Accidental parathyroidectomy during total thyroidectomy and hypoparathyroidism in a large series of 766 patients: incidence and consequences in a referral center.

PURPOSE: Transient hypoparathyroidism is the most common complication after total thyroidectomy, and accidental parathyroidectomy (AP) may be a cause. The aim of this study was to investigate the incidence of AP and its impact on postoperative calcemia. MATERIALS AND METHODS: From February 2016 to May 2018, 766 patients undergoing total thyroidectomy were prospectively included. Surgical indications, hormonal status, definitive histology, and postoperative calcium and PTH levels were analyzed. RESULTS: 578/(75.45%) were women and 188/(24.55%) men with mean age of 53.4 years. Parathyroid tissue on the thyroid specimen was observed in 40 (5.2%) patients: 30 APs and 10 parathyroid fragments. Among the 30 APs, 12 glands were intrathyroid and 18 (2.3%) in eutopic location. 97 (12.6%) patients were treated for postoperative hypocalcemia: 90 (11.7%) had transient and 5 (0.6%) definitive hypoparathyroidism; 2 were lost in follow-up. 13/30 (43.3%) with AP had transient hypoparathyroidism. A strong correlation was found (p < 0.0001) between AP and postoperative hypocalcemia. 1/30 (3.3%) patient with APs had definitive hypoparathyroidism. Transient and persistent nerve palsies were found in 10 (1.3%) and 3 (0.4%) patients, respectively. DISCUSSION: A careful examination of the thyroid gland after resection help to identify an AP that could be autotransplanted. Surgeon and hospital activity volume per years seem to reduce the risk of hypoparathyroidism. CONCLUSION: Total thyroidectomy and intrathyroid localization of parathyroid glands are risk factors for the AP. The incidence of AP was 2.3%, and this remains low due to our longstanding experience in thyroid and parathyroid surgery.

The Role of "Critical" Ultrasound Reassessment in the Decision-Making of Bethesda III Thyroid Nodules.

Background and Objectives: Bethesda III (BIII) thyroid nodules have an expected malignancy rate of 5-15%. Our purpose was to assess which US criteria are most associated with cancer risk, and the value of critical ultrasound (US) reassessment. Methods: From 2018 to 2022, 298 BIII nodules were enrolled for thyroidectomy (79 malignancies). We evaluated ultrasonographic data: hechogenicity, intralesional vascularization, spiculated margins, micro-calcifications, "taller than wide" shape, extra-thyroidal growth, size increase, as well as their association with histology. We also evaluated if the ultrasound reassessment modified the strategy. Results: Spiculated margins and microcalcification were significantly correlated with malignancy risk. Spiculated margins showed a specificity of 0.95 IC95% (0.93-0.98); sensitivity 0.70 IC95% (0.59-0.80). Microcalcifications showed a sensitivity of 0.87 CI95% (0.80-0.94); specificity 0.75 CI95% (0.72-0.83). The presence of these signs readdressed the strategy in 76/79 cases Then, the indication for surgery was appropriate in 75% of cases. Conclusions: Microcalcifications and spiculated margins should be routinely sought during a final ultrasound reassessment in BIII nodules. These signs allowed for a modification of the strategy in favor of surgery in 96% of the cases that were not otherwise referred to surgery. The importance of integrating ultrasound and cytology in the evaluation of BIII thyroid nodules is confirmed. Reassessment with ultrasound of BIII nodules allowed for a redirection of the surgical choice.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA). Recommendations of the AFCE (Francophone Association of Endocrine Surgery) with the SFE (French Society of Endocrinology) and the SFMN (French Society of Nuclear Medicine).

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) can be proposed for selected patients with a thyroid volume<45mL and/or a nodule<4cm (for Bethesda category II, III or IV lesions), or<2cm (for Bethesda category V or VI lesions), with no suspicion of lateral nodal involvement or mediastinal extension who wish to avoid a cervical scar. Such patients should have satisfactory dental status, have been educated on the specific risks of the transoral route and the need for perioperative oral care, and also fully informed regarding the lack of proof of TOETVA effectiveness in terms of quality of life and patient satisfaction. The patient should be made aware of the possibility of postoperative pain in the neck cervical and chin, which may persist for several days to a few weeks after the intervention. Transoral endoscopic thyroidectomy should be performed in centers with expertise in thyroid surgery.

