Outcomes analysis of intraoperative adjuncts during minimally invasive parathyroidectomy for primary hyperparathyroidism

BackgroundThe aim of this study was to determine whether minimally invasive radioguided parathyroidectomy (MIRP) and intraoperative parathyroid hormone–guided parathyroidectomy (ioPTH) have equivalent intermediate-term outcomes in primary hyperparathyroidism (PHPT).MethodsA retrospective study of 244 patients who underwent parathyroidectomy for PHPT in a 25-month time period was conducted. Patients who either underwent MIRP- or ioPTH-guided parathyroidectomies were included. The primary outcome was persistent disease. Conversion to bilateral exploration, complications, and multigland disease (MGD) were secondary outcomes.ResultsThere was 1 MIRP patient and no ioPTH patients who had persistent disease. The ioPTH group had more conversions to a bilateral exploration (bilateral neck exploration [BNE]) (3.7% vs 13%, P = .024). In the MIRP group, no patients were found to have MGD. In the ioPTH group, 7 patients with double adenomas and 6 patients with MGD were found (0 vs 13, P = .0028).ConclusionsioPTH facilitates successful minimally invasive parathyroidectomy (MIP) when compared with MIRP and provides cure rates similar to BNE.     

Targeted Parathyroidectomy in the Era of Intraoperative Parathormone Monitoring

A combination of preoperative localization and intraoperative parathormone (PTH) monitoring permits targeted parathyroidectomy. Multiple approaches have been developed, ranging from unilateral neck exploration (UE) to radio-guided parathyroidectomy (RP) to endoscopic parathyroidectomy (EP). The purpose of this study was to evaluate the efficacy of these approaches in the management of primary hyperparathyroidism. From June 1998 to November 2000 a total of 110 targeted parathyroid operations were performed at a university medical center. All patients underwent technetium-99m-sestamibi scanning, ultrasonography, or both prior to surgery. Intraoperative PTH monitoring was utilized in all cases. Thirty-seven patients underwent UE, 59 underwent RP, and 14 underwent EP. Follow-up ranged from 1 to 24 months. All patients were cured following parathyroidectomy as predicted by a more than 50% reduction of the intraoperative PTH level following removal of all hypersecreting glands. Altogether, 103 patients had a solitary adenoma (95%), and 1 patient had a parathyroid carcinoma. Six patients (5%) had multigland disease, including four cases of hyperplasia and two patients with a double adenoma. Eighty-three patients (75%) were discharged the day of surgery. The use of preoperative localization and intraoperative PTH monitoring permits a targeted approach to the treatment of primary hyperparathyroidism. Endocrine surgeons should be facile in all minimally invasive parathyroid techniques to individualize the operative approach.     

Directed parathyroidectomy: feasibility and performance in 100 consecutive patients with primary hyperparathyroidism

HYPOTHESIS: Directed parathyroidectomy (DP) can be successfully completed in most patients with primary hyperparathyroidism. DESIGN AND SETTING: Retrospective review at a tertiary referral center. PATIENTS: One hundred consecutive patients with untreated, sporadic primary hyperparathyroidism operated on by a single surgeon from April 1, 1999, through December 31, 2001. INTERVENTIONS: Following preoperative imaging with sestamibi scintigraphy and ultrasonography, patients underwent parathyroidectomy with intraoperative parathyroid hormone monitoring using a focused approach through a limited neck incision (DP) or bilateral neck exploration (BNE) through a standard collar incision. MAIN OUTCOME MEASURES: Extent of exploration, operative time, length of stay, morbidity, and cure. RESULTS: Directed parathyroidectomy was completed in 70 patients and BNE in 30. Bilateral neck exploration was performed as the initial procedure in 13 patients and following intraoperative conversion from attempted DP in 17. Indications for predetermined BNE were failed preoperative localization (n = 8) and concomitant thyroid disease that required operative treatment (n = 5). The need for predetermined BNE decreased as preoperative localization improved. Intraoperative factors that necessitated conversion to BNE included persistently elevated intraoperative parathyroid hormone levels that accurately predicted multiglandular disease (n = 6), incorrect localization (n = 5), and inadequate exposure (n = 6). Operative time and length of stay were less for DP compared with BNE patients (66 vs 165 minutes and 0.5 vs 1.6 days, respectively). One patient had a temporary vocal cord paresis. All patients were eucalcemic in follow-up (4 months to 3 years). CONCLUSIONS: With accurate preoperative localization and intraoperative parathyroid hormone monitoring, DP can be successfully completed in most patients with sporadic primary hyperparathyroidism. Patients benefit from DP, which reduces operative time and length of stay and facilitates rapid convalescence.     

