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OBJECTIVE: The aim of this study was to determine the success of limited neck exploration (LE) for primary hyperparathyroidism (PHP).
METHODS: Between 1999 and 2007, 1407 patients with hyperparathyroidism (HPT) underwent bilateral neck exploration (BE). Of these, 1055 patients with first-time sporadic PHP were analyzed prospectively. Based on surgeon-performed ultrasound (US) and sestamibi scan (MIBI), LE was initially performed. Regardless of results, bilateral exploration (BE) followed to identify the presence of additional parathyroid pathology.
RESULTS: Of 1055 patients, 139 (13%) were found to require concomitant thyroid surgery thus excluding LE. Of the remaining 916 patients, single gland abnormality on MIBI occurred in 682 (74%), US in 731 (80%), and concordance of both in 588 (64%). Unsuspected multigland disease (MGD) was identified at BE in 22%, 22% and 20% of patients, respectively. Adding IOPTH further reduced the incidence of unsuspected MGD to 16%, 17% and 16%. Overall, IOPTH correctly predicted MGD in only 22%. Neither concomitant non-surgical thyroid disease nor more stringent selection criteria (Ca>11mg/dl and PTH>120pg/dl) altered success rates. In patients with MGD, a subsequent gland identified was larger than the index gland in 23%. 98% of BE patients were cured of HPT.
CONCLUSIONS: This is the largest study to evaluate the incidence of additional parathyroid pathology in patients who are candidates for LE. Limitations in localizing studies and IOPTH fail to identify MGD in at least 16% of patients, risking future recurrence.

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