Localization in Secondary Hyperparathyroidism, a Case Report

Abstract

To detect hyperfunctioning glands, noninvasive procedures such as ultrasound, sestamibi scan, and magnetic resonance imaging (MRI) are widely available. Preoperative localization studies give important information and enable unilateral exploration or minimal invasive parathyroidectomy. Localization studies and parathyroid hormone assays have not clearly modified the conventional surgical approach of the disease. Controversy regarding the surgery to be favored, between subtotal parathyroidectomy and total parathyroidectomy with autotransplantation, continues against the background of relevant recurrence rates, persistent SHPT, and markedly increased complication rates in reoperation. We are presenting a case of 54-year-old male, on regular hemodialysis (HD) referred by his nephrologist for symptomatic hyperphosphatemia and osteoporosis. Phosphate binders and vitamin D failed to control the disease. Patient underwent neck exploration aiming for total parathyroidectomy, but during surgery we were able to find only the left inferior parathyroid gland. For the few months after the surgery, patient phosphate, iPTH and alkaline phosphatase still deranged. So, the decision was made to do preoperative localization study to confirm the presence and location of the remaining 3 parathyroid gland before re-exploration of the neck. Ultrasonography, computerized tomography of the neck and thorax as well as sestamibi scan done. The results were inconclusive.

Re-exploration was performed only right and left superior parathyroid glands. Still unable to localize right inferior gland. Postoperatively, biochemical derangement started to improve slowly.