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

2008; Elsevier BV; Volume: 144; Issue: 4 Linguagem: Inglês

10.1016/j.surg.2008.06.017

1532-7361

Tina Yen, Tracy Wang, Kara Doffek, Elizabeth A. Krzywda, Stuart D. Wilson,

Medical Imaging and Pathology Studies

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.