Minimally invasive surgery for primary hyperparathyroidism with or without intraoperative parathyroid hormone monitoring

Abstract

Bilateral neck exploration, the identification of all parathyroid glands and removal of all abnormal glands, has traditionally been regarded as the standard surgical strategy for the treatment of primary hyperparathyroidism (pHPT) [1][2][3][4]. However, in recent years, several investigators have questioned the routine performance of bilateral neck exploration because the cause of pHPT in most patients is a single parathyroid adenoma and preoperative imaging tests, such as Technetium-99m sestamibi scans and ultrasound examination have enabled precise localization of the affected parathyroid gland with high sensitivity [5][6][7]. Use of intraoperative PTH (IOPTH) measurement or the gamma probe with perioperative sestamibi injection has also contributed to improving results A group who underwent surgery without IOPTH monitoring (Group 1; n=87), and a group who underwent surgery with IOPTH monitoring (Group 2; n=80), in which IOPTH was measured at 5, 10, 15 minutes after excision of the abnormal parathyroid gland. Criterion for evaluation as a cure was a drop in intact PTH level of 50% or more from the preoperative baseline value. The overall cure rate in Group 1 was 93.1%. An enlarged parathyroid gland that was consistent with the results of a preoperative imaging study was found in 84 patients (96.6%). The overall cure rate in Group 2 was 97.5%. In 7 of the patients, there was no drop of 50% or more at any of the 3 points in time measured. Two of these patients were found to have had double adenomas, one on each side, during the initial surgery. Three others were eucalcemic and had normal intact PTH values after surgery, and the remaining 2 patients had persistent disease. Although preoperative localization studies are accurate and essential, IOPTH monitoring improves the cure rate of minimally invasive parathyroidectomy. IOPTH monitoring is a valuable adjunct to achieve adequate intraoperative decision-making, recognizing and resecting additional image-negative hyperfunctioning lesions.

Successful Localization of Abnormal Parathyroid Gland Using Ultrasound-Guided Methylene Blue Dye Injection in the Reoperative Neck

“…We also tested the adequacy of the resection using IOPTH determination. As reported before, IOPTH increases the success rate of parathyroid surgery [13]. Blue dyes and especially methylene blue are used intravenously for the localization of parathyroid tumors [14].…”

Gamma Probe Guided Minimally Invasive Parathyroidectomy without Quick Parathyroid Hormone Measurement in the Cases of Solitary Parathyroid Adenomas

“…Failure to detect SPA was between 1-2.7% in patients examined by both 99mTc-MIBI PS and USG, without intra-operative QPTH monitoring (12,27,28). In Kiminori et al’s study, while the cure rate was 93.1% in MIP without intra-operative QPTH measurements; in MIP with QPTH measurement, the cure was 97,5% and revealed that QPTH measurement can elicit especially the PS negative Pas determination (29). …”

Virtual Neck Exploration for Parathyroid Adenomas

“…[8][9][10] Some studies have found value in the use of IOPTH in all cases of focused exploration. 11 Others have found minimal benefit in cases of preoperative concordance, and they reserve the role of IOPTH for discordant or negative preoperative imaging. 12 The cost to benefit ratio of the IOPTH assay remains questionable.…”