Minimally invasive parathyroidectomy without intraoperative parathyroid hormone monitoring in patients with primary hyperparathyroidism

BACKGROUND: Minimally invasive parathyroidectomy (MIP) is the preferred operation for patients with primary hyperparathyroidism (HPT) and positive preoperative imaging. This non-randomized case series assessed the long-term results of MIP performed without the use of intraoperative parathyroid hormone (ioPTH) monitoring. METHODS: The study involved prospective collection of demographic, biochemical and operative details on a consecutive, unselected cohort of 298 patients who underwent surgery for non-familial primary HPT during a 5-year interval. The mean preoperative serum calcium level was 3.00 mmol/l with a mean parathyroid hormone concentration of 25.8 pmol/l. (99m)Tc-labelled sestamibi scanning and neck ultrasonography were performed in 262 patients. RESULTS: Sestamibi scan showed unilateral uptake in 182 patients and a single parathyroid adenoma was confirmed on ultrasonography in 161 patients. MIP was performed in 150 patients. The mean duration of operation was 25 (range 8-65) min. Four patients needed conversion to conventional neck exploration. There was one postoperative haematoma and three cases of temporary recurrent laryngeal nerve neuropraxia. All but four patients were normocalcaemic after MIP. All the parathyroid tumours removed were adenomas, with a mean weight of 1.3 (range 0.1-17.4) g. No patient developed recurrent HPT after a median follow-up of 16 (range 3-48) months. CONCLUSION: The outcome of MIP without ioPTH monitoring was comparable to that reported in series that used ioPTH monitoring.     

Unilateral versus bilateral neck exploration for primary hyperparathyroidism: a prospective randomized controlled trial

OBJECTIVE: To compare unilateral and bilateral neck exploration for primary hyperparathyroidism in a prospective randomized controlled trial. SUMMARY BACKGROUND DATA: Based on the assumption that unilateral neck exploration for a solitary parathyroid adenoma should reduce operating time and morbidity, a variety of minimally invasive procedures have challenged the idea that bilateral neck exploration is the gold standard for the surgical treatment of primary hyperparathyroidism. However, to date, no open prospective randomized trial has been published comparing unilateral and bilateral neck exploration. METHODS: Ninety-one patients with the preoperative diagnosis of primary hyperparathyroidism were randomized to unilateral or bilateral neck exploration. Preoperative scintigraphy and intraoperative parathyroid hormone measurement guided the unilateral exploration. Gross morphology and frozen section determined the extent of parathyroid tissue resection in the bilateral group. The primary end-point was the use of postoperative medication for hypocalcemic symptoms. RESULTS: Eighty-eight patients (97%) were cured. Histology and cure rate did not differ between the two groups. Patients in the bilateral group consumed more oral calcium, had lower serum calcium values on postoperative days 1 to 4, and had a higher incidence of early severe symptomatic hypocalcemia compared with patients in the unilateral group. In addition, for patients undergoing surgery for a solitary parathyroid adenoma, unilateral exploration was associated with a shorter operative time. The cost for the two procedures did not differ. CONCLUSIONS: Patients undergoing a unilateral procedure had a lower incidence of biochemical and severe symptomatic hypocalcemia in the early postoperative period compared with patients undergoing bilateral exploration. Unilateral neck exploration with intraoperative parathyroid hormone assessment is a valid surgical strategy in patients with primary hyperparathyroidism with distinct advantages, especially for patients with solitary parathyroid adenoma.     

Unilateral neck exploration for primary hyperparathyroidism

The operative approach to primary hyperparathyroidism due to a single adenoma remains controversial. We evaluated our experience with 75 patients presenting with primary hyperparathyroidism between January 1979 and September 1988. Prior to 1985 all patients underwent bilateral exploration. During this period, ultrasonographic localization in 6 patients proved highly accurate. Subsequently, routine preoperative ultrasonographic localization was used and patients were prospectively evaluated for the following: (1) incidence of unilateral exploration, (2) accuracy of ultrasonographic localization, (3) incidence of complications, and (4) operative time. Localization permitted unilateral exploration in 19 of 36 patients, although its accuracy depended on the interest of the radiologist involved. Institution A had an accuracy of 92%, while institution B had an accuracy of only 43%. There were fewer complications with unilateral exploration, and operative time was significantly less. Unilateral exploration based on preoperative ultrasonographic localization is recommended as the initial approach to primary hyperparathyroidism due to a single adenoma.     

