Elsevier

Surgery

Volume 144, Issue 2, August 2008, Pages 299-306
Surgery

Outcome
Role of intraoperative parathormone monitoring during parathyroidectomy in patients with discordant localization studies

https://doi.org/10.1016/j.surg.2008.03.039Get rights and content

Background

Many patients with sporadic primary hyperparathyroidism (SPHPT) have discordant preoperative Tc-99m-sestamibi (MIBI) and ultrasonography studies prior to focused parathyroidectomy (PTX). This study examines the usefulness of intraoperative parathormone monitoring (IPM) during PTX in patients with discordant preoperative localization studies.

Methods

A retrospective series of 225 consecutive SPHPT patients with MIBI scans and surgeon performed ultrasonography (SUS) prior to focused parathyroidectomy were studied. All patient operations were reviewed, and how IPM changed operative management was determined. Correct gland localization, presence of multigland disease (MGD), and operative outcome were also examined.

Results

In 225 patients, overall operative success was 97%, and IPM changed operative management in 29% of patients. In 85 patients (38%) with discordant studies, operative success was 93%; IPM changed operative management in 74% of these patients. IPM allowed for 66% (56/85) of these operations to be performed as unilateral neck exploration and confirmed removal of abnormal glands in 7 patients with MGD. In 140 patients (62%) with concordant localization, in which operative success was 99%, IPM changed operative management in only 2% (3/140) of these patients with MGD.

Conclusion

Although of marginal benefit in patients with concordant imaging studies, IPM remains essential for performing successful PTX with discordant or incorrect concordant localization.

Section snippets

Material and methods

A series of 225 consecutive patients with SPHPT underwent focused PTX with IPM at the University of Miami/Jackson Memorial Medical Center from July 2001 to June 2006. All patients with a secure biochemical diagnosis had MIBI scans and surgeon-performed ultrasonography (SUS) to localize parathyroid glands preoperatively. Indications for PTX followed the guidelines defined by the 2002 NIH Consensus Report.15 Focused PTX with IPM was attempted in all patients. The intraoperative criterion for

Results

Of the 225 consecutive patients who underwent focused PTX, 18 patients (8%) had prior PTX, and 11 patients (5%) had undergone previous thyroidectomy. A total of 213 patients (95%) had solitary parathyroid glands excised (209 hypersecreting glands, 4 carcinomas), and 12 patients (5%) had MGD. In all, 178 women and 47 men were included in the study with a mean age of 58 years (range, 16–89). The mean preoperative serum calcium was 11.9 mg/dL with a mean serum PTH level of 215 pg/mL. The mean

Discussion

In this report of 225 consecutive patients with MIBI and SUS studies who underwent focused PTX guided by IPM for SPHPT, there was a 97% operative success rate. These results are similar to those reported in which BNE was used in all patients or in those who had only concordant preoperative imaging studies.3, 4, 5, 6, 16 In this series, concordant localization studies were only observed in 62% of patients treated for SPHPT. In the remaining 38% of treated patients with discordant imaging

References (24)

  • D.D. Elliott et al.

    Parathyroid histopathology: is it of any value today?

    J Am Coll Surg

    (2006)
  • R. Udelsman

    Six hundred fifty-six consecutive explorations for primary hyperparathyroidism

    Ann Surg

    (2002)
  • Cited by (56)

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      Although not part of the current study, 44 patients had ioPTH spikes 3 times above the preincision level, with 2 having MGD (4.5%). Since this rate of MGD is consistent with rates published in the literature, ioPTH spikes should not warrant changes in current operative approach.12,18,19,21 Although the data were collected prospectively, this study is limited by its retrospective nature because other multiple intraoperative factors, such as the timing of blood draws and the degree of difficulty in locating glands, could not be captured in the database.

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      The additional use of IOPTH in patients with two concordant preoperative studies lead to 100% cure of primary hyperparathyroidism in our patient population that would not have been achieved otherwise. While the results of other studies support the concept that IOPTH is essential during parathyroidectomy in patients with discordant localization studies8,9 and in patients with only a single positive preoperative localizing study,3,10 controversy remains on whether IOPTH is necessary in patients with two concordant preoperative imaging studies demonstrating a single abnormal parathyroid gland. The positive predictive value of dual localization studies with sestamibi and ultrasound varies at each institution and has been reported to be between 95 and 100%.1,8,11

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    Presented at the 3rd Annual Academic Surgical Congress, Huntington Beach, California, February 2008.

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