Bilateral Neck Exploration for Sporadic Primary Hyperparathyroidism: Use Patterns in 5,597 Patients Undergoing Parathyroidectomy in the Collaborative Endocrine Surgery Quality Improvement Program

Background: For many surgeons, focused parathyroidectomy has become the preferred approach for management of sporadic primary hyperparathyroidism (HPT). This study describes use patterns of bilateral neck exploration (BE) by endocrine surgeons participating in the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP). Study Design: Using the CESQIP parathyroid dataset (2014 to 2017), use trends, demographic and clinical characteristics of patients undergoing BE vs focused vs focused converted to BE parathyroidectomy were compared. Preoperative, intraoperative, and postoperative variables were also analyzed. Results: Among 5,597 patients who underwent initial parathyroidectomy for HPT, BE was used in 2,253 (40%), 613 (11%) of which were converted procedures. Patients with BE were older and more likely female. Ultrasound (87%), sestamibi (66%), and CT scans (20%) were commonly used. Glands were highly localized. Intraoperative-parathyroid hormone (ioPTH) was used in >90%. Operative time >2 hours was more likely in BE (16%) and converted (30%) vs focused (3%) procedures. Two or more glands were removed in 57% of BE cases. Outpatient procedures were more common in focused cases; emergency room visits, readmissions, and complications were more likely in BE and converted cases. Concern for failure and lack of ioPTH decrease was significantly more common in BE and converted cases. Conclusions: This is the first analysis of parathyroidectomy use trends by high-volume endocrine surgeons in CESQIP. Bilateral neck exploration is a commonly used approach (40%), and conversion from focused to BE was observed in 11% of cases, despite highly localized glands. Bilateral neck exploration remains a complex and frequently used procedure, and surgeons intending to perform parathyroid surgery should be adequately trained and adept at BE.