Routine open bilateral neck exploration without preoperative localization or intraoperative parathyroid hormone assay has been repeatedly challenged over recent years as the optimal surgical strategy for the treatment of idiopathic primary hyperparathyroidism (HPT). This has prompted a review of the Oxford experience with adherence to traditional practice, questioning whether results could have been improved upon or cost justified by targeting unilateral exploration and immediate hormonal assay.
The records of all patients undergoing first-time surgery for idiopathic primary HPT over a 32-year period have been reviewed. In every patient bilateral neck exploration was performed and an attempt made to identify all four parathyroid glands. All macroscopically enlarged glands were removed and the operating time recorded. A successful outcome was defined as normocalcaemia without any therapy at 3-month review after surgery, with good cosmesis.
Between 1968 and 2000, 688 patients were operated upon; a total of 2520 parathyroids were identified, of which 968 were abnormal. A single adenoma was found in 542 patients (79 per cent) (eight in a fifth gland), multiple gland disease in 120 (17 per cent) and parathyroid carcinoma in ten (1 per cent). Mean operating time for all patients was 65 min, including those requiring thyroid lobectomy and cervical thymectomy. When a single adenoma was found in a normal anatomical site the mean operating time was 35 min. Some 672 patients (98 per cent) were treated successfully.
Open bilateral neck exploration and removal of all macroscopically enlarged parathyroid glands resulted in a high level of success in this series. No evidence has been found in a worldwide literature search to suggest that expensive high technology would have provided greater benefit for the group as a whole. © 2000 British Journal of Surgery Society Ltd