The pre-thyroidectomy surgeon's checklist. Recommendations of the AFC>E (Association francophone de chirurgie endocrinienne), with the SFE (Société française d'endocrinologie) and the SFMN (Société française de médecine nucléaire).

During the patient interview, signs of compression or invasion are sought out: dyspnea, dysphagia, dysphonia. The circumstances of discovery of the thyroid pathology are indicated. The surgeon must be closely acquainted with the EU-TIRADS and Bethesda classifications so as to be able to evaluate and explain to the patient the risk of malignancy. He must also be able to interpret a cervical ultrasound in view of proposing a procedure adapted to the pathology. Cervicothoracic CT-scan (or MRI) must be prescribed in the event of suspected plunging nodule or clinical/echography signs: non-palpable lower pole of the thyroid behind the clavicle, dyspnea, dysphagia, collateral circulation. The surgeon goes on to investigate possible relationships with adjacent organs, to evaluate extension toward the aortic arch and the positions (anterior, posterior or mixed) of the goiter, the objective being to determine the most adapted approach: classical cervicotomy, manubriotomy or sternotomy. Even in the event of a tumoral pathology, PET-FDG is not one of the imagery exams carried out systematically. Only in case of TSH < 0.5µU/mL should thyroid scintigraphy be proposed. Prior to any thyroid surgery, serum TSH levels, calcitoninemia and calcemia must be measured.

Lymph node thyroglobulin in the diagnosis of metastases of thyroid carcinoma with the thyroid in situ: A prospective intraoperative study.

BACKGROUND: The use of thyroglobulin concentration in washout fluid of fine-needle aspiration (FNA-Tg) is a procedure advocated by international guidelines to diagnose metastatic LN in papillary thyroid cancer. With the increasing use of active follow-up or lobectomy alone for low-risk thyroid cancers, the determination of the diagnostic performance of FNA-Tg in the detection of metastatic PTC when the thyroid is in situ is paramount. MATERIALS AND METHODS: Prospective study with measurement of Tg in washout fluid obtained from intraoperative fine needle aspiration (FNA) cytology in order to avoid contamination from thyroid tissue and rigorously isolated punctured nodes. Receiver-operating characteristic (ROC) curve and area under the curve (AUC), optimal threshold to discriminate benign and malignant LN, sensitivity and specificity were provided. RESULTS: a total of 58 lymph nodes from 32 patients were analyzed. ROC analysis defined the optimal cutoff values of FNA-Tg at 60 ng/ml for the diagnosis of malignant LNs in patients with a thyroid in situ. Sensitivity and specificity were 75% (95% confidence interval 57.89-86.75) and 87.5% (95%CI: 69-95.66), respectively. CONCLUSION: Our results support the hypothesis that the Tg-FNA threshold for a safe diagnosis of LN metastasis in PTC is higher in presence of a thyroid gland in situ. The use of lower thresholds could result in false positive results and lead to unnecessary surgery.

The Nexus of Hyperparathyroidism and Thyroid Carcinoma: Insights into Pathogenesis and Diagnostic Challenges-A Narrative Review.

This review investigates the intricate relationship between hyperparathyroidism (HPT) and thyroid carcinoma (TC), aiming to elucidate their coexistence, potential pathogenetic mechanisms, and clinical implications. A systematic search strategy, employing the MeSH terms 'Hyperparathyroidism' and 'Thyroid Carcinoma', spanned publications from 2013 to 2023 across the PubMed, Web of Science, and Scopus databases. Fifteen selected articles were analyzed. Studies unanimously confirm the notable association between primary hyperparathyroidism (PHPT) and thyroid nodules/cancer, with incidences ranging from 2.8% to 47.1%. Key findings reveal a predilection for papillary thyroid carcinoma (PTC) in this association, showcasing varying tumor characteristics and gender disparities. Lower preoperative serum parathyroid hormone (PTH) levels are a potential risk factor for thyroid cancer in PHPT patients. Diverse surgical approaches and tumor characteristics between PHPT and secondary hyperparathyroidism (SHPT) cases were noted. Moreover, this review underscores the scarcity of definitive guidelines in managing concurrent PHPT and thyroid conditions, advocating for comprehensive assessments to enhance diagnostic accuracy and refine therapeutic interventions. Rare coincidental associations, as highlighted by case reports, shed light on unique clinical scenarios. In essence, this review amalgamates evidence to deepen the understanding of the interplay between HPT and TC, emphasizing the need for further research to elucidate underlying mechanisms and guide clinical management.

