Abstract
BACKGROUND: Primary hyperparathyroidism is the leading cause of hypercalcemia in outpatients, and parathyroidectomy is the only curative treatment. Although initial surgery cures the majority of patients when performed by experienced surgeons, a subset of patients experience persistent or recurrent hyperparathyroidism, necessitating reoperation. Reoperation is technically demanding and associated with a higher complication risk, but it remains the only chance for a durable cure. Data on outcomes in the Middle East are scarce. METHODS: A retrospective cohort study of adults who underwent reoperation for persistent or recurrent hyperparathyroidism was conducted at tertiary centers in the Eastern Province of Saudi Arabia between 2008 and 2022. Persistent disease was defined as failure to normalize calcium and parathyroid hormone (PTH) within six months of index surgery, and recurrent disease was defined as return of hypercalcemia after at least six months of normocalcemia. Data on demographics, comorbidities, surgical and pathological features, imaging, and outcomes were collected. The primary outcome was biochemical cure at six months after reoperation. Secondary outcomes included complications, length of hospital stay, permanent hypoparathyroidism, late recurrence, and mortality. Predictors of cure were assessed using multivariable logistic regression. RESULTS: A total of 162 patients underwent reoperation (median age: 54 years; 114 (70.4%) women). Persistent hyperparathyroidism was present in 59 (36.4%) and recurrent disease in 103 (63.6%). Preoperative localization identified a lesion in 141 (87%). At reoperation, 71 (43.8%) underwent focused or minimally invasive approaches, and 76 (46.9%) underwent bilateral exploration. At six months, 131 (80.9%) achieved cure, including 42 of 59 (71.2%) with persistent disease and 89 of 103 (86.4%) with recurrent disease (p=0.02). Complications occurred in 21 (13%), including four (2.5%) with permanent recurrent laryngeal nerve injury and six (3.7%) with permanent hypoparathyroidism. On multivariable analysis, recurrent disease (adjusted odds ratio (OR): 2.4; 95% confidence interval (CI): 1.1-5.4), positive localization (OR: 3.1; 95% CI: 1.2-8.0), and adenoma pathology (OR: 2.8; 95% CI: 1.2-6.4) were independently associated with cure. CONCLUSIONS: Reoperation for persistent or recurrent hyperparathyroidism was associated with durable cure in approximately four of five patients and acceptable morbidity. Cure was more likely in patients with recurrent disease, positive preoperative localization, and adenoma pathology, underscoring the importance of comprehensive imaging and specialized surgical expertise.