Elsevier

Surgery

Volume 142, Issue 3, September 2007, Pages 398-404
Surgery

Original communication
A “defined baseline” in PTH monitoring increases surgical success in patients with multiple gland disease

https://doi.org/10.1016/j.surg.2007.05.004Get rights and content

Background

Parathyroid hormone (PTH) monitoring with a quick intact PTH (QIPTH) assay is used in minimally invasive exploration for primary hyperparathyroidism (PHPT) in order not to miss multiple gland disease (MGD). Controversy exists on which criterion is most reliable to predict cure.

Methods

QIPTH values of 310 consecutive patients (single gland disease [SGD]: n = 289; MGD: n = 21) with sporadic PHPT were analyzed using 3 different criteria: “Vienna Criterion”: ≥50% decay from a defined “baseline” level (right after induction of anesthesia before skin incision) 10 min after excision. “Miami Criterion”: ≥50% decay from highest (preincision or preexcision) value 10 min after excision; “Halle Criterion”: decay of the PTH- level to less than or equal to 35 pg/mL within 15 min after excision.

Results

The “Vienna” and “Halle Criteria” correctly detected MGD in 19 (91%) and the “Miami Criterion” in 12 (57%) of 21 patients. Incorrect prediction of incomplete excision occurred in 22 patients (8%) with SGD, using the “Vienna Criterion” (“Miami Criterion”: 2%, “Halle Criterion”: 29%). All of these were recognized intraoperatively from unintended intraoperative manipulation (n = 18), technical failure (n = 2), or borderline increased PTH values (n = 2), and they did not lead to bilateral exploration. Analyzing patients with SGD and MGD, accuracy and specificity were 92% and 89% for the “Vienna Criterion,” 93% and 54% applying the “Miami Criterion,” and 72% and 89% using the “Halle Criterion.”

Conclusion

Strict definition of a PTH “baseline level” (“Vienna Criterion”) improves intraoperative diagnosis of MGD, thus reducing reoperations and increasing long-term cure.

Section snippets

Patients and methods

Overall, 310 consecutive patients (253 females, 57 males) underwent initial parathyroid operation. All patients had biochemical evidence of sporadic PHPT. The mean preoperative albumin adjusted serum calcium level (Ca) was 2.93 mmol/L (normal range, 2.0-2.60 mmol/L), and mean intact PTH 190 pg/mL (normal range, 10-65 pg/mL).

Age was 16 to 88 years (median age, 61 years). By definition,12 93 patients (30%) showed classic symptoms of PHPT (renal, bone, and/or gastrointestinal tract manifestations,

OMIP

True positive (TP) and true negative (TN) results. The “Vienna Criterion” correctly predicted cure (TP) in 169 of 188 patients with OMIP and correctly demonstrated 1 patient not cured (TN). Overall in 170 (90.4%) patients, QIPTH correctly predicted the parathyroid metabolism.

However in the patient with the true negative PTH decay, the PTH-curve was misinterpreted as cured. The PTH-values dropped from 86 pg/mL to 45 pg/mL (drop, 47.7%). The patient showed persisting disease.

In 1 patient, QIPTH

Discussion

In minimally invasive targeted (focused, directed, limited) endoscopic or video-assisted parathyroid explorations, only the preoperatively localized parathyroid tumor is identified and no attempts are made to locate other normal parathyroid glands. Several studies have demonstrated advantages of minimally invasive techniques and/or unilateral neck exploration (besides identification of the enlarged parathyroid, a biopsy of the normal-appearing gland is also performed routinely) over BNE,

Conclusions

In patients with localized SGD, minimally invasive exploration with extirpation of the hyperfunctioning gland would be followed by lifelong normocalcemia even without intraoperative PTH monitoring. However, not all hyperfunctioning glands can be localized preoperatively and MGD is suspected by localization studies in very few patients. Thus, additional techniques have to be applied to rule out MGD intraoperatively. PTH monitoring may help to solve this issue. The “Vienna Criterion” must be

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  • Cited by (0)

    Supported by “Jubiläumsfonds der Österreichischen Nationalbank” Grant 9307.

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