Editorial: Recent Advances in Thyroid Surgery.

Thyroid surgery has been, since its earliest application, one of the most notable fields in medicine, illustrated by the fact that the Nobel Prize in Medicine was won, for the first time, for thyroid surgery by Emil Theodor Kocher (1841-1917) in 1909, for his contributions to thyroid physiology, pathology, and surgery [...].

SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Thermal ablation.

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with thermal ablation, which may constitute an alternative to thyroid surgery in selected patients.

SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Surgical treatment.

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French-speaking Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with the surgical management of thyroid nodules.

Weight Gain and Asthenia Following Thyroidectomy: Current Knowledge from Literature Review.

BACKGROUND: Thyroidectomy is a common procedure all over the world. Its complication rate is low, but some patients complain of weight gain and/or asthenia. The aim of this review is to investigate the correlation between thyroidectomy and weight change and asthenia. MATERIALS AND METHODS: Seven papers concerning weight gain and four concerning asthenia were found. RESULTS: Weight gain would seem to be more related to the change in habits after surgery. Asthenia seems to be more linked to endocrine mechanisms not yet clarified although a deficiency of triiodothyronine and its metabolites could explain some of its aspects. CONCLUSION: Patients who are candidates for thyroidectomy should be adequately informed of the onset of both possible implications of the surgical act in terms of weight gain and chronic asthenia.

Diagnostic Rechallenge with 18F-FCH PET/CT Often Allows Minimally Invasive Parathyroidectomy While Maintaining Exceptional Cure Rates.

BACKGROUND: Minimally invasive parathyroidectomy (MIP) has gained acceptance as the preferred surgical procedure for management of primary hyperparathyroidism (pHPT). Appropriate selection of patients for a MIP is a crucial step in its utilization. The aim of the study was to evaluate the role of 18F-FCH PET/CT as second-line imaging for accurately directing MIP. METHODS: This is a retrospective single-center study. Seventy-two patients with biochemical evidence of pHPT and a non-conclusive or negative first-line imaging (ultrasound and dual isotope subtraction scintigraphy) received 18F-FCH PET/CT between January 2018 and February 2020. All imaging studies were performed at our institution. Assessment of therapeutic changes and outcomes was performed. RESULTS: of the 72 patients imaged with 18F-FCH PET/CT, 54 subsequently underwent parathyroidectomy. When considering the ability of 18F-FCH PET/CT alone to predict a uniglandular disease, the sensitivity, specificity, PPV and NPV were 92.7% (95%CI: 80.1-98.5), 46.2% (19.2-74.9), PPV 87.3% (80.5-92) and NPV 61.2% (31.4-84.5), respectively. When we combined the data provided by 18F-FCH PET/CT with the data already collected from 1st line imaging we were able to complete a minimally invasive surgery in 38 of the 41 (92%) patients with a uniglandular disease. Thirteen patients (24%) had a multiglandular disease, all of them except one underwent bilateral neck exploration based on the data collected by all imaging modalities combined. Overall, cure was achieved in 53 (98%) patients. CONCLUSION: 18F-FCH PET/CT, interpreted along with first-line imaging results in selected patients, can better facilitate utilization of MIS while maintaining exceptional cure rates.

Predicting risk factors of postoperative hypocalcemia after total thyroidectomy: is safe discharge without supplementation possible? A large cohort study.