Initial neck exploration for untreated hyperparathyroidism

This study represents the experience of the Department of Surgery at the University of Louisville over a 21-year interval. Many aspects of surgical management of hyperparathyroidism have changed over the last 2 decades; controversies regarding the extent of exploration and the value of preoperative localization studies remain unresolved. One hundred ninety-three patients underwent neck exploration for hyperparathyroidism from 1976 to 1997. Data were collected from four University of Louisville-affiliated hospitals by independent evaluators. One hundred sixty patients with untreated hyperparathyroidism underwent neck exploration. Preoperative localization was carried out in 52 per cent (83 of 160). The exact location of the abnormal gland was indicated in 55 per cent (46 of 83), and the correct side of the neck was identified in 74 per cent (61 of 83). Technetium sestamibi scan was most reliable and identified the abnormality in 83 per cent (24 of 29). The average operative time with preoperative localization was 118 minutes compared with 137 minutes without preoperative localization. Intraoperative methylene blue was used in 42 of 160 neck explorations. Average operative time with methylene blue was 102 minutes compared with 124 minutes without methylene blue. Thirty-seven per cent (59 of 160) of patients underwent unilateral neck exploration. Sixty-three per cent (101 of 160) underwent bilateral exploration. Successful exploration was conducted in 98 per cent of the unilateral group and 91 per cent of the bilateral group. Postoperative local complications were essentially the same in both groups (3%), whereas temporary hypocalcemia occurred in 24 per cent (24 of 101) of the bilateral group compared with 3 per cent (2 of 59) of the unilateral group. We conclude that neck exploration for hyperparathyroidism is a highly successful, safe treatment with no mortality and minimal morbidity. Preoperative localization studies modestly reduced the duration of surgery without improving outcome.     

The utility of intraoperative bilateral internal jugular venous sampling with rapid parathyroid hormone testing

OBJECTIVE: To determine the utility of routine perioperative bilateral internal jugular venous sampling of parathyroid hormone (BIJ PTH) for localization during parathyroid surgery. SUMMARY BACKGROUND DATA: Venous sampling for PTH is a useful tool for parathyroid localization in patients undergoing reoperative surgery for hyperparathyroidism (HPT). With the development of intraoperative rapid PTH (ioPTH) testing, internal jugular PTH sampling with ioPTH testing to guide operative localization has been shown to be possible in select, difficult cases. However, the value of BIJ PTH for patients with HPT is unclear. METHODS: Between May 2004 and February 2006, 216 consecutive patients underwent neck exploration for HPT by one surgeon. Of these, 168 patients had BIJ PTH. Internal jugular venous blood was drawn from both left and right sides and analyzed for PTH using a rapid PTH assay. BIJ PTH levels were defined as lateralizing if >5% differences were observed between the right and left internal jugular vein samples. RESULTS: Of the 168 patients, 120 (71.4%) had a single parathyroid adenoma, 15 (8.9%) had double adenoma, and 33 (19.6%) had hyperplasia. The cure rate after parathyroidectomy was 98.2%. There were no complications related to BIJ PTH sampling. Sensitivity and positive predictive value of BIJ PTH for primary hyperparathyroidism were 80% and 71%, respectively. BIJ PTH was diagnostic in 95 cases (62.9%) in primary HPT. BIJ PTH successfully localized an abnormal gland in 26 of 45 (57.8%) in patients with negative sestamibi scanning. BIJ PTH was especially helpful in 18 of 168 (10.7%) cases when intraoperative peripheral parathyroid hormone did not fall by 50% and BIJ PTH successfully localized the hyperfunctioning glands. CONCLUSIONS: In patients with HPT, BIJ PTH is safe and effective, providing additional localization information in the majority of cases. BIJ PTH is particularly useful in the setting of negative sestamibi scanning and in complex multigland disease cases.     

