Denise M. Carneiro

Improved Success Rate in Reoperative Parathyroidectomy With Intraoperative PTH Assay

OBJECTIVE The clinical usefulness of preoperative localization and intraoperative PTH assay (QPTH) in primary hyperparathyroidism have been established. However, without the use of QPTH, the parathyroidectomy failure rate remains 5% to 10% in large reported series and is probably much higher in the hands of less experienced parathyroid surgeons. Persistent hypercalcemia requires another surgical procedure. The authors compared the outcomes in 50 consecutive patients undergoing more difficult secondary parathyroidectomy with and without the adjunctive support of QPTH. METHODS Two groups of similar patients underwent reoperative parathyroidectomy for failed surgery or recurrent disease. The successful return to normocalcemia in group I, with QPTH used to localize and confirm complete excision of all hyperfunctioning glands, was compared with group II, who did not have this intraoperative adjunct. RESULTS In 31/33 patients in group I, calcium levels returned to normal. With good preoperative localization studies, 17 patients underwent successful straightforward parathyroidectomies as predicted by QPTH. In the other 14 patients, QPTH assay proved extremely beneficial by facilitating localization with differential venous sampling; measuring the increase in hormone secretion after massage of specific areas; recognizing suspicious nonparathyroid tissue excised without a decrease in hormone levels, avoiding frozen-section delay; and correctly identifying the excision of abnormal tissue despite false-positive/false-negative sestamibi scans. In group II, who underwent surgery before QPTH was available, 4 of 17 patients (24%) remained hypercalcemic after extensive reexploration. CONCLUSION With the intraoperative hormone assay used to facilitate localization and confirm excision of all hyperfunctioning tissue, the success rate of reoperative parathyroidectomy has improved from 76% to 94%.

Quick Intraoperative Parathyroid Hormone Assay: Surgical Adjunct to Allow Limited Parathyroidectomy, Improve Success Rate, and Predict Outcome

Intraoperative parathyroid hormone (PTH) assay (QPTH) has made possible less invasive operative approaches in the treatment of primary hyperparathyroidism with stated advantages. When compared to the traditional bilateral neck exploration (BNE), only the targeted, hypersecreting gland is excised, leaving in situ non-visualized but normally functioning parathyroids. The QPTH-guided limited parathyroidectomy (LPX) must be able to identify multiglandular disease (MGD), predict a successful outcome, and have a low recurrence rate. In our series, 421 patients who underwent LPX were compared to 340 undergoing BNE; all operative failures and patients followed for 6 months or longer were included. Operative failure occurred if serum calcium and PTH levels were elevated within 6 months of parathyroidectomy. Multiglandular disease was defined in the LPX group as more than one gland excision guided by QPTH or operative failure after removal of a single abnormal gland; in the BNE group it was defined as excision of more than one enlarged gland. Recurrence was defined as elevated calcium and PTH after 6 months of eucalcemia. Operative failure and MGD rates were compared using chi-squared analysis. The method of Kaplan-Meier and the log-rank test were used to compare recurrence rates. Operative success was seen in 97% of LPX patients and in 94% of the BNE group (p = 0.02). Multiglandular disease was identified in 3% of LPX patients and 10% of BNE patients (p < 0.001). There was no statistical difference in the overall recurrence rates (p = 0.23). The QPTH-guided parathyroidectomy identifies MGD and allows an improved success rate with the same low recurrence rate when compared to the results of BNE.

Progress in the operative management of sporadic primary hyperparathyroidism over 34 years.