PURPOSE: With increasing economic pressures to shorten the length of hospital stay, there has been much recent interest in studying risk factors for the development of postoperative hypocalcemia after total thyroidectomy. The aim of this study was to investigate whether serum calcium and/or PTH levels can predict post-thyroidectomy hypoparathyroidism. METHODS: From January to December 2014, 477 consecutive patients undergoing total thyroidectomy were included. Corrected calcemia and PTH were systematically performed on postoperative day 1/(POD1). Symptomatic patients were treated on POD1 or POD2 with calcium and vitamin D. RESULTS: Sixty-eight patients (14.25%) were treated for postoperative hypocalcemia. No patients with calcemia ≥ 2.16 mmol/l and PTH ≥ 1.9 pmol/l were supplemented and therefore were safely discharged on POD1 (specificity = 100%). All patients with calcemia ≤ 1.89 mmol/l were treated regardless the PTH values (n = 10) (specificity = 100%). For calcium value between 1.9 and 2.16 mmol/l with a PTH > 4.7 pmol/l, nobody was treated. With a calcemia between 1.9 and 2.16 mmol/l and a PTH > 1.9 pmol/l, 44 patients did not develop any symptom. ROC curve analysis showed that combination of Cac = 2.16 mmol/l and iPTH = 4.7 pmol/l provided a sensitivity of 97.06% and a specificity of 76.53% (p < 0.0001). We therefore propose an algorithm that would allow to 70% of patients could have been discharged on POD1 without risk of hypocalcemia or overtreatment. CONCLUSION: Combination of corrected calcemia and PTH on POD1 can efficiently predict hypocalcemia and be integrated into clinical practice for personalizing lengths of hospitalization and appropriate treatment. TRIAL REGISTRATION: ClinicalTrials.gov PRS. Unique Identifying number or registration ID: NCT04372225.

Pheochromocytoma surgery without systematic preoperative pharmacological preparation: insights from a referral tertiary center experience.

BACKGROUND: Despite significant advances in imaging and genetics, as well as surgical and anesthetic innovations, morbidity in pheochromocytoma surgery remains significant. The aim of this study was to identify the predictive factors of global and cardiovascular morbidity following unilateral laparoscopic adrenalectomy for pheochromocytoma. METHODS: We conducted a retrospective study from a unicentric cohort. All patients who underwent non-converted laparoscopic unilateral adrenalectomy for pheochromocytoma between 2000 and 2017 were included. Our patients did not systematically benefit from preoperative pharmacological preparation. It is to be noted that they never received alpha-blockers. Preoperative, intraoperative, and postoperative data during follow-ups were collected. Univariate and multivariate analyses by logistic regression were performed. RESULTS: A total of 134 patients were included. Fifty-three percent of patients did not receive preoperative pharmacological preparation (PPP) and 33% neither preoperative antihypertensives nor PPP before surgery. There was no postoperative mortality. The global morbidity was 13.4%, while cardiovascular morbidity was 4.5%. The main factors associated with global morbidity were preoperative diuretics, a medical history of stroke, and the need for pressor amines postoperatively. The main factor associated with cardiovascular morbidity was the need for pressor amines postoperatively. Predictive factors of postoperative need for pressor amines for hypotension were the tumor size, preoperative beta-blockers, and/or diuretics. CONCLUSION: In this large cohort of patients, our data revealed no mortality and low global and cardiovascular morbidity rates, showing that pheochromocytoma surgery without systematic PPP and even without preoperative antihypertensives is feasible and safe for selected patients. Our data also highlight the need for a good preoperative evaluation of the patient and the tumor, in order to optimize treatments and to help the detection of high-risk patients. This also allows us to better prevent and anticipate their possible complications.

Skip metastases to lateral cervical lymph nodes in differentiated thyroid cancer: a systematic review.

Papillary thyroid carcinoma is a slow-growing cancer with a generally good prognosis that sometimes have an aggressive behaviour. Metastases to neck lymph nodes is the first step of the diffusion. The central neck compartment is involved most commonly. The ipsilateral lateral neck compartments are usually involved afterwards, and the involvement of the contralateral one is considered a quite rare occurrence. In more rare cases, metastases to lateral neck compartment without central lymph node metastasis (so called "skip metastases") could be observed. Aim of this literature review study is to analyse the average incidence, pattern and risk factors of this occurrence.This study was performed according to PRISMA criteria. A final selection of 13 articles published in English language from 1997 to 2017 was performed. Any research article, review or meta-analysis was taken into consideration. Research was expanded considering the related references of articles.The incidence of skip metastases ranged from 1.6 to 21.8%. Risk factors such as age > 45 years, size < 5 mm and tumor located in the upper pole or isthmus of thyroid gland were found.Due to the frequency of skip metastases in thyroid cancer, a careful preoperative examination of lateral lymph nodes should be necessary.