Unilateral neck exploration for primary hyperparathyroidism

Focused unilateral cervical exploration is a controversial alternative to conventional bilateral neck exploration for primary hyperparathyroidism (HPT) due to solitary adenoma. Development of preoperative localization techniques, notably isotope scintigraphy and small-part, real-time ultrasonography, has increased preoperative parathyroid tumor identification. Critics of scan directed unilateral neck exploration argue it may overlook enlarged parathyroid glands on the unexplored side, increasing the incidence of persistent and recurrent hypercalcemia. Our experience of this operation and prolonged follow-up of patients, however, confirm that it does not increase risk of persistent or recurrent HPT if a strict selection protocol is observed. This ensures the confident further development of minimally invasive surgical procedures for HPT based on the principle of a focused exploration following preoperative localization of the parathyroid adenoma.     

Minimally invasive video-assisted parathyroidectomy is a safe procedure to treat primary hyperparathyroidism

IntroductionCervical exploration to identify the four parathyroid glands was considered to be the gold standard for management of primary hyperparathyroidism. In recent years, advances in preoperative localizing techniques have led to the use of more targeted, minimally invasive procedures to remove parathyroid glands. We present our series of patients who underwent Minimally Invasive Video-Assisted Parathyroidectomy (MIVAP) procedures and our results in treating primary hyperparathyroidism.MethodsPatients who underwent video-assisted parathyroidectomy were identified from a prospectively maintained database. Clinico-pathological data including indications for surgery, complications, conversion to open procedure and success of surgery were obtained from clinical notes.ResultsA total of 56 patients underwent MIVAP between 2002 and 2010 at a district general hospital setup. The clinical indication was diagnosed primary hyperparathyroidism. Preoperative localization was attempted in all patients by sestamibi and high resolution ultrasound scans. The median age of patients was 65 years (32–82) and the median operating time was 78 min (20–168). Conversion to open procedure was done in 8/56 (14%) cases. The reason for conversion was failed exploration in 5 patients, inability to retrieve a very large friable adenoma in one patient, lipo-adenoma in one patient and very small parathyroid adenoma in one patient. Postoperative complications happened in one patient (2%) who developed postoperative sepsis resulting in temporary recurrent laryngeal nerve (RLN) palsy. All but 5 patients became normo-calcaemic following surgery.ConclusionMIVAP is a safe and effective procedure for treating patients with primary hyperparathyroidism. It also allows classical 4 gland exploration, whenever necessary.     

New operative strategies in primary hyperparathyroidism

More than 95% of patients with primary hyperparathyroidism have been treated with bilateral neck exploration by experienced surgeons. This procedure has been performed without employing preoperative localization tests or specialized techniques of intraoperative measurement. A renewed interest in unilateral neck exploration for primary hyperparathyroidism emerged (in three developments), in an attempt to maintain the excellent cure rate and to minimize the invasiveness of the procedure. The first development was the introduction of sestamibi scintigrams as a new preoperative localization technique and intraoperative nuclear mapping with a hand-held gamma probe. The localization of adenomas using this technique was much more accurate than that of previous localization studies, allowing unilateral procedures to become feasible. Sestamibi guidance enables parathyroidectomies to be performed much more rapidly through a significantly less invasive dissection. Secondly, the intraoperative quick parathyroid hormone assay allows the confirmation of removal of the parathyroid mass. The third development was endoscopic parathyroidectomy. Various approaches have been shown to be technically feasible, including endoscopic procedures that rely on CO2 insufflation to create a working space or video-assisted procedures in which the working space is maintained through conventional external retraction. Given the safety and high success rate of the standard exploration, the potential advantages of these new strategies include decreased operating time, local or regional anaesthesia rather then general anaesthesia, and smaller incisions.     

Sestamibi Scan–directed Parathyroid Surgery: Potentially High Failure Rate without Measurement of Intraoperative Parathyroid Hormone

