Original communicationA “defined baseline” in PTH monitoring increases surgical success in patients with multiple gland disease
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
References (30)
- et al.
Operative monitoring of parathyroid gland hyperfunction
Am J Surg
(1991) - et al.
Impact of localization studies on feasibility of minimally invasive parathyroidectomy in an endemic goiter region
J Am Coll Surg
(2003) - et al.
Intraoperative PTH monitoring in parathyroid hyperplasia requires stricter criteria for success
Surgery
(2004) - et al.
The influence of sample site on intraoperative PTH monitoring during parathyroidectomy
Surgery
(2004) - et al.
Comparison of intraoperative iPTH assay (QPTH) criteria in guiding parathyroidectomy: which criterion is the most accurate?
Surgery
(2003) - et al.
What is the link between nonlocalizing sestamibi scans, multigland disease, and persistent hypercalcemia?A study of 401 consecutive patients undergoing parathyroidectomy
Surgery
(2006) - et al.
Detection of multiple gland primary hyperparathyroidism in the era of minimally invasive parathyroidectomy
Surgery
(2004) - et al.
Consequences of targeted parathyroidectomy guided by localization studies without intraoperative parathyroid hormone monitoring
J Am Coll Surg
(2006) - et al.
Pitfalls of intraoperative quick parathyroid hormone monitoring and gamma probe localization in surgery for primary hyperparathyroidism
Arch Surg
(2002) - et al.
Will directed parathyroidectomy utilizing the gamma probe or intraoperative parathyroid hormone assay replace bilateral cervical exploration as the preferred operation for primary hyperparathyroidism?
World J Surg
(2002)
A quick intraoperative parathyroid hormone assay in the surgical management of patients with primary hyperparathyroidism: a study of 206 consecutive cases
Eur J Endocrinol
A spike in parathyroid hormone during neck exploration may cause a false-negative intraoperative assay result
Arch Surg
Intraoperative testing for parathyroid hormone: a comprehensive review of the use of the assay and the relevant literature
Arch Pathol Lab Med
Unilateral neck exploration under local anesthesia: the approach of choice for asymptomatic primary hyperparathyroidism
Surgery
Reoperative parathyroid surgery in the era of sestamibi scanning and intraoperative parathyroid hormone monitoring
Arch Surg
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Supported by “Jubiläumsfonds der Österreichischen Nationalbank” Grant 9307.