LARGE ADRENAL INCIDENTALOMAS REQUIRE A DEDICATED DIAGNOSTIC PROCEDURE.

Objective: The management of large nonsecreting adrenal tumors (at least 4 cm) is still a matter of debate as it is unclear whether imaging, especially 18F-fluorodeoxyglucose (FDG), can be used to characterize their potential malignancy. Moreover, the risk of new hypersecretion in nonoperated tumors is uncertain. Our aim was to better characterize these large adrenal incidentalomas. Methods: Patients followed in our center for a nonsecreting large (at least 4 cm) adrenal incidentaloma, with an initial computed tomography (CT) and 18F-FDG positron emission tomography (PET) CT, were retrospectively included. Patients who were not operated after initial diagnosis had to be followed with clinical, biological, and imaging evaluations for at least 3 years or until delayed surgery. Results: Eighty-one patients were included in the study: 44 patients (54.3%) had initial surgery while 37 were followed, including 21 (25.9%) who were operated after a mean of 19 months. Among the 65 operated patients, 13 (20%) had a malignant lesion (3 with metastasis, and 10 with adrenocortical carcinoma). Unenhanced CT <10 showed 85.6% sensitivity and 78.8% specificity; all had a 18F-FDG uptake ratio >1.5. Among the 24 patients who were followed for at least 3 years, 5 (20.8%) finally presented hypercortisolism (4 subclinical). Conclusion: As expected, large adrenal tumors are at a higher risk of malignancy. The combination of unenhanced CT <10 and 18F-FDG PET ratio <1.5 prove to be reassuring and might lead to a close follow-up rather than immediate surgery. Hormonal follow-up should be focused on the risk of hypercortisolism. Abbreviations: CI = confidence interval; CT = Computed Tomography; ENSAT = European Network for the Study of Adrenal Tumors; ESE = European Society of Endocrinology; FDG = fluorodeoxyglucose; HU = Hounsfield units; PET = positron emission tomography; ROI = regions of interest; SUV = standard uptake value.

Value of 123I/99mTc-sestamibi parathyroid scintigraphy with subtraction SPECT/CT in primary hyperparathyroidism for directing minimally invasive parathyroidectomy.

BACKGROUND: Primary hyperparathyroidism/(PHPT) is one of the most common endocrinological conditions. Surgery remains the only curative option. We have evaluated the performance of double isotope 123I/99mTc-sestamibi parathyroid scintigraphy/(PS) with subtraction SPECT/CT in PHP for identifying uniglandular disease. METHODS: Ninety PHPT patients undergoing parathyroidectomy (December 2015-August 2016) were included. All patients were evaluated with neck ultrasound/(US), PS and SPECT/CT with a new protocol. Outcomes from imaging modalities were reported as: uniglandular disease/(UGD), multiglandular disease/(MGD), or negative, and were compared to post-operative diagnoses. RESULTS: Post-operatively, 72 and 18 patients had true UGD and MGD, respectively. Sensitivities and specificities of US, pinhole scintigraphy with subtraction, pinhole and SPECT/CT with subtraction, and all modalities combined were 91.7%/38.9%, 88.9%/72.2%, 93%/66.7% and 84.72%/77.78%, respectively: specificity of US + PS superior to US alone, p = 0.074. SPECT/CT enables reclassification of doubtful uptake foci. CONCLUSIONS: Combination of neck US and PS with subtraction SPECT/CT offers a higher specificity for guiding towards minimally invasive parathyroidectomy.

Characterization of adrenocortical tumors by 18F-FDG PET/CT: Does steroid hormone hypersecretion status modify the uptake pattern?