The present study evaluated sestamibi scan–directed parathyroidectomy with intraoperative parathyroid hormone (PTH) assessment (ioPTH). The preoperative sestamibi scintigraphies were compared with the intraoperative findings for 103 patients undergoing first exploration for sporadic primary hyperparathyroidism (pHPT). Data were collected prospectively. Ninety-nine patients (96%) were cured. Patients with persistent pHPT (n = 4) all had an incorrect scintigram as well as an insufficient decline of ioPTH. At operation, 90 patients (87%) had solitary parathyroid adenoma; 12 patients had multiglandular disease. In one patient no enlarged parathyroid gland was found. Overall 77 of 118 abnormal glands (65%) were correctly identified by sestamibi scintigraphy. The sensitivity for localizing a single parathyroid adenoma was 80%. Patients with incorrect scintigrams had a higher proportion of upper pole adenomas than patients with correct scans. High glandular weight and high level of serum PTH were important factors for detectability. Sestamibi scintigraphy did not predict multiglandular disease. However, the use of ioPTH identified 8 of the 9 patients with a positive scan (a solitary focus) and multiglandular disease. In contrast, false-negative ioPTH led to four unnecessary bilateral explorations in the 63 patients with a scan-identified adenoma. With the help of ioPTH, a focused parathyroidectomy was accomplished in 43% of scan-negative patients with a solitary adenoma. In conclusion, sestamibi scintigraphy is an acceptable method for localizing a solitary parathyroid adenoma. However, the technique alone does not reliably predict multiglandular disease. Potentially the failure rate in scan-directed parathyroidectomy could increase, with up to 10% of patients without ioPTH.This article was presented at the International Association of Endocrine Surgeons meeting, Uppsala, Sweden, June 14-17, 2004.     

Limited versus radical parathyroidectomy in familial isolated primary hyperparathyroidism

BACKGROUND: Familial isolated primary hyperparathyroidism (FIHPT) is characterized by earlier onset, higher incidence of multiglandular disease, and higher recurrence rate when compared with sporadic primary hyperparathyroidism. Excision of 3.5 or 4 glands with autotransplantation has been recommended; however, these approaches lead to permanent hypoparathyroidism in 13% to 41% of patients. It is reported that many patients with FIHPT return to normocalcemia after single-gland excision. The use of preoperative localization and intraoperative parathyroid hormone assay permits limited resection of only hypersecreting glands. We report the outcome of this operative approach. METHODS: Fifteen consecutive patients with FIHPT underwent limited parathyroidectomy with resection guided by intact parathyroid hormone secretion in 2 university centers. Patients were followed up postoperatively for serum calcium and intact parathyroid hormone levels. RESULTS: With an operative success of 93%, 14 patients had only single-gland excision and 80% had unilateral neck exploration. All initial patients had their hypercalcemia corrected. In 4 reoperations, permanent hypoparathyroidism occurred in 2 patients. One recurrence was observed in 40 (8-122) months of follow-up. CONCLUSION: Limited parathyroidectomy allows successful single-gland excision in many patients with FIHPT, thus decreasing the risk of hypoparathyroidism. In these patients, a low incidence of hypoparathyroidism may be preferable to the possibility of late recurrence.     

Value of Intraoperative Parathyroid Hormone Monitoring

Background Routine use of intraoperative parathyroid hormone (IOPTH) has been challenged in both unilateral/limited (LE) and bilateral exploration (BE). To investigate this, we assessed the usefulness of IOPTH in surgical management of primary hyperparathyroidism and parathyroid carcinoma (PC). Methods Between 1998 and 2006, 1133 patients were explored for hyperparathyroidism: 185 LE, 743 BE with IOPTH, 95 BE without IOPTH, 110 reoperations, and 4 PCs. IOPTH patterns were correlated with parathyroid pathology (single adenoma [SA] or multigland disease [MGD]) and operative success. Results In LE, IOPTH returned to normal in 78% of patients; all patients had SA, and 99% were cured at a mean ± SEM of 1.2 ± .24 years; 22% of LE patients (n = 41) whose IOPTH did not return to normal were converted to BE, and all had MGD. BE with and without IOPTH was equally successful 97% and 98% (P = NS) of the time, respectively. In BE in which IOPTH did not return to normal, 9% of patients remained hypercalcemic; tumor distribution mirrored other BE patients (75% SA, 25% MGD). In reoperations, a normal final IOPTH correlated with cure in 99%; otherwise, 59% had persistent disease. Differential bilateral internal jugular vein IOPTH sampling lateralized disease in 77% of reoperations. Conclusions IOPTH is an important adjunct for successful LE by identifying the presence of MGD and avoiding operative failure. IOPTH adds little to BE; however, final IOPTH values may predict persistent disease in BE, reoperations, and PCs.     

Selective unilateral parathyroid exploration: an effective treatment for primary hyperparathyroidism

Background

Unilateral neck exploration (UNE) is a well-recognized approach in the treatment of primary hyperparathyroidism (PHP). The objective of this study was to review the success of an approach involving UNE guided by preoperative sestamibi (SM) scanning.

