Reoperative parathyroidectomy: An algorithm for imaging and monitoring of intraoperative parathyroid hormone levels that results in a successful focused approach

• Published in: Surgery Vol. 144; no. 4; pp. 611 - 621
• Main Authors: Yen, Tina W.F., MD, MS, Wang, Tracy S., MD, MPH, Doffek, Kara M., BS, Krzywda, Elizabeth A., ANP, MSN, Wilson, Stuart D., MD
• Format: Journal Article
• Language: English
• Published: United States Mosby, Inc 01.10.2008
• Subjects: Adult; Aged; Algorithms; Diagnostic Imaging - methods; Female; Follow-Up Studies; Humans; Hyperparathyroidism - diagnosis; Hyperparathyroidism - surgery; Magnetic Resonance Imaging; Male; Middle Aged; Monitoring, Intraoperative - methods; Parathyroid Hormone - analysis; Parathyroidectomy - adverse effects; Parathyroidectomy - methods; Preoperative Care - methods; Prospective Studies; Recurrence; Registries; Reoperation - methods; Risk Assessment; Safety Management; Sensitivity and Specificity; Severity of Illness Index; Surgery; Technetium Tc 99m Sestamibi; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Doppler
• ISSN: 0039-6060; 1532-7361
• DOI: 10.1016/j.surg.2008.06.017

Background Advances in preoperative imaging and use of intraoperative parathyroid hormone (IOPTH) levels are changing the approach to reoperative parathyroidectomy (ReopPTX). We sought to develop a protocol for imaging and IOPTH monitoring that allows for a focused, successful operative approach. Methods We reviewed our prospective database of consecutive patients with primary hyperparathyroidism who underwent ReopPTX with IOPTH monitoring between December 1999 and June 2007. Results Thirty-nine patients underwent 43 ReopPTXs for persistent (79%)/recurrent (21%) disease. All underwent ultrasonography and sestamibi imaging; 24 cases (56%) underwent additional imaging studies. Sensitivity of ultrasonography was 56%, sestamibi 53%, both studies 67%, computed tomography (CT) 48%, magnetic resonance imaging (MRI) 67%, and selective venous sampling (SVS) 50%. IOPTH monitoring predicted accurately cure in 100% and failure in 78%. A focused/unilateral approach was performed in 60%; median operative time was 45 minutes (range, 12–127). At last follow-up, 36 (92%) patients were normocalcemic. Conclusions We propose that ultrasonography and sestamibi studies should be done before all ReopPTXs; failure to localize should prompt sequential CT, MRI, and SVS until localization is achieved. IOPTH monitoring defines cure and is recommended for all ReopPTXs. This algorithm allows for a focused operative approach in >50% of ReopPTXs with operative times comparable with first-time, minimally invasive parathyroidectomy.