BACKGROUND: adrenal tumor-to-liver uptake value (Tmx:Lmx) on 18F-FDG PET/CT is an accurate and reproducible PET parameter in the distinction between benign and malignant adrenal masses. The potential impact of steroid hormone secretion on 18F-FDG uptake is still debatable. The aim of this study was to evaluate this relationship. METHODS: 2010-2015: 73 patients who underwent adrenalectomy for adrenocortical tumors [49 secreting/(SA) and 24 non-secreting/(NSA)] were retrospectively included in the study. Fourteen were malignant. All patients underwent hormonal evaluation, functional and anatomical imaging, Weiss scoring and Ki 67 evaluation. RESULTS: malignant tumors exhibit higher SUVmax than benign tumors (median 7.75 vs 3.06 respectively, p < 0.001) and Tmx:Lmx was 2.7 vs 1.17 for benign tumors, p < 0.001. Tmx:Lmx was positively correlated to Weiss score (p < 0.001). No significant difference was observed for Tmx:Lmx between SA and NSA overall (p = 0.851), regardless of the subgroup of tumors analyzed. Tmx:Lmx was not correlated to tumor size (p < 0.508) or 24 h free urinary cortisol level (p < 0.522). CONCLUSIONS: no correlation was observed between Tmx:Lmx and hormonal status, however the correlation between ratio, malignancy and Weiss score confirm the utility of 18F-FDG PET/CT for the differentiation of benign from malignant adrenal lesions, irrespective of the hormone secretory status of the tumor. 18F-FDG PET/CT is a useful biomarker in the diagnosis of adrenal tumors, regardless of the secretion status.

Swallowing disorders after thyroidectomy: What we know and where we are. A systematic review.

INTRODUCTION: Dysphagia and hoarseness are possible complications that can be observed in patients undergoing thyroidectomy or other neck surgery procedures. These complaints are usually related to superior and inferior laryngeal nerves dysfunction, but these can appear even after uncomplicated surgical procedure. METHODS: We reviewed the current literature available on MEDLINE database, concerning the swallowing disorders appearing after the thyroidectomy. The articles included in the review reported pathophysiology and diagnostic concerns. RESULTS: Twenty articles were selected for inclusion in the review. Depends on the possible causes of the difficulty swallowing (related to nerve damage or appearing after uncomplicated thyroidectomy), different types of diagnostic procedures could be used to study patient discomfort, as well as intraoperative nerve monitoring, fiber optic laryngoscopy, endoscopy, pH monitoring, esophageal manometry and videofluorography. Among all these procedures, videofluorography is considered the gold standard to evaluate the entire swallowing process, since that allows a real-time study of all the three phases of swallowing: oral phase, pharyngeal phase and esophageal phase. CONCLUSION: The diagnostic procedures described can help to identify the mechanisms involved in swallowing disorders, with the aim to choose the best therapeutic option. More studies are needed for understanding the causes of the dysphagia appearing after thyroidectomy.

Persistent and recurrent hyperparathyroidism.

Despite remarkable progress in imaging modalities and surgical management, persistence or recurrence of primary hyperparathyroidism (PHPT) still occurs in 2.5-5% of cases of PHPT. The aim of this review is to expose the management of persistent and recurrent hyperparathyroidism. A literature search was performed on MEDLINE using the search terms "recurrent" or "persistent" and "hyperparathyroidism" within the past 10 years. We also searched the reference lists of articles identified by this search strategy and selected those we judged relevant. Before considering reoperation, the surgeon must confirm the diagnosis of PHPT. Then, the patient must be evaluated with new imaging modalities. A single adenoma is found in 68% of cases, multiglandular disease in 28%, and parathyroid carcinoma in 3%. Others causes (<1%) include parathyromatosis and graft recurrence. The surgeon must balance the benefits against the risks of a reoperation (permanent hypocalcemia and recurrent laryngeal nerve palsy). If surgery is necessary, a focused approach can be considered in cases of significant imaging foci, but in the case of multiglandular disease, a bilateral neck exploration could be necessary. Patients with multiple endocrine neoplasia syndromes are at high risk of recurrence and should be managed regarding their hereditary pathology. The cure rate of persistent-PHPT or recurrent-PHPT in expert centers is estimated from 93 to 97%. After confirming the diagnosis of PHPT, patients with persistent-PHPT and recurrent-PHPT should be managed in an expert center with all dedicated competencies.