Background:Progress in the diagnosis, localization of abnormal parathyroids, and intraoperative management of primary hyperparathyroidism has been observed over the past 34 years. The goal of this study is to report the outcome of patients undergoing 2 different operative approaches in a single institution, showing the evolution of surgical management of sporadic primary hyperparathyroidism (SPHPT). Methods:Parathyroidectomy was performed in 890 (827 initial, 63 reoperative) patients with SPHPT using 2 different approaches: traditional bilateral neck exploration (BNE, n = 396) or limited parathyroidectomy guided by parathormone dynamics (LPX, n = 494). Seven hundred eighteen patients (335 BNE, 383 LPX) followed ≥ 6 months or identified as operative failures were studied. Operative failure is defined as hypercalcemia and high intact (1–84) parathyroid hormone molecule (iPTH) within 6 months after operation. Successful parathyroidectomy is normocalcemia for 6 months; hypercalcemia and elevated iPTH after this time is recurrent hyperparathyroidism. Results:There were 20 (6%) of 335 operative failures in the BNE group and 11 (3%) of 383 failures in the LPX group (P = 0.04). The incidence of multiglandular disease (MGD) determined by gland size (10%) versus hormone hypersecretion (3%) was statistically different (P < 0.001). Since most of the recurrences occurred later than 30 months, the incidence of recurrent hyperparathyroidism in patients followed for longer than 2.5 years was 4% (11/287) in the BNE group (average, 11.5 years) and 3% (5/183) in the LPX group (average, 4.2 years). Conclusion:LPX, with its reported advantages of minimal dissection, shorter operative time, and use in ambulatory settings, compares favorably with the traditional BNE. Parathyroidectomy guided by parathormone dynamics has an improved success rate and should be considered as a standard operative approach in SPHPT.

The evolution of parathyroidectomy failures

BACKGROUND Reported operative failure rates for primary hyperparathyroidism range from 5% to 10%. Failure has been due to multiglandular disease, ectopic parathyroid glands, errors in frozen section, and missed diagnoses. Recently, our operative approach has changed from bilateral cervical exploration to direction by preoperative localization and intraoperative quick parathyroid hormone assay. The purpose of this study is to examine the causes and rates of failure in this evolving approach to parathyroidectomy. METHODS Among 447 consecutive cases of primary hyperparathyroidectomy, 20 operative failures were examined. Three different operative approaches were compared with respect to causes and rates of failure. RESULTS From 1969 to 1989, with bilateral neck exploration, failure was due to missed diagnoses, ectopic glands, multiglandular disease, and unknown causes, with a failure rate of 5%. From 1990 to 1993, with bilateral neck exploration and quick parathyroid hormone assay, failure was due to ectopic mediastinal glands, misinterpretation of frozen section, and operative judgment, with a failure rate of 10%. From 1993 to 1998, with preoperative localization and quick parathyroid hormone assay, the two operative failures (1.5%) were due to operative judgment and misinterpretation of the quick parathyroid hormone assay. CONCLUSIONS The new surgical approach combining preoperative localization studies and intraoperative parathyroid hormone monitoring has eliminated the most common causes of parathyroidectomy failure and has significantly decreased the operative failure rate.

“Limited” Parathyroidectomy in Geriatric Patients

ObjectiveElderly patients with primary hyperparathyroidism accompanied by other diseases are often denied referral for parathyroidectomy because of the associated risks of general anesthesia and bilateral neck exploration. However, marked symptomatic improvement is recognized after successful parathyroidectomy. The purpose of this report is to examine the postoperative outcome of geriatric patients undergoing “limited” parathyroidectomy. MethodsSince 1993, 291 consecutive patients with primary hyperparathyroidism were treated with “limited” parathyroidectomy guided by preoperative localization and intraoperative parathyroid hormone assay. In 34 of the procedures (29 initial, 5 reoperations), the patient was 75 years or older; these patients are the subject of this report. Patients were followed up for serum calcium, parathyroid hormone levels, and symptomatology. ResultsTwenty-seven patients were followed up for 31 (range 6–84) months: all remained normocalcemic after single gland excision guided by intraoperative parathyroid hormone assay. Another six patients in the immediate postoperative period had normocalcemia. One patient had persistent hypercalcemia. Unilateral neck exploration was possible in 29 patients. The average operating time for initial parathyroidectomy was 50 (range 20–130) minutes. Nineteen patients were eligible for ambulatory surgery. Seven were discharged without an overnight stay, 11 had a 23-hour “social” admission, and one was kept overnight after a prolonged surgical procedure. Permanent hypoparathyroidism and laryngeal nerve injury were not observed. The mortality rate related to the procedure was 0%; there was one postoperative (do not resuscitate) death caused by colonic hemorrhage. With an average follow-up of 2 years, 64% of the patients had marked improvement of symptoms. ConclusionAdjunctive use of preoperative localization and intraoperative parathyroid hormone assay has made “limited” parathyroidectomy a safe, effective treatment option in geriatric patients with primary hyperparathyroidism.

The use of intraoperative parathyroid hormone assay (QPTH) in patients with parathyroid cancer

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