Methods

All data were gathered by retrospective chart review. All patients undergoing surgery for the treatment of primary hyperparathyroidism at a tertiary referral center over a 3-year period were included in the study cohort.

Results

Fifty-two of 80 patients (65%) had an SM scan consistent with a solitary adenoma and were eligible for a UNE, with 57.5% (46/80) undergoing a UNE. Seventy-seven of 80 (96.3%) patients were normocalcemic after initial neck exploration. UNE was curative in 50 of 52 (96.2%) UNE eligible patients and required less operative time than bilateral neck exploration (mean, 60 versus 87 minutes).

Conclusion

Selective unilateral neck exploration, guided by preoperative SM scanning, is an effective surgical approach for the management of primary hyperparathyroidism.     

Intraoperative sestamibi scanning in reoperative parathyroidectomy

BACKGROUND: Reoperative neck exploration for hyperparathyroidism is often difficult even for experienced surgeons. Recent advances in preoperative and intraoperative localization techniques have improved successful resection rates. This prospective study evaluates the accuracy and clinical utility of intraoperative technetium 99m sestamibi scanning for localizing hyperfunctioning parathyroid tissue in reoperative neck explorations. PATIENTS AND METHODS: Eleven patients underwent reoperative neck exploration for hyperparathyroidism. Two patients had 3 prior neck explorations, 1 had 2 prior neck explorations, and 8 patients had 1 prior neck operation. Preoperative studies included sestamibi scintigraphy and ultrasound in all patients, magnetic resonance imaging in 4, computed tomography scan in 3, parathyroid arteriogram in 1, and selective venous sampling in 1. All patients underwent intraoperative technetium 99m sestamibi scanning and parathyroid hormone assay. RESULTS: Preoperative technetium 99m sestamibi scanning and ultrasound each successfully localized 7 of 11 hyperfunctioning glands (64%). Intraoperative technetium 99m sestamibi scanning correctly localized 10 of 11 hyperfunctioning glands (91%). Intraoperative parathyroid hormone assay confirmed successful excision of hyperfunctioning tissue in all 11 patients. Postoperatively, all 11 patients had low-normal or normal calcium levels. CONCLUSIONS: Intraoperative technetium 99m sestamibi correctly localized 91% of hyperfunctioning glands compared with 64% localization for preoperative technetium 99m sestamibi and preoperative ultrasound. Intraoperative technetium 99m sestamibi scanning and parathyroid hormone monitoring are useful in reoperative neck explorations for hyperparathyroidism.     

Parathyroidectomy outcomes according to operative approach

Background

Parathyroidectomy for primary sporadic hyperparathyroidism (psHPT) has evolved with advances in preoperative gland localization and intraoperative parathyroid hormone (ioPTH) monitoring to minimally invasive approaches (MIPS).

Methods

Two hundred twenty patients underwent parathyroidectomy for psHPT. Forty-nine patients underwent bilateral neck exploration (BNE) (group 1), 60 patients underwent BNE with ioPTH monitoring (group 2), and 111 patients underwent MIPS with ioPTH monitoring (group 3).

Results

At 3 months postoperatively, mean serum calcium and intact parathyroid hormone (PTH) levels were similar between groups, and eucalcemia rates were 100%, 100%, and 99%. The ultimate rates of persistent disease and recurrence were also similar. Operative time was shorter in group 3 compared to group 2 (P < .001) but not group 1. Frozen sections and patient charges were significantly lower in group 3 compared to groups 1 and 2 (P < .005).

Conclusion

Parathyroidectomy for psHPT is highly successful with these techniques. When a MIPS approach can be done, it is potentially quicker and associated with lower patient charges.     

Bilateral Neck Exploration Decreases Operative Time Compared to Minimally Invasive Parathyroidectomy in Patients with Discordant Imaging

Background

Unilateral parathyroidectomy for primary hyperparathyroidism (PHPT) has a high success rate in patients with concordant imaging by sestamibi and ultrasound. However, the optimal procedure when imaging is discordant remains controversial; therefore we compared unilateral exploration with intraoperative parathyroid hormone (IOPTH) monitoring to bilateral neck exploration without IOPTH monitoring in patients with discordant localization studies.

Methods

We conducted a retrospective study of 324 consecutive patients with PHPT treated at our institution from October 2005 to September 2009. We collected information regarding imaging, localization site, procedure performed, operative time, and calcium/PTH measurements.

