Abstract: Objective To analyze the clinical effect of re-operation treatment for uremic patients complicated with persistent or recurrent secondary hyperparathyroidism (SHPT). Methods A total of 14 persistent or recurrent SHPT patients treated with re- operation of parathyroidectomy (PTX) or resection of the grafts in neck or forearm in our hospital during the period from Aug. 2012 to Dec. 2016 were enrolled in this study. Before re-operation, location of the remaining parathyroid gland in neck was identified by ultrasonography, dualphase 99Tcm-sestamibi scintigraphy (99Tcm-MIBI), computed tomography (CT) and magnetic resonance imaging (MRI). We resected the parathyroid gland in situ and grafts, especially the ectopic parathyroid gland and lymphatic adipose tissue by superior mediastinal and central compartment dissection. The changes of clinical symptoms, intact parathyroid hormone (iPTH), calcium (Ca), phosphorus (P), calcium and phosphorus product (Ca×P), alkaline phosphatase (ALP), hemoglobin (HB) and hematocrit (HCT) after the surgery were observed. Surgery complications and recurrence of SHPT were also analyzed. Results All of the 14 patients underwent the operation successfully. Pathological examination of the surgical samples found hyperplastic parathyroid issues. We resected 27 parathyroid glands, including 14 glands in situ in neck, 6 recurrent grafts and 7 ectopic glands in thymus, which located in thymus, superior mediastinum or thyroid parenchyma. The detection rates of ectopic parathyroid glands in neck by ultrasonography, 99Tcm-MIBI, CT and MRI were 33%, 72%, 56% and 60%, respectively. After the operation, clinical symptoms including ostealgia, skin itching and limb weakness improved significantly. Serum iPTH levels after the operation for 20 minutes, 24 hours, 48 hours, one month, 6 months and one year were significantly lower than the levels before operation (t=5.264, P＜0.001 after 20 minutes; t=4.836, P=0.001 after 24 hours; t=5.091, P＜0.001 after 48 hours; t=5.183, P＜0.001 after one month; t=5.398, P＜0.001 after 6 months; t=5.217, P＜0.001 after one year). After the operation for one week, serum Ca, P and Ca x P decreased significantly as compared those before the operation (t= 6.984, P＜0.001 for Ca; t=2.979, P=0.011 for P; t=4.983, P＜0.001 for Ca x P), but ALP, HB and HCT changed insignificantly (t=0.693, P=0.501 for ALP; t=1.048, P=0.319 for HB; t=1.693, P=0.129 for HCT). After the operation, hypocalcemia appeared in 13 patients and improved after calcium supplement. Temporary injury of laryngeal nerve was found in 5 cases and 2 of them had transient bucking. There was no dyspnea and death. No recurrence was found in a follow-up period of one year. Conclusion In uremic patients complicated with persistent or recurrent SHPT, accurate localization of residual parathyroid glands is essential before reoperation. During operation, ectopic parathyroid glands are explored according to the concept of superior mediastinum and central compartment dissection. The success rate of re-operation will be significantly increased after complete resection of all residual parathyroid glands.

Key words: Secondary hyperparathyroidism, Persitent, Recurrence, Re-opretion, Parathyroidectomy