A New Approach to Parathyroidectomy

Abstract

ObjectiveTo decrease the operative time for parathyroidectomy in patients with hypercalcemic (primary) hyperparathyroid disease, a combination of preoperative localization of a parathyroid tumor with an effective nuclear scan (scintigram) and intraoperative monitoring of parathyroid hormone (quick parathyroid hormone measurement) to ensure excision of all hyperfunctioning tissue was studied. Summary Background DataFor many years, persistent hypercalcemia after parathyroidectomy (3% to 10%) has been constant and is usually due to the surgeon's failure to remove all hyperfunctioning glands. A marked decrease in parathormone level after excision of a single large gland predicts operative success and a return to normal calcium levels. Conversely, persistent high levels of parathyroid hormone indicate excess secretion by another gland(s) and the need for further exploration. Recently Tc-99m-sestamibi (MIBI) scintigraphy was shown to be more effective in localizing parathyroid tumors than previous methods. A combination of both techniques could be useful to the surgeon if they improve the operative success rate and are cost-effective. MethodsParathyroidectomy was performed on 18 patients with primary hyperparathyroid disease, with tumors localized by MIBI scintigrams. When excision of the identified parathyroid gland was accomplished, the operation was terminated and quick parathyroid hormone was measured to confirm that all hyperfunctioning tissue was removed. ResultsSixteen patients with positive results of scintigram had successful parathyroidectomies confirmed by quick parathyroid hormone measurement with a cervical approach. Two patients with mediastinal tumors localized by MIBI scintigraphy could not be resected using this approach. One false-positive/false-negative scintigram was obtained. Compared with patients having parathyroidectomy without localization and hormone monitoring, the average operative time was shortened from 90 to 36 minutes. ConclusionsLocalization and successful excision of parathyroid tumors with confirmation that no other hyperfunctioning glands were present by quick parathyroid hormone monitoring can predict a return to normal calcium levels and a decrease in operative time in parathyroidectomy. 574

Feasibility of Rapid Parathormone Assay for Enabling Minimally Invasive Parathyroid Excision

“…Later, in 1994, Irvin proposed the combination of Tc-sestamibi (MIBI) scintigraphy, a preoperative tumour localisation method with rapid intraoperative parathyroid monitoring, which was considered as a notable breakthrough in the management of hyperparathyroidism. Since then, compared with the traditional bilateral neck exploration of all glands, this combination method simplified identification of the affected gland and prevented unnecessary bilateral neck exploration [10][11][12].…”

“…The average operative time for parathyroidectomy with PTH monitoring and localisation was shortened to 36 min from 90 min compared with patients having parathyroidectomy without localisation and PTH assay [10]. Finally, the conventional assay for parathormone takes a significantly longer time to perform; in contrast, the rapid PTH assay takes less time and yields clinically similar results [17].…”

“…(4) >50 % PTH drop from the highest either preincision or preexcision level 5 min after parathyroid excision [10,13]. (5) >50 % PTH drop from pre-excision level no more than 10 min after gland excision [31].…”

Significance of Rebounding Parathyroid Hormone Levels During Parathyroidectomy

“…Traditionally, parathyroidectomy was accomplished with a bilateral neck exploration where all four glands were identified and grossly abnormal glands resected. The development of intraoperative parathyroid hormone (IoPTH) monitoring enabled surgeons to offer patients a minimally invasive parathyroidectomy (MIP) (4). Since the etiology of PHPT is a single adenoma in roughly 80% of patients with PHPT, MIP involves resecting a preoperatively localized adenoma through a small incision, and then using IoPTH to confirm a cure while the patient is still in the operating room.…”

Relação entre os níveis séricos de cálcio e paratormônio e a positividade da cintilografia das paratiróides com sestamibi: análise de 194 pacientes

“…Alguns médicos têm solicitado a cintilografia das paratiróides antes da primeira cirurgia, na tentativa de localizar previamente as glândulas comprometidas e abreviar a duração da cirurgia, principalmente nos casos em que dificuldades no ato cirúrgico sejam antecipadas (obesos com pescoço curto, desvios na coluna cervical com dificuldade para realizar extensão, e cirurgias cervicais prévias), e em pacientes de alto risco que não tolerem atos cirúrgicos prolongados (cardiopatas) (6,7). Temos notado, também, que alguns exames têm sido solicitados em pacientes que não apresentam quadro laboratorial evidente de hiperparatiroidismo primário, talvez na tentativa de confirmar suspeitas clínicas da patologia.…”