Results

Of the 324 patients in the study, 79 (24 %) had discordant imaging by sestamibi and ultrasound. Of these, 62 patients (78 %) underwent bilateral neck exploration without IOPTH monitoring, and 14 patients (18 %) had unilateral exploration with IOPTH monitoring. IOPTH monitoring during unilateral exploration correctly predicted removal of single adenomas in 10/14 patients (71 %) and altered operative management in 4/14 cases (29 %), resulting in conversion to bilateral neck exploration. Operative time for unilateral exploration with IOPTH [median time: 96 min (range: 51–153 min)] was significantly increased relative to bilateral exploration [median time: 52 min (range: 28–149 min)]; p = 0.0027. We identified single-gland disease in 53/76 patients (70 %), double adenomas in 13/76 patients (17 %), and multiglandular hyperplasia in 10/76 patients (13 %). There was no difference in cure rate between these two surgical approaches (p = 1.0)

Conclusions

In contrast with prior studies, we found that operative time for unilateral exploration with IOPTH was significantly increased compared to bilateral neck exploration. In patients with discordant imaging, IOPTH is a useful adjunct in limiting exploration to a single side despite a high false negative rate.     

Outcome of parathyroidectomy for patients with renal disease and hyperparathyroidism: predictors for recurrent hyperparathyroidism

Background: A small group of patients with renal disease‐related secondary or tertiary hyperparathyroidism require surgical parathyroidectomy. Among them, 5–20% require further re‐exploration and excision of parathyroid tissue because of recurrent disease. The aims of the present study were to review the characteristics and outcomes of patients undergoing parathyroidectomy for renal disease related hyperparathyroidism and to identify the risk factors for recurrent hyperparathyroidism. Methods: Review of data from a dedicated head and neck database at Royal Prince Alfred Hospital between 1988 and 2004. Results: There were 115 patients of whom 68 (59%) patients were treated with subtotal parathyroidectomy (STP), 43 (37%) were treated with total parathyroidectomy (TP) and 4 (3%) were treated with TP with autotransplant. Of those, 11 (9.6%) patients developed recurrent hyperparathyroidism (9 had STP, 1 had TP and 1 had TP with autotransplant). On re‐exploration, persistent hyperplastic parathyroid tissue was located at the site of partially excised parathyroid gland (64%), autotransplanted parathyroid tissue (9%), anterior mediastinum (18%) and intrathyroidal parathyroid (9%). Predictors for recurrent hyperparathyroidism are STP (P= 0.049), preoperative symptom of calciphylaxis or calcinosis (P= 0.024), elevated preoperative calcium level (P= 0.007) and elevated post‐operative PTH levels (P= 0.014). Post‐operative PTH levels less than 10 pmol/L has a positive predictive value of 97.5% for cure (P= 0.02). Conclusion: More aggressive surgical approach could be indicated in patients with preoperative hypercalcaemia and calcinosis/calciphylaxis. Post‐operative PTH can be utilized as a marker for cure after parathyroidectomy in hyperparathyroidism of renal disease.     

Preoperative evaluation of patients with parathyroid adenoma: role of high-resolution ultrasonography.

BACKGROUND: Unilateral parathyroid exploration with adenoma removal and identification of a normal parathyroid gland is a controversial surgical approach to the treatment of primary hyperparathyroidism. The aim of this study was to evaluate the ability of high-resolution ultrasonography to localize adenomas preoperatively and to assess the effect of such localization on operative time. METHODS: One hundred twenty consecutive previously non-operated patients with primary hyperparathyroidism underwent ultrasonography before surgery, which consisted of unilateral neck exploration. The procedure was changed to bilateral exploration when justified by the surgical findings. RESULTS: The sensitivity and positive predictive value of the ultrasonographic examinations were 89% and 98%, respectively. These results were obtained regardless of the size of the adenoma. No significant difference was found in the presence of thyroid multinodular disease (p =.2). A positive sonographic examination decreased the operative time to an average of 59 minutes. The average size of the adenomas was 19 mm (range, 4-55 mm). A positive and highly statistically significant correlation was found between adenoma size and both preoperative calcium level (p =.01) and parathyroid hormone level (p =.0001). CONCLUSIONS: In experienced hands, high-resolution ultrasonography can be a cost-effective means of localizing parathyroid adenomas when unilateral neck exploration is considered the acceptable surgical approach.